Test Bank & Solution Manual for Olds Maternal-Newborn Nursing & Women Health Across the Lifespan, 11 by Ace Test Banks

Test Bank for Olds Maternal-Newborn Nursing & Women Health Across the Lifespan, 11 Edition

richard@qwconsultancy.com

1|Pa ge

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 1 Contemporary Maternal-Newborn Nursing 1) The nurse is speaking to students about changes in maternal-newborn care. One change is that self-care has gained wide acceptance with clients and the healthcare community due to research findings that suggest that it has which effect? A) Shortens newborn length of stay B) Decreases use of home health agencies C) Decreases healthcare costs D) Decreases the number of emergency department visits Answer: C Explanation: A) Length of stay is often determined by third-party payer (insurance company) policies as well as the physiologic stability of the mother and newborn. Home healthcare agencies often are involved in client care to decrease hospital stay time. B) Home healthcare agencies often are involved in client care to decrease hospital stay time. C) Research indicates that self-care significantly decreases healthcare costs. D) Acute emergencies are addressed by emergency departments, and are not delayed by those practicing self-care. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.A.2. Describe strategies to empower patients or families in all aspects of the healthcare process. | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Health care economic policy; reimbursement structures; accreditation standards; staffing models and productivity; supply chain models | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the impact of the self-care movement on contemporary childbirth. MNL LO: Recognize contemporary issues related to care of the childbearing family.

2) Care delivered by nurse-midwives can be safe and effective and can represent a positive response to the healthcare provider shortage. Nurse-midwives tend to use less technology, which often results in which of the following? A) There is less trauma to the mother. B) More childbirth education classes are available. C) They are instrumental in providing change in the birth environment at work. D) They advocate for more home healthcare agencies. Answer: A Explanation: A) Nurse-midwife models of care can be one way to ensure that mothers receive excellent prenatal and intrapartum care. B) It is appropriate for nurse-midwives, in conjunction with doctors and hospitals, to provide childbirth classes for expectant families. C) By working with other staff members and doctors, the nurse-midwife is able to implement changes as needed within the birthing unit. D) Clients are increasingly going home sooner, so there needs to be more follow-up in the home. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A. 6. Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Compare the nursing roles available to the maternal-newborn nurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.

3) The nurse is telling a new client how advanced technology has permitted the physician to do which of the following? A) Treat the fetus and monitor fetal development. B) Deliver at home with a nurse-midwife and doula. C) Have the father act as the coach and cut the umbilical cord. D) Breastfeed a new baby on the delivery table. Answer: A Explanation: A) The fetus is increasingly viewed as a patient separate from the mother, although treatment of the fetus necessarily involves the mother. B) A nurse-midwife and a doula are not examples of technological care. C) Fathers being present during labor and coaching their partners represents nontechnological care during childbirth. D) Breastfeeding is not an example of technology impacting care. Page Ref: 2—3 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Evaluate the potential impact of some of the special situations in contemporary maternity care. MNL LO: Recognize contemporary issues related to care of the childbearing family.

4) A nurse is examining different nursing roles. Which example best illustrates an advanced practice nursing role? A) A registered nurse who is the manager of a large obstetrical unit B) A registered nurse who is the circulating nurse during surgical deliveries (cesarean sections) C) A clinical nurse specialist working as a staff nurse on a mother-baby unit D) A clinical nurse specialist with whom other nurses consult for her expertise in caring for highrisk infants Answer: D Explanation: A) A registered nurse who is the manager of a large obstetrical unit is a professional nurse who has graduated from an accredited program in nursing and completed the licensure examination. B) A registered nurse who is a circulating nurse at surgical deliveries (cesarean sections) is a professional nurse who has graduated from an accredited program in nursing and completed the licensure examination. C) A clinical nurse specialist working as a staff nurse on a mother-baby unit might have the qualifications for an advanced practice nursing staff member but is not working in that capacity. D) A clinical nurse specialist with whom other nurses consult for expertise in caring for high-risk infants is working in an advanced practice nursing role. This nurse has specialized knowledge and competence in a specific clinical area, and is master's prepared. Page Ref: 5 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: VI. 6. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the nursing roles available to the maternal-newborn nurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.

5) A nursing student investigating potential career goals is strongly considering becoming a nurse practitioner (NP). The major focus of the NP is on which of the following? A) Leadership B) Physical and psychosocial clinical assessment C) Independent care of the high-risk pregnant client D) Tertiary prevention Answer: B Explanation: A) Leadership might be a quality of the NP, but it is not the major focus. B) Physical and psychosocial clinical assessment is the major focus of the NP. C) NPs cannot provide independent care of the high-risk pregnant client, but must work under a physician's supervision. D) The NP cannot do tertiary prevention as a major focus. Page Ref: 5 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: VI. 2. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the nursing roles available to the maternal-newborn nurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.

6) The nurse manager is consulting with a certified nurse-midwife about a client. What is the role of the CNM? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Be prepared to manage independently the care of women at low risk for complications during pregnancy and birth. B) Give primary care for high-risk clients who are in hospital settings. C) Give primary care for healthy newborns. D) Obtain a physician consultation for any technical procedures at delivery. E) Be educated in two disciplines of nursing. Answer: A, C, E Explanation: A) A CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns. B) CNMs cannot give primary care for high-risk clients who are in hospital settings. The physician provides the primary care. C) A CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns. D) The CNM does not need to obtain a physician consultation for any technical procedures at delivery. E) The CNM is educated in the disciplines of nursing and midwifery. Page Ref: 5 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Compare the nursing roles available to the maternal-newborn nurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.

7) The registered nurse who has completed a master's degree program and passed a national certification exam has clinic appointments with clients who are pregnant or seeking well-woman care. What is the role of this nurse considered to be? A) Professional nurse B) Certified registered nurse (RNC) C) Clinical nurse specialist D) Nurse practitioner Answer: D Explanation: A) A professional nurse is one who has completed an accredited basic educational program and has passed the NCLEX-RN® exam. B) A certified registered nurse (RNC) has shown expertise in the field and has taken a national certification exam. C) A clinical nurse specialist has completed a master's degree program, has specialized knowledge and competence in a specific clinical area, and often is employed in hospitals on specialized units. D) A nurse practitioner has completed either a master's or doctoral degree in nursing and passed a certification exam, and functions as an advanced practice nurse. Ambulatory care settings and the community are common sites for nurse practitioners to provide client care. Page Ref: 5 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: II.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: VI. 6. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the nursing roles available to the maternal-newborn nurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.

8) While a child is being admitting to the hospital, the parent receives information about the pediatric unit's goals, including the statement that the unit practices family-centered care. The parent asks why that is important. The nurse responds that what communication dynamic is characteristic of the family-centered care paradigm? A) The mother is the principal caregiver in each family. B) The child's physician is the key person in ensuring that the health of a child is maintained. C) The family serves as the constant influence and continuing support in the child's life. D) The father is the leader in each home; thus, all communications should include him. Answer: C Explanation: A) Culturally competent care recognizes that both matriarchal and patriarchal households exist. B) The physician is not present during the day-to-day routines in a child's life. C) Family-centered care is characterized by an emphasis on the family and family involvement throughout the pregnancy, birth, and postpartum period. D) Culturally competent care recognizes that both matriarchal and patriarchal households exist. Page Ref: 2 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 6. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in the patient and self; facilitate hope, trust and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify specific factors that contribute to a family's value system. MNL LO: Recognize contemporary issues related to care of the childbearing family.

9) The current emphasis on federal healthcare reform has yielded what unexpected benefit? A) Assessment of the details of the family's income and expenditures B) Case management to limit costly, unnecessary duplication of services C) Many healthcare providers and consumers are becoming more aware of the vitally important role nurses play in providing excellent care to clients and families D) Education of the family about the need for keeping regular well-child visit appointments Answer: C Explanation: A) Financial assessment is more commonly the function of a social worker. The social worker is part of the interdisciplinary team working with clients, and this professional's expertise is helping clients get into the appropriate programs. B) The case management activity mentioned will not provide a source of funding. C) Nurses must clearly articulate their role in the changing environment to define and differentiate practice roles and the educational preparation required for their new roles. D) The education of the family will not provide a source of funding. Page Ref: 4 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A. 4. Examine how the safety, quality and cost effectiveness of health care can be improved through the active involvement of patients and families. | AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Compare the nursing roles available to the maternal-newborn nurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.

10) For prenatal care, the client is attending a clinic held in a church basement. The client's care is provided by registered nurses and a certified nurse-midwife. What is this type of prenatal care? A) Secondary care B) Tertiary care C) Community care D) Unnecessarily costly care Answer: C Explanation: A) Secondary care is specialized care; an example is checking the hemoglobin A1C of a diabetic client at an endocrine clinic. B) Tertiary care is very specialized, and includes trauma units and neonatal intensive care units. C) Prenatal care is primary care. Community care is often provided at clinics in neighborhoods to facilitate clients' access to primary care, including prenatal care and prevention of illness. D) Community care decreases costs while improving client outcomes, and is not unnecessarily expensive. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g. transmission of disease, disease patterns, epidemiological principles); chronic disease management; health care systems; transcultural approaches to health; family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the use of community-based nursing care in meeting the needs of childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

11) The nurse at an elementary school is performing TB screenings on all of the students. Permission slips were returned for all but the children of one family. When the nurse phones to obtain permission, the parent states in clearly understandable English that permission cannot be given because the grandmother is out of town for 2 more weeks. Which cultural element is contributing to the dilemma that faces the nurse? A) Permissible physical contact with strangers B) Beliefs about the concepts of health and illness C) Religion and social beliefs D) Presence and influence of the extended family Answer: D Explanation: A) The situation the nurse faces is not being caused by permissible contact with strangers. B) The situation the nurse faces is not caused by beliefs about the concepts of health and illness. C) The situation the nurse faces is not caused by religion and social beliefs. D) The presence and influence of the extended family is contributing to the situation the nurse faces. In many cultures, a family elder is the primary decision maker when it comes to health care. In this case, the parent cannot grant permission to the nurse until the parent consults the grandmother. Page Ref: 4 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Analyze ethical challenges presented by ambiguous and uncertain clinical situations; self-assess one's own tolerance for ambiguity and uncertainty; accept the possibility of multiple "right" answers (rather than one right answer thinking) in patient care and other professional situations. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify specific factors that contribute to a family's value system. MNL LO: Recognize contemporary issues related to care of the childbearing family.

12) A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure? A) The nurse B) The physician C) The unit secretary D) The social worker Answer: B Explanation: A) It is not the nurse's legal responsibility to obtain informed consent. B) Informed consent is a legal concept designed to allow clients to make intelligent decisions regarding their own health care. Informed consent means that a client, or a legally designated decision maker, has granted permission for a specific treatment or procedure based on full information about that specific treatment or procedure as it relates to that client under the specific circumstances of the permission. The individual who is ultimately responsible for the treatment or procedure should provide the information necessary to obtain informed consent. In most instances, this is a physician. C) Unit secretaries are not responsible for obtaining informed consent. D) It is not within a social worker's scope of practice to obtain informed consent. Page Ref: 7—8 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 12. Facilitate informed patient consent for care. | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Context and Environment: Code of ethics (e.g. American Nurses Association 2005; International Council of Nurses, 2006); regulatory and professional standards (ANA Social Policy Statement [ANA, 2003]; HIPAA [Health Insurance Portability and Accountability Act]); ethical decision making modes; scope of practice considerations; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

13) A nurse who tells family members the sex of a newborn baby without first consulting the parents would have committed which of the following? A) A breach of privacy B) Negligence C) Malpractice D) A breach of ethics Answer: A Explanation: A) A breach of privacy would have been committed in this situation, because informing other family members of the child's sex without the parents' consent violates the parents' right to privacy. The right to privacy is the right of a person to keep his person and property free from public scrutiny (or even from other family members). B) Negligence is a punishable legal offense, and is more serious. C) Malpractice is a punishable legal offense, and is more serious. D) No breach of ethics has been committed in this situation. Page Ref: 8 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Ethical Practice Standards: QSEN Competencies: I. B. 13. Assess own level of communication skill in encounters with patient and families. | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and clients' right to privacy. | NLN Competencies: Context and Environment: Code of ethics (e.g. American Nurses Association 2005; International Council of Nurses, 2006); regulatory and professional standards (ANA Social Policy Statement [ANA, 2003]; HIPAA [Health Insurance Portability and Accountability Act]); ethical decision making modes; scope of practice considerations; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

14) The nursing instructor explains to the class that according to the 1973 Supreme Court decision in Roe v. Wade, abortion is legal if induced: A) Before the 30th week of pregnancy. B) Before the period of viability. C) To provide tissue for therapeutic research. D) Can be done any time if mother, doctor, and hospital all agree. Answer: B Explanation: A) This statement is not true, because the fetus is viable many weeks before the 30th week. B) Abortion can be performed legally until the period of viability. C) Abortion cannot be used for the sole purpose of providing tissue for therapeutic research. D) This is not true. Legal abortion can be done only up until the time of viability. Page Ref: 9 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Ethical Practice Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and client's right to privacy. | NLN Competencies: Context and Environment: Code of ethics (e.g. American Nurses Association 2005; International Council of Nurses, 2006); regulatory and professional standards (ANA Social Policy Statement [ANA, 2003]; HIPAA [Health Insurance Portability and Accountability Act]); ethical decision making modes; scope of practice considerations; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

15) The nurse reviewing charts for quality improvement notes that a client experienced a complication during labor. The nurse is uncertain whether the labor nurse took the appropriate action during the situation. What is the best way for the nurse to determine what the appropriate action should have been? A) Call the nurse manager of the labor and delivery unit and ask what the nurse should have done. B) Ask the departmental chair of the obstetrical physicians what the best nursing action would have been. C) Examine other charts to find cases of the same complication, and determine how it was handled in those situations. D) Look in the policy and procedure book, and examine the practice guidelines published by a professional nursing organization. Answer: D Explanation: A) The nurse should find the standards, and not rely on another person to determine appropriateness of care. B) Physician care and nursing care are very different; physicians might not be up to date on nursing standards of care or nursing policies and procedures. C) What nursing action was undertaken in a different situation might not be based on the policies and procedures or other standards of care. The quality improvement nurse will obtain the most accurate information by examining the policies, procedures, and standards of care. D) Agency policies, procedures, and protocols contain guidelines for nursing action in specific situations. Professional organizations such as the Association of Women's Health, Obstetrical, and Neonatal Nurses (AWHONN) also publish standards of practice that should guide nursing care. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV. A. 4. Explain the importance of variation and measurement in assessing quality of care. | AACN Essentials Competencies: V. 1. Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments; including local, state, national, and global healthcare trends. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

16) The nurse is reviewing care of clients on a mother-baby unit. Which situation should be reported to the supervisor? A) A 2-day-old infant has breastfed every 2-3 hours and voided four times. B) An infant was placed in the wrong crib after examination by the physician. C) The client who delivered by cesarean birth yesterday received oral narcotics. D) A primiparous client who delivered today is requesting discharge within 24 hours. Answer: B Explanation: A) Breastfeeding every 2 hours and voiding four times is within normal limits for a 2-day-old infant. There is no negligence in this situation. B) Placing an infant in the wrong crib is malpractice. Malpractice is negligent action by a professional person. C) Receiving oral narcotics at this point in the client's stay is within normal limits. There is no negligence in this situation. D) If the client is feeling well and able to care for her infant, it is normal to be discharged at this time. The mother and baby both must be within normal limits to be discharged. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

17) The nurse manager is planning a presentation on ethical issues in caring for childbearing families. Which example should the nurse manager include to illustrate maternal-fetal conflict? A) A client chooses an abortion after her fetus is diagnosed with a genetic anomaly. B) A 39-year-old nulliparous client undergoes therapeutic insemination. C) A family of a child with leukemia requests cord-blood banking at a sibling's birth. D) A cesarean delivery of a breech fetus is court ordered after the client refuses. Answer: D Explanation: A) Abortion is a different type of ethical situation. B) Achieving pregnancy through the use of therapeutic insemination is a form of reproductive assistance, and is not considered a maternal-fetal conflict. C) Cord-blood banking is a different type of ethical situation. D) Maternal-fetal conflict is a special ethical situation where the rights of the fetus and the rights of the mother are considered separately. Forced cesarean birth, coercion of mothers who practice high-risk behaviors, and, perhaps most controversial, mandating experimental in utero therapy or surgery in an attempt to correct a specific birth defect are interventions that infringe on the mother's autonomy. Page Ref: 9 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 9. Assess level of patient's decisional conflict and provide access to resources. | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Context and Environment: Show respect for others' values; appreciate diversity; be civil during relationships and work; value community empowerment and social justice; work to improve social conditions affecting health; adopt inclusive language. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

18) Client safety goals, which are evaluated and updated regularly, are requirements for what? A) Clinical practice guidelines B) Scope of practice C) Accreditation D) Standards of care Answer: C Explanation: A) Clinical practice guidelines are adopted within a healthcare setting to reduce variation in care management, to limit costs of care, and to evaluate the effectiveness of care. B) State nurse practice acts protect the public by broadly defining the legal scope of practice within which every nurse must function and by excluding untrained or unlicensed individuals from practicing nursing. C) The Joint Commission has identified client safety as an important responsibility of healthcare providers. D) Standards of care establish minimum criteria for competent, proficient delivery of nursing care. Page Ref: 7 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. A. 7. Discuss potential and actual impact of national patient safety resources, initiatives, and regulations. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Value and encourage nurses' involvement in the design, selection, implementation, and evaluation of information technologies to support patient care (e.g. as recommended by QSEN). | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

19) A fetus has been diagnosed with myelomeningocele. Which of the following surgeries would be performed to correct this condition? A) Tubal ligation B) Intrauterine fetal surgery C) Cesarean section D) Sterilization Answer: B Explanation: A) Tubal ligation is not an intrauterine fetal surgery. B) Intrauterine fetal surgery, which is generally considered experimental, is a therapy for anatomic lesions that can be corrected surgically and are incompatible with life if not treated. Examples include surgery for myelomeningocele and some congenital cardiac defects. C) A cesarean birth is not considered an intrauterine fetal surgery. D) Sterilization surgery does not involve the fetus. Page Ref: 9 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: II. B. 8. Integrate the contributions of others who play a role in helping the patient/family achieve health goals. | AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

20) A nurse is providing guidance to a group of parents of children in the infant-to-preschool age group. After reviewing statistics on the most common cause of death in this age group, the nurse includes information about prevention of which of the following? A) Cancer by reducing the use of pesticides in the home B) Accidental injury by reducing the risk of pool and traffic accidents C) Heart disease by incorporating heart-healthy foods into the child's diet D) Pneumonia by providing a diet high in vitamin C from fruits and vegetables Answer: B Explanation: A) Cancer due to pesticide use is not a large cause of death in this age group. B) Unintentional injuries cause death in infants more often than cancer, heart disease, and pneumonia. C) Heart disease is not a large cause of death in this age group. D) Pneumonia does not cause a large number of deaths. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. A. 1. Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as work-arounds and dangerous abbreviations) | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.

21) The nurse is preparing a report on the number of births by three service providers at the facility (certified nurse-midwives, family practitioners, and obstetricians). What is this an example of? A) Inferential statistics B) Descriptive statistics C) Evidence-based practice D) Secondary use of data Answer: B Explanation: A) Inferential statistics allow the investigator to draw conclusions from data to either support or refute causation. B) Descriptive statistics concisely describe phenomena such as births by providers. C) Evidence-based practice is the use of research conclusions to improve nursing care. D) Secondary use of data is analyzing data in a different way than was originally undertaken, or looking at different variables from a data set. Page Ref: 11 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values. | AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.

22) The nurse is explaining the difference between descriptive statistics and inferential statistics to a group of student nurses. To illustrate descriptive statistics, what would the nurse use as an example? A) A positive correlation between breastfeeding and infant weight gain B) The infant mortality rate in the state of Oklahoma C) A causal relationship between the number of sexual partners and sexually transmitted infections D) The total number of spontaneous abortions in drug-abusing women as compared with nondrug-abusing women Answer: B Explanation: A) A positive correlation between two or more variables is an inferential statistic. B) The infant mortality rate in the state of Oklahoma is a descriptive statistic, because it describes or summarizes a set of data. C) A causal relationship between the number of sexual partners and sexually transmitted infections is an inferential statistic. D) The total number of spontaneous abortions in drug-abusing women is an inferential statistic. Page Ref: 11 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.

23) The nurse manager is examining the descriptive statistics of increasing teen pregnancy rates in the community. Which inferential statistical research question would the nurse manager find most useful in investigating the reasons for increased frequency of teen pregnancy? A) What providers do pregnant teens see for prenatal care? B) What are the ages of the parents of pregnant teens in the community? C) Do pregnant teens drink caffeinated beverages? D) What do pregnant teens do for recreation? Answer: A Explanation: A) Understanding which providers pregnant teens are most likely to seek out for prenatal care can lead to further investigation on why prenatal care with that provider is more acceptable to teens, which in turn can lead to greater understanding of the issue of teen pregnancy. B) A question about the age of parents of pregnant teens might prove useful in seeking causes of teen pregnancy, but it is not the most useful question in understanding the increased frequency of teen pregnancy. C) Whether pregnant teens drink caffeinated beverages gives no further insight into the issues of teen pregnancy. D) Understanding the recreational activities of pregnant teens would not lead to an understanding of the issues surrounding increasing teen pregnancy rates. Page Ref: 11 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.

24) The Quality and Safety Education for Nurses (QSEN) project focused on competencies in which areas? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Client-centered care B) Teamwork and collaboration C) Evidence-based practice D) Family planning E) Injury and violence prevention Answer: A, B, C Explanation: A) The Quality and Safety Education for Nurses (QSEN) project is designed "to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work," which includes client-centered care. B) The Quality and Safety Education for Nurses (QSEN) project, is designed "to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work," which includes teamwork and collaboration. C) The Quality and Safety Education for Nurses (QSEN) project, is designed "to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work," which includes evidence-based practice. D) Healthy People 2020 focuses on family planning. E) Healthy People 2020 focuses on injury and violence prevention. Page Ref: 7 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings. | AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal, or unethical care practices. | NLN Competencies: Quality and Safety: Value and encourage nurses' involvement in the design, selection, implementation, and evaluation of information technologies to support patient care (e.g., as recommended by QSEN). | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

25) The nurse is serving on a panel to evaluate the hospital staff's reliance on evidence-based practice in their decision-making processes. Which practices characterize the basic competencies related to evidence-based practice? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Recognizing which clinical practices are supported by good evidence B) Recognizing and including clinical practice supported by intuitive evidence C) Using data in clinical work to evaluate outcomes of care D) Including quality-improvement measures in clinical practice E) Appraising and integrating scientific bases into practice Answer: A, C, E Explanation: A) Recognizing which clinical practices are supported by sound evidence is a basic competency related to evidence-based practice. B) Including clinical practice supported by intuitive evidence is not a basic competency related to evidence-based practice. C) Using data in clinical work to evaluate outcomes of care is one of the basic competencies related to evidence-based practice. D) Including quality-improvement measures is a form of evidence that can be useful in making clinical practice decisions, but it is not a basic competency related to evidence-based practice. E) Appraising and integrating scientific bases into practice is one of the characteristics of the basic competencies related to evidence-based practice. Page Ref: 7 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values. | AACN Essentials Competencies: II. 5. Participate in quality and patient safety initiatives, recognizing that these are complex system issues, which involve individuals, families, groups, communities, populations and other members of the healthcare team. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify the impact of evidence-based practice in improving the quality of nursing care for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

26) Nursing research is vital to do which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Expand the science of nursing. B) Foster evidence-based practice. C) Improve client care. D) Visually depict nursing management. E) Plan and organize care. Answer: A, B, C Explanation: A) Research is vital to expanding the science of nursing. B) Research is vital to fostering evidence-based practice. C) Research is vital to improving client care. D) The nursing process is research-based, but is not a part of the clinical pathway. Visually depicting nursing management is part of concept mapping, not nursing research. E) Organizing patient care is an aspect of the nursing process. Planning and organizing care is part of nursing care plans, not nursing research. Page Ref: 11 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III. A. 7. Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences. | AACN Essentials Competencies: III. 5. Participate in the process of retrieval, appraisal and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Identify the impact of evidence-based practice in improving the quality of nursing care for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

27) A group of nurses are meeting as identified in the image below. Which behavior are the nurses demonstrating during this meeting?

A) Privacy B) Advocacy C) Collaboration D) Informed consent Answer: C Explanation: C) Collaborative practice is a comprehensive model of health care that uses a multidisciplinary team of health professionals to provide cost-effective, high-quality care. In a successful team, each individual has autonomy but functions within a clearly defined scope of practice. In such a collaborative approach, no single profession "owns the patient." The right to privacy is the right of a person to keep his or her person and property free from public scrutiny. Advocacy is ensuring a patient receives necessary and required support. Informed consent is a legal concept designed to allow patients to make intelligent decisions regarding their own health care. Page Ref: 7 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.B.9. 9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: VI.5. 5. Demonstrate appropriate teambuilding and collaborative strategies when working with interprofessional teams. | NLN Competencies: Relationship Centered Care; Practice; Share responsibility responsibly; collaborate and work cooperatively with others. | Nursing/Integrated Concepts: Assessment; Communication and Documentation. Learning Outcome: 3 Describe the use of community-based nursing care in meeting the needs of childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family. 27 Copyright © 2020 Pearson Education, Inc.

28) The nurse is reviewing the Quality and Safety Education for Nurses (QSEN) competencies while preparing an in-service program to address safety in the neonatal intensive care unit. In which order should the nurse present these competencies? 1. Safety 2. Informatics 3. Patient-centered care 4. Quality improvement 5. Evidence-based practice 6. Teamwork and collaboration Answer: 3, 6, 5, 4, 1, 2 Explanation: The Quality and Safety Education for Nurses (QSEN) project is designed "to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. The project focuses on competencies in six areas: 1. Patient-centered care, 2. Teamwork and collaboration; 3. Evidence-based practice; 4. Quality improvement; 5. Safety; and 6. Informatics. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring. | NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

29) The nurse is ensuring that a patient has provided informed consent before agreeing to an amniocentesis. In which order should the nurse validate that informed consent was provided by the patient? 1. Information provides risk and benefits 2. Information provided clearly and concisely 3. Information included treatment alternatives 4. Information explaining the right to refuse treatment 5. Information reviews consequences if no treatment provided Answer: 2, 1, 3, 5, 4 Explanation: Several elements must be addressed to ensure that the patient has given informed consent. The information must be clearly and concisely presented in a manner understandable to the patient and must include risks and benefits, the probability of success, and significant treatment alternatives. The patient also needs to be told the consequences of receiving no treatment or procedure. Finally, the patient must be told of the right to refuse a specific treatment or procedure. Each patient should be told that refusing the specified treatment or procedure does not result in the withdrawal of all support or care. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B. 12. Facilitate informed patient consent for care. | AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring. | NLN Competencies: Context and Environment; Knowledge; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Evaluation; Nursing Process. Learning Outcome: 5 Delineate significant legal and ethical issues that influence the practice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.

30) The nurse is preparing a presentation for new labor and delivery nurses. Which cultural group should the nurse identify as having the lowest birth rate for the 20 to 24 age range? Table 1-2 Birth Rate by Age and Race of Mother, 2011 American Indian Asian or Pacific Age All Races White Black or Alaska Native Islander 10-14 0.4 0.3 0.9 0.5 0.1 15-19 31.3 29.1 47.3 36.1 10.2 15-17 15.4 14.1 24.7 18.2 4.6 18-19 54.1 50.8 78.8 61.6 18.1 20-24 85.3 83 111.9 86.6 41.9 25-29 107.2 110 101.7 75.4 93.7 30-34 96.5 100.1 74.1 47.3 114.9 35-39 47.2 47.6 38.0 23.1 64.1 40-44 10.3 10.1 9.4 5.5 15.2 45-49 0.7 0.6 0.7 0.2 1.2 Source: Martin, J.A., Hamilton, B.E., Ventura, S.J., Osterman, M.J.K., & Matthews, T.J. (2013). Births: Final data 2011. National Vital Statistics Reports, 62(1), 1-70. A) Asian B) White C) Black D) American Indian Answer: A Explanation: A) For the 20 to 24 age group, the lowest birth rate is within the Asian or Pacific Islander cultural group. The birth rate for Whites for this age range is the next lowest. The birth rate for American Indians within this age group is the third highest and the highest birth rate for this age group is within the Black cultural group. Page Ref: 11-12 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: V. 6. Explore the impact of sociocultural, economic, legal and political factors influencing healthcare delivery and practice. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 6 Evaluate the potential impact of some of the special situations in contemporary maternity care. MNL LO: Recognize contemporary issues related to care of the childbearing family.

31) The manager of a maternal-child care area is preparing information to share with nursing staff regarding the leading causes of infant death in the United States. In which order, from most to least frequent, should the manager provide this information? 1. SIDS 2. Low birth weight 3. Unintentional injuries 4. Maternal complications 5. Congenital malformation Answer: 5, 2, 1, 4, 3 Explanation: The five leading causes of deaths of infants in the United States, from highest to lowest in frequency, are congenital malformations, low birth weight, SIDS, maternal complications, and unintentional injuries. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: V. 6. Explore the impact of sociocultural, economic, legal and political factors influencing healthcare delivery and practice. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 6 Evaluate the potential impact of some of the special situations in contemporary maternity care. MNL LO: Recognize contemporary issues related to care of the childbearing family.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 2 Families, Cultures, and Complementary Therapies 1) A couple who came to the United States two years ago with their two children are seeing the nurse in the community clinic. The nurse knows their family is acculturating when the mother makes which statement? A) "The children are much less well-behaved than they used to be." B) "Our diet now includes hamburgers and French fries." C) "We celebrate the same holidays that we used to at home." D) "When the children leave the house, I worry about them." Answer: B Explanation: A) Concern about behavior of the children is nearly universal, and is not an indicator of a family's acculturation. B) Inclusion of fast food in the diet is an indication of acculturation, because it shows a belief in the nutritional value of these foods and an acceptance of purchasing fast food as equivalent in value to home-cooked meals. C) The holidays that are celebrated might not change as a part of acculturation. D) Concern about the children leaving the home is universal, and is not an indicator of a family's acculturation. Page Ref: 20 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

2) Which of the following best describes a nuclear family? A) An unmarried woman who chooses to conceive or adopt without a life partner. B) Children live in a household with both biologic parents and no other relatives or persons. C) A couple shares household and childrearing responsibilities with parents, siblings, or other relatives. D) The head of the household is widowed, divorced, abandoned, separated, or most often, the mother remains unmarried. Answer: B Explanation: A) The single mother by choice family represents a family composed of an unmarried woman who chooses to conceive or adopt without a life partner. B) In the nuclear family, children live in a household with both biologic parents and no other relatives or persons. C) In an extended family, a couple shares household and childrearing responsibilities with parents, siblings, or other relatives. D) In the single-parent family, the head of the household is widowed, divorced, abandoned, separated, or most often, the mother remains unmarried. Page Ref: 17 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

3) What is the term for when children alternate between two homes, spending varying amounts of time with each parent in a situation called co-parenting and usually involving joint custody? A) Blended or reconstituted nuclear family B) Extended kin network family C) Binuclear family D) Extended family Answer: C Explanation: A) The blended or reconstituted nuclear family includes two parents with biologic children from a previous marriage or relationship who marry or cohabitate. B) An extended kin network family is a specific form of an extended family in which two nuclear families of primary or unmarried kin live in proximity to each other. C) A binuclear family is a post-divorce family in which the biologic children are members of two nuclear households, with parenting by both the father and the mother. D) In an extended family, a couple shares household and childrearing responsibilities with parents, siblings, or other relatives. Page Ref: 18 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

4) Duvall's eight stages in the family life cycle of a traditional nuclear family have been used as the foundation for contemporary models that describe the developmental processes and role expectations for different family types. Which of the following is an example of Stage IV of this family life cycle? A) Families launching young adults (all children leave home) B) Families with preschool-age children (oldest child is between 2.5 and 6 years of age) C) Middle-aged parents (empty nest through retirement) D) Families with schoolchildren (oldest child is between 6 and 13 years of age) Answer: D Explanation: A) Stage VI is families launching young adults (all children leave home). B) Stage III is families with preschool-age children (oldest child is between 2.5 and 6 years of age). C) Stage VII is middle-aged parents (empty nest through retirement). D) Stage IV is families with schoolchildren (oldest child is between 6 and 13 years of age). Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the stages of a family life cycle. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

5) A 7-year-old client tells the nurse that "Grandpa, Mommy, Daddy, and my brother live at my house." The nurse identifies this as what type of family? A) Binuclear B) Extended C) Gay or lesbian D) Traditional Answer: B Explanation: A) A binuclear family includes divorced parents with joint custody of their biologic children, who alternate spending varying amounts of time in the home of each parent. B) An extended family consists of a couple who share the house with their parents, siblings, or other relatives. C) A gay or lesbian family is composed of two same-sex domestic partners; they might not have children. D) The traditional nuclear family consists of a husband provider, a wife who stays home, and the biologic children of this union. Page Ref: 17 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

6) A nurse is performing an assessment on a family with a father and mother who both work. What type of family does she record this family as being? A) A traditional nuclear family B) A dual-career/dual-earner family C) An extended family D) An extended kin family Answer: B Explanation: A) The traditional nuclear family is defined as a husband provider, a wife who stays home, and children. B) A dual-career/dual-earner family is characterized by both parents working, either by choice or necessity. C) An extended family is defined as a couple who share household and childrearing responsibilities with parents, siblings, or other relatives. D) An extended kin family is a specific form of an extended family in which two nuclear families of primary or unmarried kin live in close proximity to each other. Page Ref: 17 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

7) Why is it important for the nurse to understand the type of family that a client comes from? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Family structure can influence finances. B) Some families choose to conceive or adopt without a life partner. C) The nurse can anticipate which problems a client will experience based on the type of family the client has. D) Understanding if the client's family is nuclear or blended will help the nurse teach the client the appropriate information. E) The values of the family will be predictable if the nurse knows what type of family the client is a part of. Answer: A, B Explanation: A) Single-parent families often face difficulties because the sole parent may lack social and emotional support, need assistance with childrearing issues, and face financial strain. B) In the single mother by choice family, the mother is typically older, college-educated, and financially stable and has contemplated pregnancy significantly prior to conceiving. C) Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided. D) Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided. E) Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided. Page Ref: 17—19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

8) The public health nurse is working with a student nurse. The student nurse asks which of the six groups of people they have seen today are considered to be families. How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "The married heterosexual couple without children" B) "The gay couple with two adopted children" C) "The unmarried heterosexual couple with two biological children" D) "The lesbian couple not living together that have no children" E) "The married heterosexual couple with three children, living with grandparents" Answer: A, B, C, E Explanation: A) Families take many forms in today's society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. A couple without children is still a family. B) Families take many forms in today's society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. Gay and lesbian families are those in which two or more people who share a same-sex orientation live together, or in which a gay or lesbian single parent rears a child. C) Families take many forms in today's society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. A family may be formed without a legal marriage. D) A couple not living together and without children together are considered dating and not yet a family. E) Families take many forms in today's society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. Extended family members, including parents or grandparents, will often live with their adult children or grandchildren, creating intergenerational families. Page Ref: 17 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. C. 5. Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Demonstrate self-awareness, self-care, self-growth, be open and nonjudgmental. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

9) In assessing a new family coming to the clinic, the nurse determines they are an extended kin family because the family exhibits what as characteristics of an extended kin network family? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) A sharing of a social support network B) Each family establishes their own sources of goods and services C) Elderly parents share housing D) Children are members of two nuclear families E) A sharing of goods and services Answer: A, E Explanation: A) Extended kin family networks share a social support network. B) Extended kin family networks share goods and services, rather than establishing their own sources of goods and services. C) Elderly parents sharing a household is a feature of the extended family system. D) Children being members of two nuclear families applies to the binuclear family. E) Extended kin family networks share goods and services. Page Ref: 17 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: RelationshipCentered Care: Demonstrate self-awareness, self-care, self-growth; be open and non-judgmental. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

10) The transcultural nursing theory was developed in 1961 by Dr. Madeleine Leininger. Its foundation is in which of the following? A) The framework categorizes a family's progression over time B) The family life cycle of a traditional nuclear family C) Anthropology and nursing D) Holistic health beliefs Answer: C Explanation: A) Family development theories use a framework to categorize a family's progression over time according to specific, typical stages in family life. B) Duvall's eight stages is the foundation of the family life cycle of a traditional nuclear family. C) Transcultural nursing theory is rooted in caring that embraces the beliefs and practices of individuals or groups of similar or different cultures. D) An example of a holistic health belief is the hot and cold theory of disease. Page Ref: 19 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Identify prevalent cultural norms related to childbearing and childrearing. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

11) The nurse is preparing a community presentation on family development. Which statement should the nurse include? A) The youngest child determines the family's current stage. B) A family does not experience overlapping of stages. C) Family development ends when the youngest child leaves home. D) The stages describe the family's progression over time. Answer: D Explanation: A) The youngest child is not a marker for which stage the family is in. B) Families with more than one child can experience multiple stages simultaneously. C) Families' development continues after the youngest child leaves home. D) Family development stages describe the changes and adaptations that a family goes through over time as children are added to the family. Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the stages of a family life cycle. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

12) In learning about Duvall's life-cycle stages ascribed to traditional families, the nursing student recognizes that developmental tasks of each stage include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Adjusting to new roles as mother and father B) Working out authority and socialization roles with the school C) Becoming a single parent with custodial responsibilities D) Becoming a couple and dating E) Adjusting to the loss of a spouse Answer: A, B, E Explanation: A) Adjusting to new roles as mother and father occurs in Stage II, which describes childbearing families with infants. B) Working out authority and socialization roles with schools occurs in Stage IV, which describes families with school-age children. C) Traditional family life-cycle stages do not include those in which divorce occurs. D) Becoming a couple and dating occurs before marriage, and is not a part of the traditional family life-cycle stages. E) Stage VIII includes adjusting to the loss of a spouse. Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the stages of a family life cycle. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

13) The nurse is planning a community education program on the role of complementary and alternative therapies during pregnancy. Which statement about alternative and complementary therapies should the nurse include? A) "They bring about cures for illnesses and diseases." B) "They are invasive but effective for achieving health." C) "They emphasize prevention and wellness." D) "They prevent pregnancy complications." Answer: C Explanation: A) These therapies emphasize prevention and wellness, aiming for holistic health rather than cure or treatment. B) Most alternative and complimentary therapies are noninvasive. The only ones that are invasive are acupuncture, herbs, and foods. C) Complementary and alternative therapies have many benefits during pregnancy. They emphasize prevention and wellness, aiming for holistic health rather than cure or treatment. D) No method of treatment can prevent all pregnancy complications. Page Ref: 27—30 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: II. A. 2. Describe scopes of practice and roles of health care team members. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Teamwork: Contribution of other individuals and groups in helping patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Differentiate between complementary and alternative therapies. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

14) The nurse is preparing to assess the development of a family new to the clinic. The nurse understands that which of the following is the primary use of a family assessment tool? A) Obtain a comprehensive medical history of family members. B) Determine to which clinic the client should be referred. C) Predict how a family will likely change with the addition of children. D) Understand the physical, emotional, and spiritual needs of members. Answer: D Explanation: A) The medical history is one area that is explored using a family assessment tool, but it is not the primary use of the family assessment. B) Although referrals might take place as a result of the family assessment findings, this is not the primary purpose of the assessment. C) Family development models help predict how a family will likely change with the addition of children. D) Understanding the physical, emotional, and spiritual needs of members is the main reason for using a family assessment tool. Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

15) The nurse in the community should use a family assessment tool to obtain what type of information? A) How long the family has lived at its current address B) What other health insurance the family has had in the past C) How the family meets its nutritional needs and obtains food D) What eye color the family desires in its unborn child Answer: C Explanation: A) The length of time at a residence is not included in the family assessment tool. B) Past health insurance coverage is not included in the family assessment tool. C) A family assessment is a collection of data about the family's type and structure, current level of functioning, support system, sociocultural background, environment, and needs. D) Desired eye color of a child is not included in the family assessment tool. Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: VI. A. 2. Identify essential information that must be available in a common database to support patient care. | AACN Essentials Competencies: IV. 7. Recognize the role of information technology in improving patient care outcomes and creating a safe care environment. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

16) In assessing a family, the community nurse uses a family assessment tool, which provides an organized framework to collect data concerning which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Access to laundry and grocery facilities B) Access to health care C) Sharing of religious beliefs and values D) Acculturation to traditional lifestyles E) Ability to include a new spouse into the family unit Answer: A, B, C Explanation: A) Measuring access to laundry, grocery, and recreational facilities that meet the physical, emotional, and spiritual needs of members is part of the family assessment tool. B) Measuring access to healthcare that meets the physical, emotional, and spiritual needs of members is part of the family assessment tool. C) Learning about shared religious beliefs and values, which meet the physical, emotional, and spiritual needs of members, is part of the family assessment tool. D) Acculturation to traditional lifestyles is not measured with the family assessment tool. E) The ability to include a new spouse into the family unit is a developmental task/stage of those who are divorced, and is not a part of the family assessment tool. Page Ref: 19 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: VI. B. 1. Seek education about how information is managed in care settings before providing care. | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing care. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

17) The nurse is assessing a client who reports seeing an acupuncturist on a weekly basis to treat back pain. The nurse understands that acupuncture is an example of what? A) A risky practice without evidence of efficacy B) A folk remedy C) A complementary therapy D) An alternative therapy Answer: C Explanation: A) Acupuncture has been used in traditional Chinese medicine for over 3000 years. Good evidence is available on the efficacy of acupuncture for treatment of chronic pain. B) A folk remedy is a practice of a cultural group that either has no evidence to support efficacy or has been found not to have an effect. C) Acupuncture is a therapy that is used in conjunction with conventional medical treatment, and therefore is an example of a complementary therapy. D) Acupuncture is not categorized as an alternative therapy, because it is used in conjunction with conventional medical treatment. Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: II. A. 2. Describe scope of practice and roles of health care team members. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care. | NLN Competencies: Teamwork: Contribution of other individuals and groups in helping patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 7 Differentiate between complementary and alternative therapies. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

18) In working with immigrants in an inner-city setting, the nurse recognizes that acculturation of immigrants often brings with it which of the following benefits? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Improved socioeconomic status B) Use of preventive care services C) Better nutrition D) Increase in substance abuse over time E) More physician visits due to language barriers Answer: A, B, C Explanation: A) Improvement of socioeconomic status is a benefit of acculturation in the United States. B) Acculturation of immigrants increases the likelihood that the family members will use preventive health services. C) Improved socioeconomic status leads to better nutrition and access to health care. D) Substance abuse tends to increase over time as immigrants acculturate, especially among Hispanics. E) Language barriers with physicians tend to decrease the use of healthcare services. Page Ref: 20 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Identify prevalent cultural norms related to childbearing and childrearing. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

19) The nurse is caring for a postpartal client of Hmong descent who immigrated to the United States 5 years ago. The client asks for the regular hospital menu because American food tastes best. The nurse assesses this response to be related to which of the following cultural concepts? A) Acculturation B) Ethnocentrism C) Enculturation D) Stereotyping Answer: A Explanation: A) Acculturation (assimilation) is the correct assessment because the client adapted to a new cultural norm in terms of food choices. B) Ethnocentrism refers to a social identity that is associated with shared behaviors and patterns. C) Enculturation occurs when culture is learned and passed on from generation to generation, and often happens when a group is isolated. D) Stereotyping is the assumption that all members of a group have the same characteristics. Page Ref: 20 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Identify prevalent cultural norms related to childbearing and childrearing. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

20) The nurse is teaching a community education class on complementary and alternative therapies. To assess learning, the nurse asks, "In traditional Chinese medicine, what is the invisible flow of energy in the body that maintains health and ensures physiologic functioning?" Which answer indicates that teaching was successful? A) Meridians B) Chi C) Yin D) Yang Answer: B Explanation: A) Meridians are the 14 pathways along which energy flows, connecting all parts of the body. B) Chi is the energy that flows through the body along meridians, or pathways, to maintain health. C) Yin and yang are opposites. Yin is the female force: passive, cool, wet, and close to the earth. D) Yin and yang are opposites. Yang is the masculine force: aggressive, hot, dry, and celestial. Page Ref: 28 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Differentiate between complementary and alternative therapies. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

21) During the assessment phase of a family, the community nurse recognizes that culture influences childrearing and childbearing in which of the following ways? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Beliefs about the importance of children B) Beliefs and attitudes about pregnancy C) Norms regarding infant feeding D) Acculturation is important in rearing children E) Time orientation to the future is very important Answer: A, B, C Explanation: A) Culture influences beliefs about the importance of children. B) Culture influences attitudes about pregnancy and the right vs. the obligation of women to bear children. C) Culture influences infant feeding norms and practices. D) Acculturation is not important in rearing children. E) Time orientation is a cultural difference and can emphasize the past, present, or future. It does not influence childbearing and childrearing. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. C. 1. Value seeing health care situations "through patient's eyes." | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Affirm and value diversity. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Identify prevalent cultural norms related to childbearing and childrearing. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

22) The nurse is teaching a class to the community on mind-based therapies. A class participant gives an example of a friend with leukemia who was taught by her complementary therapist to concentrate on making antibodies that will fight and kill the cancer cells in the bloodstream. How would the nurse identify this technique? A) Guided imagery B) Qigong C) Biofeedback D) Homeopathy Answer: A Explanation: A) Guided imagery is a state of intense, focused concentration used to create compelling mental images and is useful in imagining a desired effect. B) Qigong involves the use of breathing, meditation, self-massage, and movement. C) Biofeedback is learning to control physiologic responses to stimuli or thoughts. D) Homeopathy is not a mind-body therapy, but uses the concept of like curing like. Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 6. Describe strategies to empower patients or families in all aspects of the health care process. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and selfdetermination and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Summarize the benefits and risks of complementary health approaches. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

23) The nurse is admitting a Hispanic woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask? A) "What other treatments have you used for your abdominal pain?" B) "In what country were you were born?" C) "When you talk to family members, how close do you stand?" D) "How would you describe your role within your family?" Answer: A Explanation: A) Knowing what other treatments the client has used for pain is most important because some traditional or folk remedies include the use of herbs, which can have medication interactions. B) Although information about the country of birth is helpful, it is not a physiological issue. Asking other questions is a higher priority. C) Although understanding the client's perception of appropriate personal space is helpful, it is not a physiological issue. Asking other questions is a higher priority. D) Although understanding the client's family roles is helpful, it is not a physiological issue. Asking other questions is a higher priority. Page Ref: 21 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups and communities, and populations. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Summarize the importance of cultural competency in providing nursing care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

24) The nurse works in a facility that cares for clients from a broad range of racial, ethnic, cultural, and religious backgrounds. Which statement should the nurse include in a presentation to recently hired nurses on the client population of the facility? A) "Our clients come from a broad range of backgrounds, but we have a good interpreter service." B) "Many of our clients come from backgrounds different from your own, but it doesn't cause problems for the nurses." C) "Because most of the doctors are bilingual, we don't have to deal with the differences in cultural backgrounds of our clients." D) "Understanding the common values and health practices of our diverse clients will facilitate better care and health outcomes." Answer: D Explanation: A) The role of a foreign language interpreter is to facilitate communication. The interpreter might not be able to interpret the cultural practices of clients. An example is a Spanish interpreter: The interpreter might be from Spain, but interprets language for clients from Guatemala and Nicaragua, countries about which the interpreter might know virtually nothing. B) Racial, ethnic, cultural, and religious backgrounds of clients have significant implications for how the clients perceive health, illness, and health care. It is important for nurses to understand the backgrounds of the client population that attends that facility. C) Bilingual physicians, like all physicians, have very busy schedules, and often do not understand nursing care. It is the responsibility of the nurse to become familiar with the backgrounds of the client population. D) Because of the implications for care based on cultural background, it is important for nurses to understand the backgrounds of the client population that accesses the facility. Without cultural awareness, caregivers tend to project their own cultural responses onto foreign-born clients; clients from different socioeconomic, religious, or educational groups; or clients from different regions of the country. Page Ref: 21—22 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: RelationshipCentered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Summarize the importance of cultural competency in providing nursing care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

25) The nurse manager in a hospital with a large immigrant population is planning an in-service. Aware of how ethnocentrism affects nursing care, the nurse manager asks, "The belief that one's own values and beliefs are the only or the best values has which of the following results?" A) It implies newcomers to the United States should adopt the norms and values of the country. B) It can create barriers to communication through misunderstanding. C) It leads to an expectation that all clients will exhibit pain the same way. D) It improves the quality of care provided to culturally diverse client bases. Answer: B Explanation: A) Although acculturation involves adoption of some of the majority culture's practices and beliefs, each cultural group will continue to hold and express its own set of values and beliefs. B) When the nurse assumes that a client has the same values and beliefs as the nurse, misunderstanding will frequently occur, which in turn can negatively impact nurse-client communication. Ethnocentrism is the conviction that the values and beliefs of one's own cultural group are the best or only acceptable ones. C) Expression of pain is one area that varies greatly from one culture to another. D) The belief that one's own values and beliefs are the best will not improve the quality of care provided to culturally diverse client bases. Page Ref: 24 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I. C. 1. Value seeing health care situation "through patients' eyes." | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Summarize the importance of cultural competency in providing nursing care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

26) The client reports using an alternative therapy that involves the manipulation of soft tissues. This therapy has reduced the client's stress, diminished pain, and increased circulation. Which therapy has this client most likely received? A) Guided imagery B) Homeopathy C) Massage therapy D) Reflexology Answer: C Explanation: A) Guided imagery involves picturing a desired outcome. B) Homeopathy uses the concept of like curing like. C) Massage therapy involves the manipulation of soft tissues. D) Reflexology is the application of pressure to designated points or reflexes on the client's feet, hands, or ears using the thumb and fingers. Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 2. Communicate patient values, preferences, and expressed needs to other members of the health care team. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care. | NLN Competencies: Relationship-centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Summarize the benefits and risks of complementary health approaches. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

27) A nurse is working in a clinic where clients from several cultures are seen. As a first step toward the goal of personal cultural competence, the nurse will do which of the following? A) Enhance cultural skills. B) Gain cultural awareness. C) Seek cultural encounters. D) Acquire cultural knowledge. Answer: B Explanation: A) Ways to enhance cultural skill include learning a prevalent language and learning how to recognize health-manifesting skin color variations in different races. B) One begins to gain cultural competence by gaining cultural awareness or by gaining an effective and cognitive self-awareness of personal worldview biases, beliefs, etc. C) During daily interactions with clients from diverse backgrounds, these cultural encounters allow the nurse to appreciate the uniqueness of individuals from varying backgrounds. D) Another early step, although not the first step, is acquiring cultural knowledge, and includes studying information about the beliefs, biological variations, and favored treatments of specific cultural groups. Page Ref: 23 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care. | NLN Competencies: Relationship-centered Care: Communicate information effectively: listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Summarize the importance of cultural competency in providing nursing care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

28) When teaching a culturally diverse group of childbearing families about hospital birthing options, the culturally competent nurse does which of the following? A) Understands that the families have the same values as the nurse B) Teaches the families how childbearing takes place in the United States C) Insists that the clients answer questions instead of their husbands D) Incorporates the specific beliefs of the cultural groups that are attending the class Answer: D Explanation: A) Assuming that the families have the same values as the nurse is ethnocentrism. B) Although it is important to explain health care during pregnancy and childbearing, this is not the top priority. C) The husband's answering questions might be a cultural norm, and insisting that the client answer could decrease the family's trust in the healthcare system. D) Providing culturally competent care involves recognizing the importance of the childbearing family's value system, acknowledging that differences occur among people, and respecting and responding to ethnic diversity in a way that leads to mutually desirable outcomes. Page Ref: 23 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care. | NLN Competencies: Relationship-centered Care: Communicate information effectively: listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Summarize the importance of cultural competency in providing nursing care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

29) Which questions are appropriate for the nurse to ask during a cultural assessment of a client who is new to the clinic? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) What genetic and other biological differences affect caregiving? B) Which family member must be consulted for decisions about care? C) What type of healthcare provider is the most appropriate? D) Does the client have beliefs or traditions that might impact the care plan? E) Are communications patterns established? Answer: B, C, D Explanation: A) Genetic and biological differences are health concerns, such as hypertension that the nurse must keep in mind, but the nurse would not ask about genetic and biological differences during a cultural assessment. B) It is important that the nurse recognize cultural differences in regard to which family member must be consulted for decisions about care. C) Some cultures do not allow a person of the opposite sex to touch the client. Cultural sensitivity will recognize and allow for this. D) The nurse must be aware of traditions and beliefs that might impact the care plan. E) Communication patterns will have been established. The nurse must be able to communicate with the client, using the patterns of communication the client uses. Page Ref: 27 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care. | NLN Competencies: Relationship-centered Care: Communicate information effectively: listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Summarize the importance of cultural competency in providing nursing care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

30) The nurse is working with a client whose religious beliefs differ from those of the general population. What is the best nursing intervention to use to meet the specific spiritual needs of this family? A) Ask how important the client's religious and spiritual beliefs are when making decisions about health care. B) Show respect while allowing time and privacy for religious rituals. C) Ask for the client's opinion on what caused the illness. D) Identify healthcare practices forbidden by religious or spiritual beliefs. Answer: B Explanation: A) Considering the impact of religious and spiritual beliefs might be part of the spiritual assessment process but is not an intervention. B) Providing spiritually sensitive care involves determining the current spiritual and religious beliefs and practices that will affect the mother and baby, accommodating these practices where possible, and examining one's own spiritual or religious beliefs to be more aware and able to provide nonjudgmental care. C) Asking what caused the client's illness is not an intervention, and does nothing to meet the spiritual needs specific to the family. D) Identifying what health practices might be forbidden by the family's beliefs might be part of the spiritual assessment process, but is not an intervention. Page Ref: 22—23 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Religious and Spiritual Influences on Health Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed need. | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify key considerations in providing spiritually sensitive care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

31) The labor and delivery nurse is caring for a laboring client who has asked for a priest to visit her during labor. The client's mother died during childbirth, and although there were no complications during her pregnancy, the client is fearful of her own death during labor. What would be the best way for the nurse to respond? A) "Nothing is going to happen to you. We'll take very good care of you during your birth." B) "Would you like to have an epidural so that you won't feel the pain of the contractions?" C) "The priest won't be able to prevent complications, and might get in the way of your providers." D) "Would you like me to contact someone from your parish or our hospital chaplain to come see you?" Answer: D Explanation: A) Avoid statements of reassurance, as there are no guarantees of outcome during health care. Using such statements shuts down effective communication because the client's concern is downplayed. B) The client's expressed concern is not about pain; it is a fear of death and a desire to see a priest. The nurse should address the client's concern directly. C) Although this statement is true, it is not therapeutic. It downplays the client's concerns, and will shut down effective communication. The nurse should address the concerns the client expresses. D) Providing spiritually sensitive care involves determining the current spiritual and religious beliefs and practices that will affect the mother and baby and accommodating these practices where possible. Page Ref: 26 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Religious and Spiritual Influences on Health Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed need. | AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Identify key considerations in providing spiritually sensitive care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

32) The client reports relief from headaches when she rubs the temples on each side of her head. The nurse understands that this is a form of which of the following? A) Acupressure B) Acupuncture C) Reflexology D) Hydrotherapy Answer: A Explanation: A) Acupressure uses pressure from the fingers and thumbs to stimulate pressure points to relieve symptoms. B) Acupuncture uses 6-12 very fine stainless steel needles to stimulate specific points, depending on the client's medical assessment and condition. C) Reflexology is a form of massage that involves the application of pressure to designated points or reflexes on the client's feet, hands, or ears using the thumb and fingers. D) Hydrotherapy is therapy that makes use of hot or cold moisture in any form. Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 2. Describe strategies to empower patients or families in all aspects of the health care process. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health and illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Summarize the benefits and risks of complementary health approaches. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

33) The nurse is reviewing a list of families scheduled for community health visits. To visit these families according to the family life cycle each is in, in which order from first to last should the nurse visit these families? 1. Family with a 12-month-old child 2. Family whose oldest child is in the 5th grade 3. Family whose oldest child is attending college 4. Family whose youngest child just got a driver's license 5. Family whose youngest child got married last weekend 6. Family whose male partner retired from full-time employment Answer: 1, 2, 4, 3, 5, 6 Explanation: According to the family life cycle stages, the family with a 12-month-old child would be seen first. The family with the oldest child in 5th grade would be seen second. Third, the family with the oldest child in college would be seen. The fourth family seen should be the one with the child who just received a driver's license. The fifth family would be the one whose youngest child was married the previous weekend. And the last family would be the one with a new retiree. Page Ref: 19 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Planning; Nursing Process. Learning Outcome: 2 Identify the stages of a family life cycle. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

34) The community nurse is planning to visit a family. The grandparents are helping the adult parents with child-rearing activities. For which type of family should the nurse plan care? A) Nuclear B) Blended C) Binuclear D) Extended Answer: D Explanation: D) In an extended family, a couple shares household and childrearing responsibilities with parents, siblings, or other relatives. Families may reside together to share housing expenses and child care. In many cases, a child may be residing with a grandparent and one parent because of issues associated with unemployment, parental separation, parental death, or parental substance abuse. Grandparents may raise children due to the inability of parents to care for their own children. In the nuclear family, children live in a household with both biologic parents and no other relatives or persons. The blended family includes two parents with biologic children from a previous marriage or relationship who marry or cohabitate. A binuclear family is a post-divorce family in which the biologic children are members of two nuclear households, with parenting by both the father and the mother. Page Ref: 17 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Planning; Nursing Process. Learning Outcome: 1 Compare the characteristics of different types of families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

35) A pregnant patient from a culture that treats hot and cold conditions with food is experiencing a severe lower back ache. According to the table shown here, which food should the nurse provide to help this patient? Table 2-2 Hot and Cold Conditions and Foods Cold Food Used to Hot Food Used to Hot Condition Treat Hot Condition Cold Condition Treat Cold Condition Diarrhea Barley water Cancer Beef Fever Chicken Earaches Cheese Constipation Dairy products Headaches Eggs Infection Raisins Musculoskeletal Grains (other than conditions barley) Kidney problems Fish Pneumonia Liquor Liver conditions Cucumber Menstrual cramps Pork Sore throats Fresh fruits Malaria Onions Stomach ulcers Fresh vegetables Arthritis Spicy foods Goat meat Rhinitis Chocolate Colic Warm water and honey Source: Data from Purnell, L.D. (2009). Guide to culturally competent health care. Philadelphia, PA: F.A. Davis; Purnell, L.D. (2013). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis; Spector, R.E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson. A) Green salad B) Glass of milk C) String cheese D) Sliced orange Answer: C Explanation: C) A back ache is a cold musculoskeletal condition and should be treated with a hot food such as string cheese. Salad, milk, and oranges are cold foods and would not be appropriate to treat a cold condition. Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Implementation; Nursing Process. Learning Outcome: 5 Discuss the use of a cultural assessment tool as a means of providing culturally sensitive care. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

36) A pregnant patient is attending a class to learn the movements identified in the following photo. What is the primary reason for the patient to learn these movements?

A) Stimulate the flow of chi B) Stimulate pressure points C) Mind control over the body D) Correct spinal misalignment Answer: A Explanation: A) The patient is practicing Qi gong, which is designed to stimulate the flow of chi. Acupressure uses pressure from the fingers and thumbs to stimulate pressure points. Biofeedback is a method used to help individuals learn to control their physiologic responses based on the concept that the mind controls the body. Chiropractic is based on concepts of manipulation to address health problems that are thought to be the result of abnormal nerve transmissions (subluxation) caused by misalignment of the spine. Page Ref: 29 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Planning; Nursing Process. Learning Outcome: 7 Differentiate between complementary and alternative therapies. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

37) During a home visit the nurse observes a new mother performing the following action. What should the nurse document that the mother is doing with the child?

A) Massage B) Acupressure C) Biofeedback D) Moxibustion Answer: A Explanation: A) Infant massage is also growing in popularity in the United States, and many parents have learned to massage their infants and young children. Acupressure uses pressure from the fingers and thumbs to stimulate pressure points. Biofeedback is a method used to help individuals learn to control their physiologic responses based on the concept that the mind controls the body. Moxibustion involves the application of heat from a small piece of burning herb called moxa (Artemisia vulgaris). Page Ref: 30 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person's development. Nursing/Integrated Concepts: Assessment; Communication and Documentation. Learning Outcome: 9 Describe complementary therapies appropriate for the nurse to use with childbearing and childrearing families. MNL LO: Demonstrate ability to incorporate culturally competent care for patients and families.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 3 Health Promotion 1) The clinic nurse is returning phone calls. Which call should the nurse return first? A) The call from a 22-year-old reporting that she has menstrual cramps and vomiting every month B) The call from a 17-year-old asking whether there is a problem with using one tampon for a whole day C) The call from a 46-year-old mother of a teen wondering if her daughter should be on birth control D) The call from a 34-year-old requesting information on douching after intercourse Answer: B Explanation: A) Because vomiting can lead to dehydration, this client is not completely normal or stable, but is not the top priority. B) Using a single tampon for an entire day can lead to toxic shock syndrome, a potentially lifethreatening condition. This client needs education on the danger of using one tampon longer than 3-6 hours. C) A sexually active teen could be at risk for unintended pregnancy, as well as sexually transmitted infections. However, it is unclear whether the daughter is sexually active. This call is a low priority. D) This client requires education, but is not a top priority. Page Ref: 37 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts Nursing Process: Implementation. Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

2) The nurse who is taking a sexual history from a client should do which of the following? A) Ask questions that the client can answer with "yes" or "no." B) Ask mostly open-ended questions. C) Have the client fill out a comprehensive questionnaire and review it after the client leaves. D) Try not to make much direct eye contact. Answer: B Explanation: A) Open-ended questions are often useful in eliciting information. Yes-or-no answers will not provide the necessary information. B) Open-ended questions are often useful in eliciting information. C) Asking a client to fill out a questionnaire about sexual history is not appropriate. D) It is helpful to use direct eye contact as much as possible, unless culturally unacceptable. Page Ref: 36 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: RelationshipCentered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

3) A client asks her nurse, "Is it okay for me to take a tub bath during the heavy part of my menstruation?" What is the nurse's correct response? A) "Tub baths are contraindicated during menstruation." B) "You should shower and douche daily instead." C) "Either a bath or a shower is fine at that time." D) "You should bathe and use a feminine deodorant spray during menstruation." Answer: C Explanation: A) Bathing in a tub is not contraindicated during menses. B) Douching should be avoided during menstruation. C) Bathing, whether it is a tub bath or a shower, is as important (if not more so) during menses as at any other time. D) Bathing is as important (if not more so) during menses as at any other time, but feminine deodorant sprays are unnecessary. Page Ref: 38 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 6. Use information and communication technologies in preventive care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

4) Which client would the nurse document as exhibiting signs and symptoms of primary dysmenorrhea? A) 17-year-old, has never had a menstrual cycle B) 16-year-old, had regular menses for 4 years, but has had no menses in 4 months C) 19-year-old, regular menses for 5 years that have suddenly become painful D) 14-year-old, irregular menses for 1 year, experiences cramping every cycle Answer: D Explanation: A) This is primary amenorrhea, or the lack of menses. B) Secondary amenorrhea is the term used when a client has had regular cycles that cease. C) Secondary dysmenorrhea is the sudden onset of pain and discomfort with menses. D) Dysmenorrhea, or painful menstruation, occurs at, or a day before, the onset of menstruation and disappears by the end of menses. Primary dysmenorrhea is defined as cramps without underlying disease. Page Ref: 39 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

5) The nurse is interviewing an adolescent client. The client reports a weight loss of 50 pounds over the last 4 months, and reports running at least 5 miles per day. The client asserts that her menarche was 5 years ago. Her menses are usually every 28 days, but her last menstrual period was 4 months ago. The client denies any sexual activity. Which is the best statement for the nurse to make? A) "Your lack of menses might be related to your rapid weight loss." B) "It is common and normal for runners to stop having any menses." C) "Increase your intake of iron-rich foods to reestablish menses." D) "Adolescents rarely have regular menses, even if they used to be regular." Answer: A Explanation: A) Secondary amenorrhea can be caused by rapid weight loss, including the development of the eating disorders anorexia and bulimia. Runners with low body fat might have irregular menses, but amenorrhea is not a normal condition. B) It is common for runners to have amenorrhea, but it is not normal. C) Iron deficiency does not impact menstrual regularity. D) Although the first year or two after menarche might be characterized by irregular menses, once menses are established and regular, a lack of menses is secondary amenorrhea. Page Ref: 38 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Identify causes of amenorrhea. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

6) A client comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for 2 years. What is the most likely cause for the client's complaint? A) Primary dysmenorrhea B) Secondary dysmenorrhea C) Menorrhagia D) Hypermenorrhea Answer: B Explanation: A) Primary dysmenorrhea is defined as cramps without underlying disease. B) Secondary dysmenorrhea is associated with pathology of the reproductive tract, and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device. C) Menorrhagia is excessive, profuse menstrual flow. D) Hypermenorrhea is an abnormally long menstrual flow. Page Ref: 39 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

7) The nurse is teaching a group of women about menopause at a community clinic. The nurse tells them that the best indicator of menopause is which of the following symptoms? A) No menses for 8 consecutive months B) Hot flashes and night sweats C) FSH levels rise and ovarian follicles cease to produce estrogen D) Diagnosed with osteoporosis 4 months ago Answer: C Explanation: A) Eight consecutive months of amenorrhea are enough to qualify as menopause. B) Although hot flashes and night sweats are common in menopause, they are not the most reliable indicator of menopause. C) Examining FSH and estrogen levels is a very accurate indication of menopause. D) Menopause is not the only cause of osteoporosis; therefore, the diagnosis of osteoporosis 4 months ago is not an indicator of menopause. Page Ref: 43 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

8) A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend which of the following? A) Petroleum jelly B) A water-soluble lubricant C) Body cream or body lotion D) Less-frequent intercourse Answer: B Explanation: A) Petroleum jelly is not a healthy choice for vaginal lubrication. B) A water-soluble jelly should be used. C) Body creams and body lotions are not healthy choices for vaginal lubrication. D) "Less-frequent intercourse" is an inappropriate response. Page Ref: 49 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

9) A 49-year-old client comes to the clinic with complaints of severe perimenopausal symptoms including hot flashes, night sweats, urinary urgency, and vaginal dryness. The physician has prescribed a combination hormone replacement therapy of estrogen and progestin. When the client asks the nurse why she must take both hormones, what is the nurse's best reply? A) "Hot flashes respond better when replacement includes both hormones." B) "You are having very severe symptoms, so you need more hormones replaced." C) "There is an increased risk of tissue abnormality inside the uterus if only one is given." D) "Your blood pressure can become elevated if only one hormone is used." Answer: C Explanation: A) Estrogen, not progestin, improves hot flashes and most other perimenopausal symptoms. B) The severity of symptoms will be considered by the physician in determining the appropriate dose for the client. C) Estrogen alone, in a woman with a uterus (unopposed estrogen), increases the risk of endometrial (the lining of the uterus) cancer by eightfold and, therefore, is never given without progesterone in these women. D) Estrogen therapy does not cause hypertension. Page Ref: 46—47 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

10) A female patient with amenorrhea is suspected to have pituitary dysfunction. For which health problems should the nurse explain that the patient will most likely be evaluated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cancer 2. Adenoma 3. Head trauma 4. Turner syndrome 5. Polycystic ovarian syndrome Answer: 1, 2, 3 Explanation: In pituitary dysfunction, cancer and head trauma can cause hypopituitarism. A pituitary adenoma can cause changes in the hormones that the pituitary gland manufactures. Turner syndrome is a genetic disorder that is linked to chronic anovulation or ovarian failure. Polycystic ovarian syndrome is a cause of chronic anovulation. Page Ref: 38 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Context and Environment; Knowledge; chronic disease management. | Nursing/Integrated Concepts: Planning; Nursing Process. Learning Outcome: 3 Identify causes of amenorrhea. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

11) A patient in her late 40s asks the nurse what she should expect when entering menopause. In which order should the nurse identify changes that the patient will experience during menopause? 1. Amenorrhea 2. Anovulation 3. Reduced fertility 4. Changes in menstrual flow 5. Menstrual cycle irregularities Answer: 2, 3, 4, 5, 1 Explanation: Beginning 2 to 8 years before menopause, women experience episodes of anovulation, reduced fertility, decreased or increased menstrual flow, menstrual cycle irregularities, and then, ultimately, amenorrhea. Page Ref: 44—45 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

12) A female patient experiencing menopause is concerned that periodic lapses of memory are symptoms of Alzheimer disease. What should the nurse review with the patient to reduce the risk of developing Alzheimer disease (AD)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increase rest 2. Stop smoking 3. Exercise regularly 4. Eat a healthy diet 5. Maintain mental activity Answer: 2, 3, 4, 5 Explanation: Lifestyle practices may help prevent AD include smoking cessation, regular exercise of at least 30 minutes 5 days a week, eating a healthy diet, and remaining mentally active. Increased rest does not help prevent AD. Page Ref: 46 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Nursing Process. Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

13) A patient experiencing menopause asks what complementary and alternative therapy can be taken to reduce the symptoms. After reviewing the patient's health history, for which problems should the nurse encourage the patient to avoid taking phytoestrogens? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Allergy to soy 2. Currently taking tamoxifen 3. Treated for breast cancer 5 years ago 4. Surgery for uterine fibroids in her 20s 5. Experiences insomnia several times a week Answer: 2, 3, 4 Explanation: Women who have had or are at risk for diseases that are affected by hormones, such as breast cancer or uterine fibroids, and women who are taking medications that increase estrogen levels in the body such as tamoxifen need to be especially careful about using phytoestrogens. An allergy to soy and experiencing insomnia are not reasons for the patient to avoid taking phytoestrogens. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Nursing Process. Learning Outcome: 7 Identify medical and complementary therapies to alleviate the discomforts of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

14) The nurse is preparing an educational seminar for a group of middle-aged healthy women on health screening recommendations. What information should the nurse include during this educational session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Get a Pap test every 3 years 2. Schedule mammograms every 5 years 3. Get testing for HIV before the age of 60 4. Have a screening for colorectal cancer 5. Have blood pressure measured every year if 140/90 Answer: 3, 4 Explanation: A Pap test every 3 years is appropriate for women between the ages of 18 and 39. Mammograms should be obtained every 2 years through age 74. If the blood pressure measurement is 140/90 or higher, treatment should be discussed with the doctor or nurse. There is no age limit for HIV testing. Patient should be tested for HIV at least once if age 65 and have never been tested. Starting at age 50, patients should be screened for colorectal cancer. Page Ref: 42 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 4 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

15) The nurse is preparing to assess the sexual history of a 35-year-old female patient. Which approach should the nurse first use to facilitate this data collection? A) Ask if the patient is sexually active B) Review the present method of birth control C) Determine the patient's number of children D) Talk about the patient's medical-surgical history Answer: D Explanation: A) Asking if the patient is sexually active, reviewing the present method of birth control, and determining the patient's number of children are all intimate areas that should not be used to start a sexual history. B) Asking if the patient is sexually active, reviewing the present method of birth control, and determining the patient's number of children are all intimate areas that should not be used to start a sexual history. C) Asking if the patient is sexually active, reviewing the present method of birth control, and determining the patient's number of children are all intimate areas that should not be used to start a sexual history. D) When taking a history, the interview should start with less intimate areas, such as medical and surgical history, and then proceed to the sexual history toward the end of the history-taking session. This approach helps the woman develop a comfort level with the nurse before disclosing personal information. Page Ref: 35—36 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

16) A 40-year-old patient is being seen in the clinic for gynecological changes. Which approaches should the nurse use when completing this patient's health interview? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Avoid writing B) Clarify terms used C) Maintain eye contact D) Analyze body language E) Use simple yes-no questions Answer: A, B, C, D Explanation: A) When conducting a sexual history the nurse should avoid writing, clarify terms being used, maintain eye contact unless it is culturally inappropriate, and analyze the patient's body language. Using closed questions will limit the amount of information collected and should be avoided. B) When conducting a sexual history the nurse should avoid writing, clarify terms being used, maintain eye contact unless it is culturally inappropriate, and analyze the patient's body language. Using closed questions will limit the amount of information collected and should be avoided. C) When conducting a sexual history the nurse should avoid writing, clarify terms being used, maintain eye contact unless it is culturally inappropriate, and analyze the patient's body language. Using closed questions will limit the amount of information collected and should be avoided. D) When conducting a sexual history the nurse should avoid writing, clarify terms being used, maintain eye contact unless it is culturally inappropriate, and analyze the patient's body language. Using closed questions will limit the amount of information collected and should be avoided. E) When conducting a sexual history the nurse should avoid writing, clarify terms being used, maintain eye contact unless it is culturally inappropriate, and analyze the patient's body language. Using closed questions will limit the amount of information collected and should be avoided. Page Ref: 35—36 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

17) When analyzing data collected during a sexual history, the nurse notes that a patient has limited information about contraception. What should the nurse do to address this patient's need? A) Provide the patient with the information B) Suggest that the patient talk with the nurse practitioner C) Schedule an appointment for the patient to see the midwife D) Discuss the implications if contraception is not used correctly Answer: A Explanation: A) If a deficiency in knowledge is identified the nurse can identify a plan of care to address this deficiency and provide the teaching. The patient does not need to talk with a nurse practitioner or a midwife to discuss contraception. The implications of inappropriately used contraception can be included when discussing the individual types with the patient. B) If a deficiency in knowledge is identified the nurse can identify a plan of care to address this deficiency and provide the teaching. The patient does not need to talk with a nurse practitioner or a midwife to discuss contraception. The implications of inappropriately used contraception can be included when discussing the individual types with the patient. C) If a deficiency in knowledge is identified the nurse can identify a plan of care to address this deficiency and provide the teaching. The patient does not need to talk with a nurse practitioner or a midwife to discuss contraception. The implications of inappropriately used contraception can be included when discussing the individual types with the patient. D) If a deficiency in knowledge is identified the nurse can identify a plan of care to address this deficiency and provide the teaching. The patient does not need to talk with a nurse practitioner or a midwife to discuss contraception. The implications of inappropriately used contraception can be included when discussing the individual types with the patient. Page Ref: 35—36 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

18) During a health interview focused on sexual history, a female patient makes a statement about douching and intercourse. What should the nurse do in response to this statement? A) Recommend the frequency of douching B) Explain the proper procedure to douche C) Take the time now to educate the patient about the practice D) Document that the patient has misunderstandings about the use of douches Answer: C Explanation: A) It is essential that the nurse listen and use teachable moments to educate women about their bodies. Since the patient mentioned douching and intercourse, the time to review information about that practice with the patient is now. The nurse needs to do more than recommend the frequency of douching or explain the proper douching procedure. The nurse also needs to do more than document that the patient has misunderstandings about the use of douches. B) It is essential that the nurse listen and use teachable moments to educate women about their bodies. Since the patient mentioned douching and intercourse, the time to review information about that practice with the patient is now. The nurse needs to do more than recommend the frequency of douching or explain the proper douching procedure. The nurse also needs to do more than document that the patient has misunderstandings about the use of douches. C) It is essential that the nurse listen and use teachable moments to educate women about their bodies. Since the patient mentioned douching and intercourse, the time to review information about that practice with the patient is now. The nurse needs to do more than recommend the frequency of douching or explain the proper douching procedure. The nurse also needs to do more than document that the patient has misunderstandings about the use of douches. D) It is essential that the nurse listen and use teachable moments to educate women about their bodies. Since the patient mentioned douching and intercourse, the time to review information about that practice with the patient is now. The nurse needs to do more than recommend the frequency of douching or explain the proper douching procedure. The nurse also needs to do more than document that the patient has misunderstandings about the use of douches. Page Ref: 37 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

19) The nurse is preparing an educational session for high school female students on self-care during menstruation. What should the nurse include regarding care when using a tampon? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Wash hands before inserting a tampon B) Wash hands after inserting the tampon C) Change the tampon every 8 to 12 hours D) Use tampons with the minimum amount of absorbency E) Avoid touching the part that will be inserted into the vagina Answer: A, B, D, E Explanation: A) Teaching about the use of tampons should include washing the hands before and after inserting the tampon, using tampons with the least amount of absorbency, and to avoid touching the part of the tampon that will be inserted into the vagina. Tampons should be changed every 3 to 6 hours. B) Teaching about the use of tampons should include washing the hands before and after inserting the tampon, using tampons with the least amount of absorbency, and to avoid touching the part of the tampon that will be inserted into the vagina. Tampons should be changed every 3 to 6 hours. C) Teaching about the use of tampons should include washing the hands before and after inserting the tampon, using tampons with the least amount of absorbency, and to avoid touching the part of the tampon that will be inserted into the vagina. Tampons should be changed every 3 to 6 hours. D) Teaching about the use of tampons should include washing the hands before and after inserting the tampon, using tampons with the least amount of absorbency, and to avoid touching the part of the tampon that will be inserted into the vagina. Tampons should be changed every 3 to 6 hours. E) Teaching about the use of tampons should include washing the hands before and after inserting the tampon, using tampons with the least amount of absorbency, and to avoid touching the part of the tampon that will be inserted into the vagina. Tampons should be changed every 3 to 6 hours. Page Ref: 37—38 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Quality and Safety: Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Teaching/Learning. Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. MNL LO: Demonstrate ability to incorporate health promotion activities for women. 19 Copyright © 2020 Pearson Education, Inc.

20) A female patient schedules an appointment for a gynecologic examination. Which finding should indicate to the nurse that the patient is experiencing a vaginal infection? A) Foul odor from used tampons B) Scant menstrual flow at the end of the cycle C) Abdominal bloating a few days prior to menstruation D) Saturating a tampon every 2 hours during menstruation Answer: A Explanation: A) An unusual odor when using tampons could indicate an infection. Scant menstrual flow at the end of the cycle is an expected finding. Abdominal bloating a few days prior to menstruation could be associated with premenstrual syndrome. Saturating a tampon every 2 hours during menstruation could indicate abnormal bleeding which should be evaluated. B) An unusual odor when using tampons could indicate an infection. Scant menstrual flow at the end of the cycle is an expected finding. Abdominal bloating a few days prior to menstruation could be associated with premenstrual syndrome. Saturating a tampon every 2 hours during menstruation could indicate abnormal bleeding which should be evaluated. C) An unusual odor when using tampons could indicate an infection. Scant menstrual flow at the end of the cycle is an expected finding. Abdominal bloating a few days prior to menstruation could be associated with premenstrual syndrome. Saturating a tampon every 2 hours during menstruation could indicate abnormal bleeding which should be evaluated. D) An unusual odor when using tampons could indicate an infection. Scant menstrual flow at the end of the cycle is an expected finding. Abdominal bloating a few days prior to menstruation could be associated with premenstrual syndrome. Saturating a tampon every 2 hours during menstruation could indicate abnormal bleeding which should be evaluated. Page Ref: 38 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

21) A female patient asks what can be done to control vaginal odor. How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Wear cotton underwear B) Use a mild vaginal deodorant C) Schedule douching to occur weekly D) Cleanse from front to back when toileting E) Use soap and water to cleanse the perineum Answer: A, D, E Explanation: A) To control vaginal odor the patient should be instructed to wear cotton underwear, cleanse from front to back when toileting, and to use soap and water to cleanse the perineum. Vaginal deodorants and douching are not recommended. B) To control vaginal odor the patient should be instructed to wear cotton underwear, cleanse from front to back when toileting, and to use soap and water to cleanse the perineum. Vaginal deodorants and douching are not recommended. C) To control vaginal odor the patient should be instructed to wear cotton underwear, cleanse from front to back when toileting, and to use soap and water to cleanse the perineum. Vaginal deodorants and douching are not recommended. D) To control vaginal odor the patient should be instructed to wear cotton underwear, cleanse from front to back when toileting, and to use soap and water to cleanse the perineum. Vaginal deodorants and douching are not recommended. E) To control vaginal odor the patient should be instructed to wear cotton underwear, cleanse from front to back when toileting, and to use soap and water to cleanse the perineum. Vaginal deodorants and douching are not recommended. Page Ref: 38 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Quality and Safety: Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Teaching/Learning. Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

22) The nurse suspects that a female patient is experiencing amenorrhea because of ovarian failure. For which situation should the nurse assess this patient? A) Severe stress B) Recent head trauma C) Treatment for cancer D) Antianxiety medication Answer: C Explanation: A) Chemotherapy and radiation are reasons for the development of ovarian failure. Severe stress, antianxiety medication, and head trauma can cause hypothalamic dysfunction as a reason for amenorrhea. B) Chemotherapy and radiation are reasons for the development of ovarian failure. Severe stress, antianxiety medication, and head trauma can cause hypothalamic dysfunction as a reason for amenorrhea. C) Chemotherapy and radiation are reasons for the development of ovarian failure. Severe stress, antianxiety medication, and head trauma can cause hypothalamic dysfunction as a reason for amenorrhea. D) Chemotherapy and radiation are reasons for the development of ovarian failure. Severe stress, antianxiety medication, and head trauma can cause hypothalamic dysfunction as a reason for amenorrhea. Page Ref: 38 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 3 Identify causes of amenorrhea. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

23) A patient with amenorrhea has an elevated serum prolactin level. Which diagnostic test should the nurse expect will be prescribed for this patient? A) Laparoscopy B) Abdominal ultrasound C) CT scan of the abdomen D) Magnetic resonance imaging (MRI) Answer: D Explanation: A) If serum prolactin levels are elevated, magnetic resonance imaging (MRI) will be ordered to rule out a pituitary tumor. A laparoscopy, abdominal ultrasound, or CT scan of the abdomen is not indicated for a patient with amenorrhea and an elevated serum prolactin level. B) If serum prolactin levels are elevated, magnetic resonance imaging (MRI) will be ordered to rule out a pituitary tumor. A laparoscopy, abdominal ultrasound, or CT scan of the abdomen is not indicated for a patient with amenorrhea and an elevated serum prolactin level. C) If serum prolactin levels are elevated, magnetic resonance imaging (MRI) will be ordered to rule out a pituitary tumor. A laparoscopy, abdominal ultrasound, or CT scan of the abdomen is not indicated for a patient with amenorrhea and an elevated serum prolactin level. D) If serum prolactin levels are elevated, magnetic resonance imaging (MRI) will be ordered to rule out a pituitary tumor. A laparoscopy, abdominal ultrasound, or CT scan of the abdomen is not indicated for a patient with amenorrhea and an elevated serum prolactin level. Page Ref: 38 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 3 Identify causes of amenorrhea. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

24) A 38-year-old patient is concerned that a month after becoming a widow, her menstrual cycles stopped. What should the nurse suspect as being the cause for this patient's secondary amenorrhea? A) Ovarian failure B) Pituitary dysfunction C) Severe or prolonged stress such as that which occurs with an unexpected death can lead to hypothalamic dysfunction. Ovarian failure is related to exposure to radiation, chemotherapy, viral infection, and surgical removal of the ovary. Pituitary dysfunction is related to pituitary tumors or disease, use of antipsychotic medication, low prolactin levels, head trauma, and cancer. With an anatomic abnormality the patient would not have had a menstrual cycle. D) Hypothalamic dysfunction Answer: D Explanation: A) Severe or prolonged stress such as that which occurs with an unexpected death can lead to hypothalamic dysfunction. Ovarian failure is related to exposure to radiation, chemotherapy, viral infection, and surgical removal of the ovary. Pituitary dysfunction is related to pituitary tumors or disease, use of antipsychotic medication, low prolactin levels, head trauma, and cancer. With an anatomic abnormality the patient would not have ever had a menstrual cycle. B) Severe or prolonged stress such as that which occurs with an unexpected death can lead to hypothalamic dysfunction. Ovarian failure is related to exposure to radiation, chemotherapy, viral infection, and surgical removal of the ovary. Pituitary dysfunction is related to pituitary tumors or disease, use of antipsychotic medication, low prolactin levels, head trauma, and cancer. With an anatomic abnormality the patient would not have had a menstrual cycle. C) Severe or prolonged stress such as that which occurs with an unexpected death can lead to hypothalamic dysfunction. Ovarian failure is related to exposure to radiation, chemotherapy, viral infection, and surgical removal of the ovary. Pituitary dysfunction is related to pituitary tumors or disease, use of antipsychotic medication, low prolactin levels, head trauma, and cancer. With an anatomic abnormality the patient would not have had a menstrual cycle. D) Severe or prolonged stress such as that which occurs with an unexpected death can lead to hypothalamic dysfunction. Ovarian failure is related to exposure to radiation, chemotherapy, viral infection, and surgical removal of the ovary. Pituitary dysfunction is related to pituitary tumors or disease, use of antipsychotic medication, low prolactin levels, head trauma, and cancer. With an anatomic abnormality the patient would not have had a menstrual cycle. Page Ref: 38 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 3 Identify causes of amenorrhea. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

25) A 17-year-old high school student comes into the nurse's office to find out what to do about severe menstrual cramps. What should the nurse recommend to this student? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Rest B) Good nutrition C) Regular exercise D) Application of heat E) D & C of the uterus Answer: A, B, C, D Explanation: A) Treatment of primary dysmenorrhea includes rest, good nutrition, regular exercise, and application of heat. D & C of the uterus is a treatment for secondary dysmenorrhea. B) Treatment of primary dysmenorrhea includes rest, good nutrition, regular exercise, and application of heat. D & C of the uterus is a treatment for secondary dysmenorrhea. C) Treatment of primary dysmenorrhea includes rest, good nutrition, regular exercise, and application of heat. D & C of the uterus is a treatment for secondary dysmenorrhea. D) Treatment of primary dysmenorrhea includes rest, good nutrition, regular exercise, and application of heat. D & C of the uterus is a treatment for secondary dysmenorrhea. E) Treatment of primary dysmenorrhea includes rest, good nutrition, regular exercise, and application of heat. D & C of the uterus is a treatment for secondary dysmenorrhea. Page Ref: 39 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 4 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

26) A 30-year-old patient who experiences severe premenstrual syndrome every month asks for nonpharmacologic suggestions to treat this disorder. What should the nurse recommend? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Eat more frequent meals B) Engage in aerobic activity C) Limit alcohol to two drinks per day D) Restrict the intake of chocolate and coffee E) Increase the intake of fruits and vegetables Answer: A, B, D, E Explanation: A) Nonpharmacologic approaches for treating premenstrual syndrome include eating more frequent meals, engaging in aerobic activity, restricting the intake of chocolate and coffee, and increasing the intake of fruits and vegetables. Alcohol should be restricted and not limited to two drinks per day. B) Nonpharmacologic approaches for treating premenstrual syndrome include eating more frequent meals, engaging in aerobic activity, restricting the intake of chocolate and coffee, and increasing the intake of fruits and vegetables. Alcohol should be restricted and not limited to two drinks per day. C) Nonpharmacologic approaches for treating premenstrual syndrome include eating more frequent meals, engaging in aerobic activity, restricting the intake of chocolate and coffee, and increasing the intake of fruits and vegetables. Alcohol should be restricted and not limited to two drinks per day. D) Nonpharmacologic approaches for treating premenstrual syndrome include eating more frequent meals, engaging in aerobic activity, restricting the intake of chocolate and coffee, and increasing the intake of fruits and vegetables. Alcohol should be restricted and not limited to two drinks per day. E) Nonpharmacologic approaches for treating premenstrual syndrome include eating more frequent meals, engaging in aerobic activity, restricting the intake of chocolate and coffee, and increasing the intake of fruits and vegetables. Alcohol should be restricted and not limited to two drinks per day. Page Ref: 39—40 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 4 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

27) During an assessment, the nurse determines that a female patient is at risk for developing osteoporosis. Which information did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Body weight of 120 lb B) Plays tennis twice a week C) Smokes 2 packs per day of cigarettes D) Ingests 2 to 3 cocktails every day E) Mother diagnosed with osteoporosis Answer: A, C, D, E Explanation: A) Risk factors for the development of osteoporosis include body weight less than 127 lbs., smoking cigarettes, ingestion of alcohol, and having a family history of osteoporosis. An active lifestyle is an action to reduce the risk of developing osteoporosis. B) Risk factors for the development of osteoporosis include body weight less than 127 lbs., smoking cigarettes, ingestion of alcohol, and having a family history of osteoporosis. An active lifestyle is an action to reduce the risk of developing osteoporosis. C) Risk factors for the development of osteoporosis include body weight less than 127 lbs., smoking cigarettes, ingestion of alcohol, and having a family history of osteoporosis. An active lifestyle is an action to reduce the risk of developing osteoporosis. D) Risk factors for the development of osteoporosis include body weight less than 127 lbs., smoking cigarettes, ingestion of alcohol, and having a family history of osteoporosis. An active lifestyle is an action to reduce the risk of developing osteoporosis. E) Risk factors for the development of osteoporosis include body weight less than 127 lbs., smoking cigarettes, ingestion of alcohol, and having a family history of osteoporosis. An active lifestyle is an action to reduce the risk of developing osteoporosis. Page Ref: 45 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: VII. 2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

28) The nurse is preparing a program about osteoporosis for a group of community members. What should the nurse emphasize as being the greatest risk factor for the development of this disorder? A) Family history B) Caucasian race C) Sedentary lifestyle D) Low lifetime intake of calcium Answer: A Explanation: A) The greatest influencing factor for the development of osteoporosis is a family history of osteoporosis. Although Caucasian race, sedentary lifestyle, and low lifetime intake of calcium are risk factors, the greatest factor is family history. B) The greatest influencing factor for the development of osteoporosis is a family history of osteoporosis. Although Caucasian race, sedentary lifestyle, and low lifetime intake of calcium are risk factors, the greatest factor is family history. C) The greatest influencing factor for the development of osteoporosis is a family history of osteoporosis. Although Caucasian race, sedentary lifestyle, and low lifetime intake of calcium are risk factors, the greatest factor is family history. D) The greatest influencing factor for the development of osteoporosis is a family history of osteoporosis. Although Caucasian race, sedentary lifestyle, and low lifetime intake of calcium are risk factors, the greatest factor is family history. Page Ref: 45 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Planning; Teaching/Learning. Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

29) A premenopausal female received a recommendation by her healthcare provider to have a bone mineral density (BMD) test done. What should the nurse identify as being the reason for the test at this time in the patient's life? A) History of an eating disorder B) Takes NSAIDs for osteoarthritis C) Lives with a spouse who smokes cigarettes D) Surgery for carpal tunnel syndrome last year Answer: A Explanation: A) BMD testing may be indicated for premenopausal women with certain medical conditions such as eating disorders. BMD testing is not indicated when taking NSAIDs for osteoarthritis, living with a spouse who smokes, or after having carpal tunnel surgery. B) BMD testing may be indicated for premenopausal women with certain medical conditions such as eating disorders. BMD testing is not indicated when taking NSAIDs for osteoarthritis, living with a spouse who smokes, or after having carpal tunnel surgery. C) BMD testing may be indicated for premenopausal women with certain medical conditions such as eating disorders. BMD testing is not indicated when taking NSAIDs for osteoarthritis, living with a spouse who smokes, or after having carpal tunnel surgery. D) BMD testing may be indicated for premenopausal women with certain medical conditions such as eating disorders. BMD testing is not indicated when taking NSAIDs for osteoarthritis, living with a spouse who smokes, or after having carpal tunnel surgery. Page Ref: 47—48 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

30) A patient who is postmenopausal is encouraged to take calcium 1500 mg every day. How should the nurse instruct the patient to take this supplement? A) Take calcium 750 mg with breakfast and dinner B) Take the complete dose first thing in the morning C) Take the complete dose prior to bedtime every day D) Take calcium 500 mg three times a day with meals Answer: D Explanation: A) Calcium supplementation is most effective when single doses do not exceed 500 mg and when taken with a meal. Taking calcium 750 mg twice a day is less effective. Taking calcium 1500 mg in the morning or at night is not recommended since the mineral will not have peak absorption. B) Calcium supplementation is most effective when single doses do not exceed 500 mg and when taken with a meal. Taking calcium 750 mg twice a day is less effective. Taking calcium 1500 mg in the morning or at night is not recommended since the mineral will not have peak absorption. C) Calcium supplementation is most effective when single doses do not exceed 500 mg and when taken with a meal. Taking calcium 750 mg twice a day is less effective. Taking calcium 1500 mg in the morning or at night is not recommended since the mineral will not have peak absorption. D) Calcium supplementation is most effective when single doses do not exceed 500 mg and when taken with a meal. Taking calcium 750 mg twice a day is less effective. Taking calcium 1500 mg in the morning or at night is not recommended since the mineral will not have peak absorption. Page Ref: 48 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation/Teaching/Learning. Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

31) A patient with osteoporosis wants a medication that does not need to be taken every day. What should the nurse expect to be prescribed for this patient? A) Teriparatide (Forteo) B) Alendronate (Fosamax) C) Zoledronic acid (Zometa®) D) Salmon calcitonin (Miacalcin®) Answer: C Explanation: A) Zoledronic acid (Zometa®) is administered via IV once a year. Teriparatide (Forteo) necessitates a daily subcutaneous injection. Alendronate (Fosamax) is a daily oral medication. Salmon calcitonin (Miacalcin®) is to be taken daily as a nasal spray. B) Zoledronic acid (Zometa®) is administered via IV once a year. Teriparatide (Forteo) necessitates a daily subcutaneous injection. Alendronate (Fosamax) is a daily oral medication. Salmon calcitonin (Miacalcin®) is to be taken daily as a nasal spray. C) Zoledronic acid (Zometa®) is administered via IV once a year. Teriparatide (Forteo) necessitates a daily subcutaneous injection. Alendronate (Fosamax) is a daily oral medication. Salmon calcitonin (Miacalcin®) is to be taken daily as a nasal spray. D) Zoledronic acid (Zometa®) is administered via IV once a year. Teriparatide (Forteo) necessitates a daily subcutaneous injection. Alendronate (Fosamax) is a daily oral medication. Salmon calcitonin (Miacalcin®) is to be taken daily as a nasal spray. Page Ref: 48 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Planning. Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

32) The nurse is identifying complementary and alternative therapies for a patient with a history of liver disorders who is experiencing symptoms of menopause. Which herbal supplement should this patient be counseled to avoid? A) Ginger B) Ginseng C) Red clover D) Black cohosh Answer: D Explanation: A) Black cohosh has been associated with liver inflammation and disease. Ginger is useful to control nausea and vomiting. Ginseng helps with mood symptoms and sleep disorders. Red clover helps with hot flashes. Ginger, ginseng, and red clover are not associated with liver disease. B) Black cohosh has been associated with liver inflammation and disease. Ginger is useful to control nausea and vomiting. Ginseng helps with mood symptoms and sleep disorders. Red clover helps with hot flashes. Ginger, ginseng, and red clover are not associated with liver disease. C) Black cohosh has been associated with liver inflammation and disease. Ginger is useful to control nausea and vomiting. Ginseng helps with mood symptoms and sleep disorders. Red clover helps with hot flashes. Ginger, ginseng, and red clover are not associated with liver disease. D) Black cohosh has been associated with liver inflammation and disease. Ginger is useful to control nausea and vomiting. Ginseng helps with mood symptoms and sleep disorders. Red clover helps with hot flashes. Ginger, ginseng, and red clover are not associated with liver disease. Page Ref: 49 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 7 Identify medical and complementary therapies to alleviate the discomforts of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

33) A premenopausal patient is experiencing vaginal dryness. What pharmacological intervention should the nurse suggest for this patient's symptom? A) Local low-dose vaginal estrogen B) Testosterone replacement therapy C) Menopausal hormone therapy with testosterone D) Menopausal hormone therapy with estrogen alone Answer: A Explanation: A) Local low-dose vaginal estrogen is generally recommended to treat vaginal dryness or dyspareunia. Women are not provided with testosterone alone replacement therapy. Menopausal hormone therapy with testosterone helps to improve libido. Hormone therapy containing estrogen only is given to women who have undergone a hysterectomy. B) Local low-dose vaginal estrogen is generally recommended to treat vaginal dryness or dyspareunia. Women are not provided with testosterone alone replacement therapy. Menopausal hormone therapy with testosterone helps to improve libido. Hormone therapy containing estrogen only is given to women who have undergone a hysterectomy. C) Local low-dose vaginal estrogen is generally recommended to treat vaginal dryness or dyspareunia. Women are not provided with testosterone alone replacement therapy. Menopausal hormone therapy with testosterone helps to improve libido. Hormone therapy containing estrogen only is given to women who have undergone a hysterectomy. D) Local low-dose vaginal estrogen is generally recommended to treat vaginal dryness or dyspareunia. Women are not provided with testosterone alone replacement therapy. Menopausal hormone therapy with testosterone helps to improve libido. Hormone therapy containing estrogen only is given to women who have undergone a hysterectomy. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 7 Identify medical and complementary therapies to alleviate the discomforts of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

34) A patient experiencing symptoms of menopause asks if there are any vitamin supplements she should take at this time. Which vitamins should the nurse suggest to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Vitamin A B) Vitamin C C) Vitamin D D) Vitamin E E) Vitamin B complex Answer: C, D, E Explanation: A) Therapeutic modalities proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years include vitamins E, D, and B complex. Vitamins A and C have not been identified as being beneficial to reduce the symptoms associated with menopause. B) Therapeutic modalities proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years include vitamins E, D, and B complex. Vitamins A and C have not been identified as being beneficial to reduce the symptoms associated with menopause. C) Therapeutic modalities proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years include vitamins E, D, and B complex. Vitamins A and C have not been identified as being beneficial to reduce the symptoms associated with menopause. D) Therapeutic modalities proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years include vitamins E, D, and B complex. Vitamins A and C have not been identified as being beneficial to reduce the symptoms associated with menopause. E) Therapeutic modalities proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years include vitamins E, D, and B complex. Vitamins A and C have not been identified as being beneficial to reduce the symptoms associated with menopause. Page Ref: 48 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 7 Identify medical and complementary therapies to alleviate the discomforts of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

35) During a wellness visit, a 50-year-old female experiencing menopause says that she jogs three times a week and feels like her symptoms are becoming worse. What should the nurse recommend to help with the discomfort of menopause? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Yoga B) Tai chi C) Meditation D) Weight lifting E) Kegel exercises

Answer: A, B, C Explanation: A) A variety of therapeutic modalities have been proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years, including mind-body practices such as yoga, tai chi, and meditation. Weight lifting helps maintain bone mass caused by the reduction in estrogen. Kegel exercises help maintain vaginal muscle tone and increase blood circulation to the perineal area. B) A variety of therapeutic modalities have been proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years, including mind-body practices such as yoga, tai chi, and meditation. Weight lifting helps maintain bone mass caused by the reduction in estrogen. Kegel exercises help maintain vaginal muscle tone and increase blood circulation to the perineal area. C) A variety of therapeutic modalities have been proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years, including mind-body practices such as yoga, tai chi, and meditation. Weight lifting helps maintain bone mass caused by the reduction in estrogen. Kegel exercises help maintain vaginal muscle tone and increase blood circulation to the perineal area. D) A variety of therapeutic modalities have been proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years, including mind-body practices such as yoga, tai chi, and meditation. Weight lifting helps maintain bone mass caused by the reduction in estrogen. Kegel exercises help maintain vaginal muscle tone and increase blood circulation to the perineal area. E) A variety of therapeutic modalities have been proposed as treatment or prevention measures for the discomforts and ailments of the perimenopausal and postmenopausal years, including mind-body practices such as yoga, tai chi, and meditation. Weight lifting helps maintain bone mass caused by the reduction in estrogen. Kegel exercises help maintain vaginal muscle tone and increase blood circulation to the perineal area. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 7 Identify medical and complementary therapies to alleviate the discomforts of menopause. MNL LO: Demonstrate ability to incorporate health promotion activities for women.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 4 Family Planning 1) A client asks the nurse, "Can you explain to us how to use the basal body temperature method to detect ovulation and prevent pregnancy?" What is the nurse's best response? A) "Take your temperature every evening at the same time and keep a record for a period of several weeks. A noticeable drop in temperature indicates that ovulation has occurred." B) "Take your temperature every day at the same time and keep a record of the findings. A noticeable rise in temperature indicates ovulation." C) "Take your temperature each day, immediately upon awakening, and keep a record of each finding. A noticeable rise in temperature indicates that ovulation is about to occur." D) "This is an unscientific and unproven method of determining ovulation, and is not recognized as a means of birth control." Answer: C Explanation: A) Taking the temperature every evening at the same time would not provide information about when ovulation occurs. B) Taking the temperature every day at the same time would not necessarily provide accurate information about when ovulation occurs. C) The basal body temperature method is used to detect ovulation by an increase in the basal temperature during the menstrual cycle. It requires that the woman take her temperature every morning upon awakening (before any activity) and record the findings on a temperature graph, and is based on the fact that the temperature almost always rises and remains elevated after ovulation because of the production of progesterone, a thermogenic (heat-producing) hormone. D) Using basal body temperature to determine the timing of ovulation is a proven scientific method, and is recognized as an effective means of birth control. Page Ref: 55 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discuss types of fertility awareness-based methods (FAB) such as natural family planning (NFP). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

2) The nurse in the clinic instructs a client who is using the natural method of contraception to begin counting the first day of her cycle as which day? A) The day her menstrual period ceases B) The first day after her menstrual period ceases C) The first day of her menstrual period D) The day of ovulation Answer: C Explanation: A) The day her menstrual period ceases is not an indicator of the first day of the cycle. B) The first day after her menstrual period ceases is not an indicator of the first day of the cycle. C) The first day of menstruation is the first day of the cycle. D) The day of ovulation is not an indicator of the first day of the cycle. Page Ref: 55 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss types of fertility awareness-based methods (FAB) such as natural family planning (NFP). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

3) A client in the women's clinic asks the nurse, "How is the cervical mucus method of contraception different from the rhythm method?" The appropriate response by the nurse is that the cervical mucus method is which of the following? A) More effective for women with irregular cycles B) Not acceptable to women of many different religions C) Harder to work with than the rhythm method D) Requires an artificial substance or device Answer: A Explanation: A) The cervical mucus method (Billings Ovulation Method) can be used by women with irregular cycles. B) The cervical mucus method (Billings Ovulation Method) can be used by women of many religions, and is safe and free. C) The cervical mucus method (Billings Ovulation Method) is easier to implement than is the rhythm method for most women. D) The cervical mucus method (Billings Ovulation Method) does not require any artificial device. Page Ref: 54 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discuss types of fertility awareness-based methods (FAB) such as natural family planning (NFP). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

4) A client who wants to use the vaginal sponge method of contraception shows that she understands the appropriate usage when she makes which statement? A) "I need to use a lubricant prior to insertion." B) "I need to add spermicidal cream prior to intercourse." C) "I need to moisten it with water prior to use." D) "I need to leave it in no longer than 6 hours." Answer: C Explanation: A) Lubricant and spermicidal cream are not needed with the vaginal sponge. B) Lubricant and spermicidal cream are not needed with the vaginal sponge. C) To activate the spermicide in the vaginal sponge, it must be moistened thoroughly with water. D) The sponge can remain in place for 24 hours. Page Ref: 56 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

5) A female client who is 36 years old, weighs 200 pounds, is monogamous, and does not smoke desires birth control. The nurse understands that which contraceptive method is inappropriate for this client? A) Intrauterine device B) Vaginal sponge C) Combined oral contraceptives D) Transdermal hormonal contraception Answer: D Explanation: A) This client may use an intrauterine device. B) This client may use the vaginal sponge. C) This client may use combined oral contraceptives. D) Transdermal hormonal contraception is contraindicated because of the client's weight. Page Ref: 64—65 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 6 Compare progestin-only hormonal contraceptive methods to combined hormonal estrogen-progestin methods of the following: Medroxyprogesterone acetate injection (Depo-Provera), the norethindrone "mini-pill" (Micronor), and etonogestrel subdermal implant (Nexplanon). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

6) When assessing a client asking about birth control, the nurse knows that the client would not be a good candidate for Depo-Provera (DMPA) if which of the following is true? A) She wishes to get pregnant within 3 months. B) She is a nursing mother. C) She has a vaginal prolapse. D) She weighs 200 pounds. Answer: A Explanation: A) Return of fertility after use may be delayed for an average of 10 months. B) A nursing mother can use Depo-Provera. C) Obesity and vaginal prolapse do not contraindicate the use of Depo-Provera. D) Obesity and vaginal prolapse do not contraindicate the use of Depo-Provera. Page Ref: 65 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare progestin-only hormonal contraceptive methods to combined hormonal estrogen-progestin methods of the following: Medroxyprogesterone acetate injection (Depo-Provera), the norethindrone "mini-pill" (Micronor), and etonogestrel subdermal implant (Nexplanon). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

7) A couple asks the nurse what is the safest method of sterilization. What should the nurse reply? A) "Laparotomy tubal ligation." B) "Laparoscopy tubal ligation." C) "Minilaparotomy." D) "Vasectomy." Answer: D Explanation: A) A laparotomy tubal ligation is a female sterilization procedure that involves more risks. B) A laparoscopy tubal ligation is a female sterilization procedure that involves more risks. C) Minilaparotomy is a female sterilization procedure that involves more risks. D) Vasectomy (male sterilization) is a relatively minor procedure. Page Ref: 66 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Contrast the forms of sterilization (tubal ligation and vasectomy) with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

8) When the nurse is teaching a woman about the use of a diaphragm, it is important to instruct her that the diaphragm should be rechecked for correct size how often? A) Every five years routinely B) When weight gain or loss beyond five pounds has occurred C) After each birth D) Only after significant weight loss Answer: C Explanation: A) The diaphragm should be rechecked for correct size after each childbirth and whenever a woman has gained or lost 10 pounds or more. B) The diaphragm should be rechecked for correct size after each childbirth and whenever a woman has gained or lost 10 pounds or more. C) The diaphragm should be rechecked for correct size after each childbirth and whenever a woman has gained or lost 10 pounds or more. D) The diaphragm should be rechecked for correct size after each childbirth and whenever a woman has gained or lost 10 pounds or more. Page Ref: 58 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

9) What issues should the nurse consider when counseling a client on contraceptive methods? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Cultural perspectives on menstruation and pregnancy B) Effectiveness of the method C) Future childbearing plans D) Whether the client is a vegetarian E) Age at menarche Answer: A, B, C Explanation: A) Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, and long-term effects. Many outside factors influence this choice, including cultural practices, religious beliefs, personality, cost, effectiveness, availability, misinformation, practicality of method, and selfesteem. B) Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, and long-term effects. Many outside factors influence this choice, including cultural practices, religious beliefs, personality, cost, effectiveness, availability, misinformation, practicality of method, and self-esteem. C) Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, and long-term effects. Many outside factors influence this choice, including cultural practices, religious beliefs, personality, cost, effectiveness, availability, misinformation, practicality of method, and self-esteem. D) Vegetarianism has no impact on contraceptive method use. E) Age at menarche has no impact on contraceptive method use. Page Ref: 53 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: Patient-centered Care: Skills: Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: Clinical Prevention and Population Health: Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

10) Extended use of combined oral contraceptives (COCs) reduces the side effects of COCs such as which of the following? A) Cramping B) Hypertension C) Breast tenderness D) Bloating Answer: B Explanation: A) Extended use of COCs reduces the side effects of COCs such as bloating, headache, breast tenderness, cramping, and swelling. B) Complications of COCs include: myocardial infarction, stroke, blood clots, and hypertension. C) Extended use of COCs reduces the side effects of COCs such as bloating, headache, breast tenderness, cramping, and swelling. D) Extended use of COCs reduces the side effects of COCs such as bloating, headache, breast tenderness, cramping, and swelling. Page Ref: 63 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan and in all healthcare settings. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Summarize the key points that women who use combined hormonal contraceptives (estrogen and a progestin) should know, including the correct procedure for use, common side effects, warning signs, and noncontraceptive benefits of the following: Combined oral contraceptive pills, contraceptive patch (Xulane), and contraceptive vaginal ring (NuvaRing). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

11) The nurse is discussing the use of contraception with a client who has just become sexually active. What factors should the nurse include when educating the client on contraceptive methods? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Contraindications in the client's health history B) Religious or moral beliefs C) Partner's belief in the effectiveness of the choice D) Personal preferences to use method E) Future childbearing plans Answer: A, B, D, E Explanation: A) Decisions about contraception should take into consideration any contraindications the client might have. B) Religious or moral beliefs often impact which choices are acceptable. C) The partner's belief in the effectiveness has no bearing on the actual effectiveness. D) Personal preferences need to be considered when deciding on a contraceptive method. E) Plans for future children should be considered before determining whether sterilization should be performed. Page Ref: 53 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active relationships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

12) The nurse is preparing educational materials at a family planning clinic. The client who is an appropriate candidate for using emergency contraception would be one who reports which of the following? A) Forgetting to start her pill pack yesterday B) Unprotected intercourse during her menses C) That a condom broke yesterday in the middle of her cycle D) Increased dysmenorrhea since IUC insertion Answer: C Explanation: A) The client who forgot to start a new pill pack on time might not have had intercourse. B) Intercourse during menses does not lead to pregnancy. C) Research indicates that oral hormonal EC taken as soon as possible within 72 hours, but up to 5 days, can reduce the risk of pregnancy after a single act of unprotected intercourse by at least 74%. D) An IUC in place prevents conception, so emergency contraception is not indicated. Page Ref: 56 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Identify the appropriate time frame for initiating postcoital emergency contraception (EC). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

13) The nurse is developing a teaching plan for a client undergoing a tubal ligation. What information should be included in the plan? A) The surgical procedure is easily reversible. B) Laparotomy is performed following a vaginal birth. C) Minilaparotomy is performed in the postpartum period soon after a vaginal birth. D) Tubal ligation can be done at any time the woman is either pregnant or not pregnant. Answer: C Explanation: A) Reversal of a tubal ligation depends on the type of procedure performed. Although theoretically reversible, clients are advised that the method should be considered irreversible. B) Laparotomy is performed following a cesarean birth or other abdominal surgery. C) A tubal ligation minilaparotomy is performed in the postpartum period soon after a vaginal birth. D) Tubal ligation can be done at any time the woman is not pregnant. Page Ref: 66 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Skills: Engage patients and designated surrogates in active relationships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and followup throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 10 Contrast the forms of sterilization (tubal ligation and vasectomy) with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

14) A client who was raped is extremely upset when a pregnancy test confirms that she is pregnant, and requests information regarding pregnancy termination. Which statement is best for the nurse to make? A) "Abortion is morally wrong, and should not be undertaken." B) "Hypertension is a risk with any abortion." C) "Surgical abortion in the first trimester is technically easier and safer than abortion in the second trimester." D) "The most accurate method to determine gestational age are the results of a pregnancy test." Answer: C Explanation: A) Many nurses are strongly opposed to abortion for religious, ethical, cultural, or personal reasons. In order to be effective in a therapeutic relationship, the nurse must avoid being judgmental. B) Endometritis is a risk with any abortion. C) Second-trimester abortion (greater than 13 weeks' gestation up to 24 weeks or per state law) may be done medically or surgically. D) The most accurate method to determine gestational age is by sonographic determination. Page Ref: 68 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. C. 11. Respect patient preferences for degree of active engagement in care process. | AACN Essentials Competencies: II. 8. Promote achievement of safe and quality outcomes of care for diverse populations. | NLN Competencies: RelationshipCentered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 11 Compare medical and surgical approaches to pregnancy termination. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

15) A patient using the calendar rhythm method of birth control asks for assistance to calculate her most fertile period. She states that her shortest cycle is 22 days and her longest cycle is 40 days. Using this information, which day should the nurse identify as being the end of the patient's fertile period? Answer: 29 Explanation: The calendar rhythm method (CRM) is based on the assumption that ovulation tends to occur 14 days (plus or minus 2 days) before the start of the next menstrual period. The fertile phase is calculated from 18 days before the end of the shortest recorded cycle through 11 days from the end of the longest recorded cycle. For this situation the where the cycle lasts from 22 to 40 days, the fertile phase would be calculated as day 4 (22-18) to day 29 (40-11). The last day of the fertile phase would be day 29. Page Ref: 54 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 2 Discuss types of fertility awareness-based methods (FAB) such as natural family planning (NFP). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

16) A female patient comes into the community clinic with the following chart and asks the nurse for help understanding what needs to be done. Which method of birth control should the nurse review with the patient?

A) Two-day method B) Basal body temperature C) Calendar rhythm method D) Billings ovulation method Answer: B Explanation: B) The basal body temperature (BBT) method provides an objective record of fertile days and is used to detect ovulation by an increase in the basal temperature during the menstrual cycle. It requires that the woman take her temperature every morning upon awakening (before any activity) and record the findings on a temperature graph. This method is based on the fact that the temperature almost always rises and remains elevated after ovulation because of the production of progesterone. The calendar rhythm method (CRM) is based on the assumption that ovulation tends to occur 14 days (plus or minus 2 days) before the start of the next menstrual period. The two-day method is based on a woman's ability to distinguish the difference between progesterone-mediated and estrogen-mediated cervical mucus that is present at her introitus before she urinates, preferably in the afternoon and evening. The Billings Ovulation Method involves the assessment of cervical mucus changes that occur during the menstrual cycle. Page Ref: 55 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 2 Discuss types of fertility awareness-based methods (FAB) such as natural family planning (NFP). MNL LO: Demonstrate understanding of family planning in the care of patients and families. 16 Copyright © 2020 Pearson Education, Inc.

17) The nurse is coordinating educational materials in the patient training room. For which method of birth control should the nurse place the following diagram?

A) Diaphragm B) Cervical cap C) Male condom D) Female condom Answer: D Explanation: D) The female condom is inserted slowly by gently pushing the applicator toward the small of the back. The diaphragm is a barrier method that consists of a steel band that forms a ring and is covered with latex or silicone so that when the diaphragm is inserted, the ring lodges high in the vagina, covering the cervix. The cervical cap is reusable, looks like a small sailor's cap, and is made of soft silicone. The dome of the cap fits over the cervix, while the soft brim flares out slightly and conforms to the shape of the vagina. A strap placed over the dome permits easier removal. The cap is available in three sizes and should be used with a spermicide. The male condom is applied to the erect penis, rolled from the tip to the end of the shaft, before vulvar or vaginal contact. Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. | Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

18) The nurse is reviewing the insertion of a diaphragm with a female patient. At which step in the process is the following diagram to be used?

A) Before storing B) After removing C) Prior to inserting D) Determine leaking Answer: C Explanation: C) The diagram demonstrates the application of jelly to the rim and center of the diaphragm which is done before insertion. The diaphragm should be washed and dried before storing. There is no reason to apply jelly after removing the diaphragm. Water or a light source is used to determine if the diaphragm is leaking. Page Ref: 59 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

19) The nurse is preparing to meet with a female patient to review the most appropriate contraceptive method. In which order should the nurse complete the steps of this process? 1. Emphasize actions if pregnancy occurs 2. Instruct on the use of the selected method 3. Review side effects and warning symptoms 4. Assess for medical contraindications to specific methods 5. Learn about lifestyle, attitudes, religious beliefs and plans for children Answer: 4, 5, 2, 3, 1 Explanation: In addition to completing a history and assessing for any medical contraindications to specific methods, spend time with a woman learning about her lifestyle, personal attitudes about particular contraceptive methods, religious and cultural beliefs, personal biases, and plans for future childbearing. Once the woman chooses a method, help her learn to use it effectively. Review any possible side effects and warning symptoms related to the method chosen and counsel the woman about what action to take if she suspects she is pregnant. Page Ref: 53 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

20) After reviewing approaches for contraception with a female client, the nurse is concerned that barrier methods will not achieve the client's goal to prevent pregnancy. What did the client say to cause the nurse to draw this conclusion? A) "My partner doesn't mind wearing condoms." B) "I don't want to have to put anything in myself." C) "We should use a condom even with a diaphragm." D) "I know that spermicides are inserted before intercourse." Answer: B Explanation: A) The client's request to not have to insert anything to prevent pregnancy indicates that the barrier method of a female diaphragm would not be an appropriate method of birth control because the client will not be motivated to use it. Wearing condoms and appropriately using spermicides indicates that the client would adhere to the use of a barrier method. B) The client's request to not have to insert anything to prevent pregnancy indicates that the barrier method of a female diaphragm would not be an appropriate method of birth control because the client will not be motivated to use it. Wearing condoms and appropriately using spermicides indicates that the client would adhere to the use of a barrier method. C) The client's request to not have to insert anything to prevent pregnancy indicates that the barrier method of a female diaphragm would not be an appropriate method of birth control because the client will not be motivated to use it. Wearing condoms and appropriately using spermicides indicates that the client would adhere to the use of a barrier method. D) The client's request to not have to insert anything to prevent pregnancy indicates that the barrier method of a female diaphragm would not be an appropriate method of birth control because the client will not be motivated to use it. Wearing condoms and appropriately using spermicides indicates that the client would adhere to the use of a barrier method. Page Ref: 56 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Teaching/Learning. Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

21) The nurse is reviewing the spermicidal agent nonoxynol-9 (N-9) with a client planning to use the barrier method to prevent pregnancy. What should the nurse emphasize when teaching about this preparation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) It does not cause toxicity. B) It is inserted after intercourse. C) It has no systemic side effects. D) It can be purchased over-the-counter. E) It reduces the risk of sexually transmitted infections.

Answer: A, C, D Explanation: A) The major advantages of spermicidal preparations include low local toxicity, lack of systemic side effects, and ease of obtaining through an over-the-counter purchase. Spermicides are inserted before intercourse. Nonoxyol-9 does not offer protection against the organisms that cause gonorrhea, chlamydia, or HIV/AIDS and may actually increase a woman's risk of HIV infection. B) The major advantages of spermicidal preparations include low local toxicity, lack of systemic side effects, and ease of obtaining through an over-the-counter purchase. Spermicides are inserted before intercourse. Nonoxyol-9 does not offer protection against the organisms that cause gonorrhea, chlamydia, or HIV/AIDS and may actually increase a woman's risk of HIV infection. C) The major advantages of spermicidal preparations include low local toxicity, lack of systemic side effects, and ease of obtaining through an over-the-counter purchase. Spermicides are inserted before intercourse. Nonoxyol-9 does not offer protection against the organisms that cause gonorrhea, chlamydia, or HIV/AIDS and may actually increase a woman's risk of HIV infection. D) The major advantages of spermicidal preparations include low local toxicity, lack of systemic side effects, and ease of obtaining through an over-the-counter purchase. Spermicides are inserted before intercourse. Nonoxyol-9 does not offer protection against the organisms that cause gonorrhea, chlamydia, or HIV/AIDS and may actually increase a woman's risk of HIV infection. E) The major advantages of spermicidal preparations include low local toxicity, lack of systemic side effects, and ease of obtaining through an over-the-counter purchase. Spermicides are inserted before intercourse. Nonoxyol-9 does not offer protection against the organisms that cause gonorrhea, chlamydia, or HIV/AIDS and may actually increase a woman's risk of HIV infection. Page Ref: 56 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. | Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Identify the only spermicide preparation currently available in the United States. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

22) A client is planning to use condoms with a spermicidal cream as contraception. What should the nurse include when reviewing this method with the client? A) Coat the condom with spermicide before using B) Insert the spermicide 1 hour before having intercourse C) Insert the cream high into the vagina and remain supine D) Wait 15 minutes after inserting the spermicide into the vagina Answer: D Explanation: A) The spermicidal preparation is inserted into the vagina before intercourse. The nurse needs to instruct the woman to insert any of these spermicidal preparations high in the vagina as close to the cervix as possible. Maintaining a supine position after application will help keep the preparation in the vagina after it dissolves. The spermicide is not applied to the condom. The spermicide does not need to be inserted 1 hour before intercourse. Waiting 15 minutes is appropriate if the spermicide is a suppository. B) The spermicidal preparation is inserted into the vagina before intercourse. The nurse needs to instruct the woman to insert any of these spermicidal preparations high in the vagina as close to the cervix as possible. Maintaining a supine position after application will help keep the preparation in the vagina after it dissolves. The spermicide is not applied to the condom. The spermicide does not need to be inserted 1 hour before intercourse. Waiting 15 minutes is appropriate if the spermicide is a suppository. C) The spermicidal preparation is inserted into the vagina before intercourse. The nurse needs to instruct the woman to insert any of these spermicidal preparations high in the vagina as close to the cervix as possible. Maintaining a supine position after application will help keep the preparation in the vagina after it dissolves. The spermicide is not applied to the condom. The spermicide does not need to be inserted 1 hour before intercourse. Waiting 15 minutes is appropriate if the spermicide is a suppository. D) The spermicidal preparation is inserted into the vagina before intercourse. The nurse needs to instruct the woman to insert any of these spermicidal preparations high in the vagina as close to the cervix as possible. Maintaining a supine position after application will help keep the preparation in the vagina after it dissolves. The spermicide is not applied to the condom. The spermicide does not need to be inserted 1 hour before intercourse. Waiting 15 minutes is appropriate if the spermicide is a suppository. Page Ref: 56—57 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. | Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Identify the only spermicide preparation currently available in the United States. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

23) A sexually active female asks why an HIV test is needed since she uses condoms with spermicidal agents when having intercourse. How should the nurse respond to this client? A) "Condoms do not protect against contracting HIV." B) "Spermicides only control bacteria and not viruses." C) "All sexually active people are at risk for contracting HIV." D) "The spermicide can make your vaginal cells more susceptible to HIV." Answer: D Explanation: A) Research suggests that N-9 does not offer protection against the organisms that cause HIV/AIDS, and N-9 alone may actually increase a woman's risk of HIV infection because it has a negative effect on the integrity of vaginal cells, making them more susceptible to invasion by organisms such as HIV. Condoms do help reduce the risk of contracting HIV. Spermicides are prepared to render sperm inactive, not to kill bacteria or viruses. Although all sexually active individuals are at some risk for contracting HIV, this does not explain why the client should be tested for the virus. B) Research suggests that N-9 does not offer protection against the organisms that cause HIV/AIDS, and N-9 alone may actually increase a woman's risk of HIV infection because it has a negative effect on the integrity of vaginal cells, making them more susceptible to invasion by organisms such as HIV. Condoms do help reduce the risk of contracting HIV. Spermicides are prepared to render sperm inactive not to kill bacteria or viruses. Although all sexually active individuals are at some risk for contracting HIV, this does not explain why the client should be tested for the virus. C) Research suggests that N-9 does not offer protection against the organisms that cause HIV/AIDS, and N-9 alone may actually increase a woman's risk of HIV infection because it has a negative effect on the integrity of vaginal cells, making them more susceptible to invasion by organisms such as HIV. Condoms do help reduce the risk of contracting HIV. Spermicides are prepared to render sperm inactive not to kill bacteria or viruses. Although all sexually active individuals are at some risk for contracting HIV, this does not explain why the client should be tested for the virus. D) Research suggests that N-9 does not offer protection against the organisms that cause HIV/AIDS, and N-9 alone may actually increase a woman's risk of HIV infection because it has a negative effect on the integrity of vaginal cells, making them more susceptible to invasion by organisms such as HIV. Condoms do help reduce the risk of contracting HIV. Spermicides are prepared to render sperm inactive not to kill bacteria or viruses. Although all sexually active individuals are at some risk for contracting HIV, this does not explain why the client should be tested for the virus. Page Ref: 56 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Identify the only spermicide preparation currently available in the United States. MNL LO: Demonstrate understanding of family planning in the care of patients and families. 24 Copyright © 2020 Pearson Education, Inc.

24) The nurse suspects that a client is experiencing adverse effects from the progestin within a combined oral contraceptive. What did the nurse assess to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Pruritus B) Headache C) Hirsutism D) Weight gain E) Hypertension Answer: A, C, D Explanation: A) Pruritus, hirsutism (facial hair), and weight gain are adverse effects of progestin within a combined oral contraceptive. Headache and hypertension are adverse effects of estrogen within a combined oral contraceptive. B) Pruritus, hirsutism (facial hair), and weight gain are adverse effects of progestin within a combined oral contraceptive. Headache and hypertension are adverse effects of estrogen within a combined oral contraceptive. C) Pruritus, hirsutism (facial hair), and weight gain are adverse effects of progestin within a combined oral contraceptive. Headache and hypertension are adverse effects of estrogen within a combined oral contraceptive. D) Pruritus, hirsutism (facial hair), and weight gain are adverse effects of progestin within a combined oral contraceptive. Headache and hypertension are adverse effects of estrogen within a combined oral contraceptive. E) Pruritus, hirsutism (facial hair), and weight gain are adverse effects of progestin within a combined oral contraceptive. Headache and hypertension are adverse effects of estrogen within a combined oral contraceptive. Page Ref: 64 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. | Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation. Learning Outcome: 5 Summarize the key points that women who use combined hormonal contraceptives (estrogen and a progestin) should know, including the correct procedure for use, common side effects, warning signs, and noncontraceptive benefits of the following: Combined oral contraceptive pills, contraceptive patch (Xulane), and contraceptive vaginal ring (NuvaRing). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

25) During a follow-up wellness visit, the nurse determines that a female client is experiencing favorable outcomes after starting combined oral contraceptives. What data did the nurse use to determine this? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Reduced appetite B) Reduced menstrual flow C) Fewer menstrual cramps D) No pain with ovulation E) Cycle is regular at 28 days Answer: B, C, D, E Explanation: A) Combined oral contraceptives have noncontraceptive benefits that include reduced menstrual flow, fewer menstrual cramps, mittelschmerz or pain with ovulation disappearing, and a more regular cycle. Combined oral contraceptives do not affect appetite. B) Combined oral contraceptives have noncontraceptive benefits that include reduced menstrual flow, fewer menstrual cramps, mittelschmerz or pain with ovulation disappearing, and a more regular cycle. Combined oral contraceptives do not affect appetite. C) Combined oral contraceptives have noncontraceptive benefits that include reduced menstrual flow, fewer menstrual cramps, mittelschmerz or pain with ovulation disappearing, and a more regular cycle. Combined oral contraceptives do not affect appetite. D) Combined oral contraceptives have noncontraceptive benefits that include reduced menstrual flow, fewer menstrual cramps, mittelschmerz or pain with ovulation disappearing, and a more regular cycle. Combined oral contraceptives do not affect appetite. E) Combined oral contraceptives have noncontraceptive benefits that include reduced menstrual flow, fewer menstrual cramps, mittelschmerz or pain with ovulation disappearing, and a more regular cycle. Combined oral contraceptives do not affect appetite. Page Ref: 63 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation. Learning Outcome: 5 Summarize the key points that women who use combined hormonal contraceptives (estrogen and a progestin) should know, including the correct procedure for use, common side effects, warning signs, and noncontraceptive benefits of the following: Combined oral contraceptive pills, contraceptive patch (Xulane), and contraceptive vaginal ring (NuvaRing). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

26) A client who has been using transdermal hormonal contraception comes in for a routine wellness visit. Which finding should cause the nurse to question if the client should continue to use this form of contraception? A) Body weight of 179 lb B) Skin breakdown at the site of the patch C) Drinks 2 cups of caffeinated coffee a day D) Bicycles at the gym three evenings a week Answer: B Explanation: A) Women who have a skin disorder that may result in a reaction at the site of application may not be candidates for the patch. Body weight needs to be below 198 lbs. for the patch. Caffeine and exercise are not contraindications for using the patch for contraception. B) Women who have a skin disorder that may result in a reaction at the site of application may not be candidates for the patch. Body weight needs to be below 198 lbs. for the patch. Caffeine and exercise are not contraindications for using the patch for contraception. C) Women who have a skin disorder that may result in a reaction at the site of application may not be candidates for the patch. Body weight needs to be below 198 lbs. for the patch. Caffeine and exercise are not contraindications for using the patch for contraception. D) Women who have a skin disorder that may result in a reaction at the site of application may not be candidates for the patch. Body weight needs to be below 198 lbs. for the patch. Caffeine and exercise are not contraindications for using the patch for contraception. Page Ref: 64 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation. Learning Outcome: 6 Compare progestin-only hormonal contraceptive methods to combined hormonal estrogen-progestin methods of the following: Medroxyprogesterone acetate injection (Depo-Provera), the norethindrone "mini-pill" (Micronor), and etonogestrel subdermal implant (Nexplanon). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

27) A female client comes into the clinic for a pregnancy test because she took the morning after pill immediately after having unprotected intercourse 3 days ago and has not had a menstrual period. What should the nurse respond to this client? A) "I'll make sure you have one during this visit." B) "You should wait for two weeks before having a pregnancy test." C) "It's unlikely that you are pregnant. Wait a few days and then take a pregnancy test." D) "How long did you wait to take the morning after pill after having unprotected intercourse?" Answer: B Explanation: A) The woman should have her normal menses 2 weeks after taking emergency contraception. If she does not, she should follow up with a pregnancy test. A pregnancy test is not needed during this visit. The nurse has no way of knowing if the client is pregnant. The morning after pill should ideally be taken within 72 hours after having unprotected intercourse but can be taken up to 5 days after unprotected intercourse. B) The woman should have her normal menses 2 weeks after taking emergency contraception. If she does not, she should follow up with a pregnancy test. A pregnancy test is not needed during this visit. The nurse has no way of knowing if the client is pregnant. The morning after pill should ideally be taken within 72 hours after having unprotected intercourse but can be taken up to 5 days after unprotected intercourse. C) The woman should have her normal menses 2 weeks after taking emergency contraception. If she does not, she should follow up with a pregnancy test. A pregnancy test is not needed during this visit. The nurse has no way of knowing if the client is pregnant. The morning after pill should ideally be taken within 72 hours after having unprotected intercourse but can be taken up to 5 days after unprotected intercourse. D) The woman should have her normal menses 2 weeks after taking emergency contraception. If she does not, she should follow up with a pregnancy test. A pregnancy test is not needed during this visit. The nurse has no way of knowing if the client is pregnant. The morning after pill should ideally be taken within 72 hours after having unprotected intercourse but can be taken up to 5 days after unprotected intercourse. Page Ref: 66 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 9 Identify the appropriate time frame for initiating postcoital emergency contraception (EC). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

28) A female college student comes into the student health clinic, concerned about being pregnant from unprotected intercourse the evening before. What should the school nurse counsel this student? A) "Take Plan B One Step now." B) "Take 1 pill of Plan B now and the second pill in 5 days." C) "Take one half of Plan B One Step now and the second half in 3 days." D) "Wait 5 days and take 1 pill of Plan B followed by the second pill in 2 days." Answer: A Explanation: A) Plan B One-Step is one pill containing 1.5 mg of levonorgestrel which should be taken as one dose within 72 hours of unprotected intercourse. Plan B comes as two tablets of 0.75 mg levonorgestrel to be taken at once and should be taken as soon after coitus as possible. The pill in Plan B One-Step does not need to be split or taken days apart. The Plan B pills should be taken immediately and not after waiting for 5 days. B) Plan B One-Step is one pill containing 1.5 mg of levonorgestrel which should be taken as one dose within 72 hours of unprotected intercourse. Plan B comes as two tablets of 0.75 mg levonorgestrel to be taken at once and should be taken as soon after coitus as possible. The pill in Plan B One-Step does not need to be split or taken days apart. The Plan B pills should be taken immediately and not after waiting for 5 days. C) Plan B One-Step is one pill containing 1.5 mg of levonorgestrel which should be taken as one dose within 72 hours of unprotected intercourse. Plan B comes as two tablets of 0.75 mg levonorgestrel to be taken at once and should be taken as soon after coitus as possible. The pill in Plan B One-Step does not need to be split or taken days apart. The Plan B pills should be taken immediately and not after waiting for 5 days. D) Plan B One-Step is one pill containing 1.5 mg of levonorgestrel which should be taken as one dose within 72 hours of unprotected intercourse. Plan B comes as two tablets of 0.75 mg levonorgestrel to be taken at once and should be taken as soon after coitus as possible. The pill in Plan B One-Step does not need to be split or taken days apart. The Plan B pills should be taken immediately and not after waiting for 5 days. Page Ref: 66 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Identify the appropriate time frame for initiating postcoital emergency contraception (EC). MNL LO: Demonstrate understanding of family planning in the care of patients and families.

29) A female client with an intrauterine device calls the clinic because she is unable to locate the strings after her last menstrual period. What should the nurse counsel this client? A) Schedule an appointment immediately B) Wait a few days and recheck for the strings C) Take a tub bath and then recheck for the strings D) Perform a douche and then recheck for the strings Answer: A Explanation: A) Women with intrauterine contraception should contact their healthcare providers if the strings are missing. The client should not wait a few days, take a tub bath, or douche before rechecking for the strings. B) Women with intrauterine contraception should contact their healthcare providers if the strings are missing. The client should not wait a few days, take a tub bath, or douche before rechecking for the strings. C) Women with intrauterine contraception should contact their healthcare providers if the strings are missing. The client should not wait a few days, take a tub bath, or douche before rechecking for the strings. D) Women with intrauterine contraception should contact their healthcare providers if the strings are missing. The client should not wait a few days, take a tub bath, or douche before rechecking for the strings. Page Ref: 61 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Delineate the advantages and disadvantages of intrauterine contraception (IUC) as a method of birth control, as well as the differences between the IUCs with hormones and the one with copper. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

30) A female client is disappointed to learn that intrauterine contraception is not an option. For what reason is this form of contraception contraindicated for this client? A) Diabetes B) Breast cancer C) Endometriosis D) Uterine surgery Answer: C Explanation: A) Intrauterine contraception is contraindicated in endometriosis. Intrauterine contraception is an excellent contraceptive option for women with diabetes; it may also be used in women with a history of breast cancer or uterine surgery. B) Intrauterine contraception is contraindicated in endometriosis. Intrauterine contraception is an excellent contraceptive option for women with diabetes; it may also be used in women with a history of breast cancer or uterine surgery. C) Intrauterine contraception is contraindicated in endometriosis. Intrauterine contraception is an excellent contraceptive option for women with diabetes; it may also be used in women with a history of breast cancer or uterine surgery. D) Intrauterine contraception is contraindicated in endometriosis. Intrauterine contraception is an excellent contraceptive option for women with diabetes; it may also be used in women with a history of breast cancer or uterine surgery. Page Ref: 63 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 7 Delineate the advantages and disadvantages of intrauterine contraception (IUC) as a method of birth control, as well as the differences between the IUCs with hormones and the one with copper. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

31) The nurse is teaching a client who is having the Skyla LNg-IUC device inserted for contraception. What should the nurse emphasize to the client about this device? A) This device will provide protection for 5 years B) This device will provide protection for 10 years C) This device should not be used with a copper allergy D) This device has a silver ring and could interfere with an MRI Answer: D Explanation: A) The Skyla LNg-IUC device has a radiopaque silver ring at the top of the "T." The technician must be informed of this device if an MRI is required at any time. The Mirena levonorgestrel intrauterine system (LNg-IUC) provides protection for 5 years. The Copper IUC (ParaGard T 380A) provides protection for 10 years. The Skyla LNg-IUC device does not contain copper. B) The Skyla LNg-IUC device has a radiopaque silver ring at the top of the "T." The technician must be informed of this device if an MRI is required at any time. The Mirena levonorgestrel intrauterine system (LNg-IUC) provides protection for 5 years. The Copper IUC (ParaGard T 380A) provides protection for 10 years. The Skyla LNg-IUC device does not contain copper. C) The Skyla LNg-IUC device has a radiopaque silver ring at the top of the "T." The technician must be informed of this device if an MRI is required at any time. The Mirena levonorgestrel intrauterine system (LNg-IUC) provides protection for 5 years. The Copper IUC (ParaGard T 380A) provides protection for 10 years. The Skyla LNg-IUC device does not contain copper. D) The Skyla LNg-IUC device has a radiopaque silver ring at the top of the "T." The technician must be informed of this device if an MRI is required at any time. The Mirena levonorgestrel intrauterine system (LNg-IUC) provides protection for 5 years. The Copper IUC (ParaGard T 380A) provides protection for 10 years. The Skyla LNg-IUC device does not contain copper. Page Ref: 61 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Delineate the advantages and disadvantages of intrauterine contraception (IUC) as a method of birth control, as well as the differences between the IUCs with hormones and the one with copper. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

32) A client scheduled to have a Mirena levonorgestrel intrauterine system (LNg-IUC) inserted asks how this device stops conception. What should the nurse say in response to this client? A) "It stops ovulation." B) "It slows sperm motility." C) "It shortens the menstrual cycle." D) "It causes the lining of the uterus to waste away." Answer: D Explanation: A) The Mirena LNg-IUCs causes the lining of the uterus (endometrium) to become waste away. This device does not stop ovulation, slow sperm motility, or shorten the menstrual cycle. B) The Mirena LNg-IUCs causes the lining of the uterus (endometrium) to become waste away. This device does not stop ovulation, slow sperm motility, or shorten the menstrual cycle. C) The Mirena LNg-IUCs causes the lining of the uterus (endometrium) to become waste away. This device does not stop ovulation, slow sperm motility, or shorten the menstrual cycle. D) The Mirena LNg-IUCs causes the lining of the uterus (endometrium) to become waste away. This device does not stop ovulation, slow sperm motility, or shorten the menstrual cycle. Page Ref: 61 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Delineate the advantages and disadvantages of intrauterine contraception (IUC) as a method of birth control, as well as the differences between the IUCs with hormones and the one with copper. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

33) The nurse is completing the health history for a client desiring the Essure method of permanent sterilization. What should the nurse specifically ask when assessing this client? A) "Are you allergic to any metals?" B) "How many children do you have?" C) "When was your last menstrual period?" D) "Is your spouse aware of the procedure?" Answer: A Explanation: A) The Essure® method of permanent sterilization uses a nickel-titanium alloy. The client should be asked about having an allergy to nickel. The number of children, last menstrual period, and spouse's knowledge about the procedure are not essential when completing the client's health history prior to this method of sterilization. B) The Essure® method of permanent sterilization uses a nickel-titanium alloy. The client should be asked about having an allergy to nickel. The number of children, last menstrual period, and spouse's knowledge about the procedure are not essential when completing the client's health history prior to this method of sterilization. C) The Essure® method of permanent sterilization uses a nickel-titanium alloy. The client should be asked about having an allergy to nickel. The number of children, last menstrual period, and spouse's knowledge about the procedure are not essential when completing the client's health history prior to this method of sterilization. D) The Essure® method of permanent sterilization uses a nickel-titanium alloy. The client should be asked about having an allergy to nickel. The number of children, last menstrual period, and spouse's knowledge about the procedure are not essential when completing the client's health history prior to this method of sterilization. Page Ref: 66 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 10 Contrast the forms of sterilization (tubal ligation and vasectomy) with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

34) A client is being prepared to take the oral mifepristone-vaginal misoprostol treatment for an abortion. For which reasons should the nurse instruct the client to contact the healthcare provider within 24 hours? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Nausea B) Itchy skin C) Weakness D) Stomach pain E) Bloody discharge Answer: A, C, D Explanation: A) A woman who has taken the oral mifepristone-vaginal misoprostol regimen and within 24 hours develops nausea, weakness, or stomach pain should contact the healthcare provider immediately. Itchy skin and bloody discharge are not identified as needing to be reported to the healthcare provider. B) A woman who has taken the oral mifepristone-vaginal misoprostol regimen and within 24 hours develops nausea, weakness, or stomach pain should contact the healthcare provider immediately. Itchy skin and bloody discharge are not identified as needing to be reported to the healthcare provider. C) A woman who has taken the oral mifepristone-vaginal misoprostol regimen and within 24 hours develops nausea, weakness, or stomach pain should contact the healthcare provider immediately. Itchy skin and bloody discharge are not identified as needing to be reported to the healthcare provider. D) A woman who has taken the oral mifepristone-vaginal misoprostol regimen and within 24 hours develops nausea, weakness, or stomach pain should contact the healthcare provider immediately. Itchy skin and bloody discharge are not identified as needing to be reported to the healthcare provider. E) A woman who has taken the oral mifepristone-vaginal misoprostol regimen and within 24 hours develops nausea, weakness, or stomach pain should contact the healthcare provider immediately. Itchy skin and bloody discharge are not identified as needing to be reported to the healthcare provider. Page Ref: 69 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 11 Compare medical and surgical approaches to pregnancy termination. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

35) A client at 10 weeks' gestation is scheduled for a surgical abortion. Which approaches may be used to dilate the cervix for the procedure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Misoprostol B) Mifepristone C) Metal dilators D) Sterile seaweed E) Paracervical block Answer: A, B, C, D Explanation: A) After 8 weeks' gestation, the cervix is dilated with misoprostol or mifepristone, mechanically with metal dilators, or osmotically with sterile seaweed. A paracervical block is used to anesthetize the cervix. B) After 8 weeks' gestation, the cervix is dilated with misoprostol or mifepristone, mechanically with metal dilators, or osmotically with sterile seaweed. A paracervical block is used to anesthetize the cervix. C) After 8 weeks' gestation, the cervix is dilated with misoprostol or mifepristone, mechanically with metal dilators, or osmotically with sterile seaweed. A paracervical block is used to anesthetize the cervix. D) After 8 weeks' gestation, the cervix is dilated with misoprostol or mifepristone, mechanically with metal dilators, or osmotically with sterile seaweed. A paracervical block is used to anesthetize the cervix. E) After 8 weeks' gestation, the cervix is dilated with misoprostol or mifepristone, mechanically with metal dilators, or osmotically with sterile seaweed. A paracervical block is used to anesthetize the cervix. Page Ref: 68 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of client-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 11 Compare medical and surgical approaches to pregnancy termination. MNL LO: Demonstrate understanding of family planning in the care of patients and families.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 5 Commonly Occurring Infections 1) A nonpregnant client is diagnosed with bacterial vaginosis (BV). What does the nurse expect to administer? A) Penicillin G 2 million units IM one time B) Zithromax 1 mg PO bid for 2 weeks C) Doxycycline 100 mg PO bid for a week D) Metronidazole 500 mg PO bid for a week Answer: D Explanation: A) Penicillin is not used to treat bacterial vaginosis. B) Zithromax is not used to treat bacterial vaginosis. C) Doxycycline is not used to treat bacterial vaginosis. D) The nonpregnant woman who is diagnosed with bacterial vaginosis (BV) is treated with metronidazole 500 mg orally twice a day for 7 days. Page Ref: 78 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

2) The nurse is providing discharge instructions to a client with a diagnosis of vulvovaginal candidiasis (VVC), and knows the client understands when she makes which of the following statements? A) "I need to apply the miconazole for 10 days." B) "I need to douche daily." C) "I need to add yogurt to my diet." D) "I need to wear nylon panties." Answer: C Explanation: A) Applying miconazole for 10 days does not prevent or assist in treating vulvovaginal candidiasis. B) Douching daily does not prevent or assist in treating vulvovaginal candidiasis. C) Yogurt helps reestablish normal vaginal flora. D) Wearing nylon panties does not prevent or assist in treating vulvovaginal candidiasis. Page Ref: 77 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

3) The nurse provides a couple with education about the consequences of not treating chlamydia, and knows they understand when they make which statement? A) "She could become pregnant." B) "She could have severe vaginal itching." C) "He could get an infection in the tube that carries the urine out." D) "It could cause us to develop a rash." Answer: C Explanation: A) Chlamydia does not cause a woman to become pregnant. B) Chlamydia does not cause vaginal itching. C) Chlamydia is a major cause of nongonococcal urethritis (NGU) in men. D) Chlamydia does not cause a rash. Page Ref: 77 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

4) The nurse is seeing clients in the women's clinic. Which client should be treated with ceftriaxone IM and doxycycline orally? A) A pregnant client with gonorrhea and a yeast infection B) A nonpregnant client with gonorrhea and chlamydia C) A pregnant client with syphilis D) A nonpregnant client with chlamydia and trichomoniasis Answer: B Explanation: A) A pregnant client would not be treated with doxycycline. B) The combined treatment of ceftriaxone IM and doxycycline orally provides dual treatment for gonorrhea and chlamydia, which frequently occur together. C) The combined treatment of ceftriaxone IM and doxycycline orally is not the correct treatment for syphilis, and a pregnant client would not be treated with doxycycline. D) The combined treatment of ceftriaxone IM and doxycycline orally is not the correct treatment for trichomoniasis. Page Ref: 77 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Teamwork: Function completely within one's own scope of practice as leader and member of the healthcare team and manage delegation effectively. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

5) The nurse is providing follow-up education to a client just diagnosed with vaginal herpes. What statement by the client verifies correct knowledge about vaginal herpes? A) "I should douche daily to prevent infection." B) "I could have another breakout during my period." C) "I am more likely to develop cancer of the cervix." D) "I should use sodium bicarbonate on the lesions to relieve discomfort." Answer: B Explanation: A) Douching does not prevent infection. B) Menstruation seems to trigger recurrences of herpes. C) There is no relation between herpes and cancer of the cervix. D) Burow's (aluminum acetate) solution, not sodium bicarbonate, relieves discomfort. Page Ref: 80 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to a woman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

6) The nurse seeing a client just diagnosed with Chlamydia trachomatis knows that which client is at greatest risk for the infection? A) 16-year-old sexually active girl, using no contraceptive B) 22-year-old mother of two, developed dyspareunia C) 35-year-old woman on oral contraceptives D) 48-year-old woman with hot flashes and night sweats Answer: A Explanation: A) Teens have the highest incidence of sexually transmitted infections, especially chlamydia. A client not using contraceptives is not using condoms, which decrease the risk of contracting a STI. B) Dyspareunia sometimes develops with chlamydia infection, but dyspareunia is not a symptom specific to chlamydia. C) There is no correlation between oral contraceptive use and an increased rate of chlamydia infection. Additionally, chlamydia is more commonly seen in young women. D) This client is experiencing signs of menopause, not of chlamydia infection. Page Ref: 78 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concept: Nursing Process: Assessment. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

7) A client comes to the clinic complaining of difficulty urinating, flu-like symptoms, genital tingling, and blister-like vesicles on the upper thigh and vagina. She denies having ever had these symptoms before. The medication the physician is most likely to order would be: A) Oral acyclovir B) Ceftriaxone IM C) Azithromycin PO D) Penicillin G IM Answer: A Explanation: A) Malaise, dysuria, and tingling or painful vesicles are indicative of a primary herpes simplex outbreak. Acyclovir treats herpes. B) Ceftriaxone IM does not treat herpes. C) Azithromycin does not treat herpes. D) Penicillin does not treat herpes. Page Ref: 80 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

8) The nurse is caring for a client hospitalized for pelvic inflammatory disease. Which nursing intervention would have priority? A) Encourage oral fluids B) Administer cefotetan IV C) Enforce bed rest D) Remove IUC, if present Answer: B Explanation: A) Encouraging oral fluids is not a priority. B) Administration of medications to treat the disease is the first priority. C) Bed rest is not a priority. D) Removal of an IUC is not a nursing intervention. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 11. Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

9) The nurse obtains a health history from four clients. To which client should she give priority for teaching about cervical cancer prevention? A) Age 30, treated for PID B) Age 25, monogamous C) Age 20, pregnant D) Age 27, uses a diaphragm Answer: A Explanation: A) Exposure to sexually transmitted infections increases the risk of abnormal cell changes and cervical cancer. B) Practicing monogamy does not increase the risk of cervical cancer. C) Pregnancy does not increase the risk of cervical cancer. D) Use of a diaphragm does not increase the risk of cervical cancer. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to a woman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

10) The nurse is discharging a client after hospitalization for pelvic inflammatory disease (PID). Which statements indicate that teaching was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "I might have infertility because of this infection." B) "It is important for me to finish my antibiotics." C) "Tubal pregnancy could occur after PID." D) "My PID was caused by a yeast infection." E) "I am going to have an IUD placed for contraception." Answer: A, B, C Explanation: A) Women sometimes become infertile because of scarring in the fallopian tubes as a result of the inflammation of PID. B) Antibiotic therapy should always be completed when a client is diagnosed with any infection. C) The tubal scarring that occurs from tubal inflammation during PID can prevent a fertilized ovum from passing through the tube into the uterus, causing an ectopic or tubal pregnancy. D) PID is caused by bacteria, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae. E) An intrauterine device (IUD) in place increases the risk of developing PID; a client who has a history of PID is not a good candidate for an IUD. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

11) Which of the following diagnostic tests would the nurse question when ordered for a client diagnosed with pelvic inflammatory disease (PID)? A) CBC (complete blood count) with differential B) Venereal Disease Research Laboratory (VDRL) C) Throat culture for Streptococcus A D) RPR (Rapid Plasma Reagin) Answer: C Explanation: A) CBC with differential will be ordered to give an indication of the severity of the infection. B) The Venereal Disease Research Laboratory (VDRL) test checks for syphilis. C) Streptococcus of the throat is not associated with PID. D) RPR is a test for syphilis, a cause of PID. Page Ref: 84 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

12) Women with pyelonephritis during pregnancy are at significantly increased risk for which condition? A) Foul-smelling discharge B) Ectopic pregnancy C) Preterm labor D) A colicky large intestine Answer: C Explanation: A) Foul-smelling discharge is not a symptom of pyelonephritis. B) Ectopic pregnancy is not a symptom of pyelonephritis. C) Women with pyelonephritis during pregnancy are at significantly increased risk of preterm labor, preterm birth, development of adult respiratory distress syndrome, and septicemia. D) A colicky large intestine is an incorrect response. Page Ref: 85 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

13) The nurse is preparing an education session for women on the prevention of urinary tract infections (UTIs). Which statement should be included? A) Lower urinary tract infections rarely occur in women. B) The most common causative organism of cystitis is E. coli. C) Wiping from back to front after a BM will help prevent a UTI. D) Back pain often develops with a lower urinary tract infection. Answer: B Explanation: A) About 60% of women will experience an episode of cystitis during their lifetime. B) E. coli is present in 75% to 90% of women with UTIs. C) Wiping from back to front increases the risk of UTIs because the E. coli of the bowel is being drawn toward the urethra. Women should be instructed always to wipe from front to back. D) Low back or flank pain is a sign of pyelonephritis, which is an upper urinary tract infection. Page Ref: 85 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

14) The nurse in the community clinic is preparing educational materials to be used for teaching patients with sexually transmitted infections. What information should the nurse include regarding the medications metronidazole or tinidazole? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Take this medication until symptoms disappear 2. Abstain from all alcohol while taking these medications 3. Stop taking oral contraceptives while taking these medications 4. Abstain from all alcohol for 72 hours after completing tinidazole 5. Abstain from all alcohol for 24 hours after completing metronidazole Answer: 2, 4, 5 Explanation: Alcohol should be avoided when taking either metronidazole or tinidazole. When combined with alcohol, both metronidazole and tinidazole can produce effects similar to that of alcohol and Antabuse–abdominal pain, flushing, and tremors. The CDC (2010b) recommends abstaining from alcohol for 24 hours after completing metronidazole and 72 hours after completing tinidazole. If the woman is taking oral contraceptives, a backup nonhormonal contraceptive method is recommended during treatment with metronidazole. The patient should be encouraged to complete the full course of prescribed medications. Page Ref: 74 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

15) A patient is concerned about contracting herpes genitalis from a sexual partner and asks the nurse what to expect if the infection is present. In which order should the nurse explain the infection to the patient? 1. Emotional trigger occurs 2. Lesions spontaneously appear 3. Take oral acyclovir as prescribed 4. Virus enters a dormant phase with no lesions 5. Development of single or multiple blister-like vesicles Answer: 5, 3, 4, 1, 2 Explanation: The primary episode (first outbreak) of herpes genitalis is characterized by the development of single or multiple blister-like vesicles. Primary episodes usually last the longest and are the most severe. The recommended treatment of the first clinical episode of genital herpes is oral acyclovir, valacyclovir, or famciclovir. After the lesions heal, the virus enters a dormant phase, residing in the nerve ganglia of the affected area. Recurrences are usually less severe than the initial episode and seem to be triggered by emotional stress, menstruation, ovulation, pregnancy, and frequent or vigorous intercourse. Recurrence of the lesions is less severe. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

16) A female patient comes into the clinic because of concerns about a sore that was present on her labia but spontaneously healed. During the interview the patient asks what could occur if the infection is syphilis. In what order should the nurse explain the course of this sexually transmitted infection? 1. Latent period with no lesions 2. Development of a chancre sore 3. Skin eruptions and sore throat occur 4. Tertiary stage with various symptoms 5. Development of a fever, weight loss, and malaise Answer: 2, 5, 3, 1, 4 Explanation: Syphilis is divided into early and late stages. During the early stage (primary), a chancre appears at the site where the T. pallidum organism entered the body. Symptoms include slight fever, loss of weight, and malaise. The chancre persists for about 4 weeks and then disappears. In 6 weeks to 6 months, secondary symptoms appear. Skin eruptions called condylomata lata, which resemble wart-like plaques and are highly infectious, may appear on the vulva. Other secondary symptoms are acute arthritis, enlargement of the liver and spleen, nontender enlarged lymph nodes, iritis, and a chronic sore throat with hoarseness. A latent phase with no lesions may be followed by a tertiary stage. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

17) While assisting a female client into the lithotomy position for a pelvic examination the nurse observes the following on the patient's perineum. For which health problem should the nurse expect orders to be written by the healthcare provider?

A) Syphilis B) Gonorrhea C) Chlamydia D) Human papillomavirus Answer: A Explanation: A) This is condylomata acuminata which is a skin change associated with secondary symptoms of syphilis. This finding is not associated with gonorrhea, chlamydia, or human papillomavirus. Page Ref: 81 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptions of the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

18) A pregnant patient is concerned about the development of several urinary tract infections (UTIs) over the last few months of her pregnancy. What should the nurse explain as reasons for the development of these infections in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Decrease in bladder tone 2. Hyperemic bladder mucosa 3. Urethral stricture and loss of micturition reflex 4. Ureters elongate and are displaced by the uterus 5. Distal ureters hypertrophy leading to ureteral stenosis Answer: 1, 2, 4, 5 Explanation: A number of structural and functional changes occur during pregnancy that predispose pregnant women to urinary tract infections. Ureters elongate and are laterally displaced by the gravid uterus. Progesterone, which relaxes smooth muscles, can facilitate hypertrophy of the distal ureters with resulting ureteral stenosis and dilation, especially in the second half of pregnancy. Though the bladder has an increased capacity in pregnancy, it also has a decreased tone because progesterone relaxes the smooth muscle. Estrogen causes the bladder mucosa to become hyperemic and more susceptible to trauma and infection. Pregnancy does not cause urethral strictures and loss of the micturition reflex. Page Ref: 84—85 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

19) The nurse suspects that a patient is experiencing bacterial vaginosis. What finding caused the nurse to make this clinical determination? A) Dysuria B) Vaginal itching C) Thick white vaginal discharge D) Fishy odor to vaginal discharge Answer: D Explanation: D) The person with bacterial vaginosis may have a thin watery discharge with a fishy odor. Dysuria, vaginal itching, and thick white vaginal discharge are manifestations of vulvovaginal candidiasis. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

20) A patient in the 2nd trimester of pregnancy is diagnosed with bacterial vaginosis. Which medication regimen should the nurse expect to be prescribed for this patient? A) Metronidazole 500 mg orally one dose B) Metronidazole 250 mg orally once a day for 7 days C) Metronidazole 500 mg orally twice a day for 7 days D) Metronidazole 250 mg orally twice a day for 14 days Answer: C Explanation: C) The recommended treatment of bacterial vaginosis during pregnancy is Metronidazole 500 mg orally twice a day for 7 days. One dose of metronidazole is not sufficient. Metronidazole 250 mg should be taken 3 times for 7 days to be effective. Metronidazole 250 mg does not need to be taken for 14 days. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

21) The nurse is concerned that a patient is at risk for developing vulvovaginal candidiasis (VVC). What assessment information caused the nurse to have this concern? Select all that apply. 1. 16 weeks pregnant 2. +3 glucose in the urine 3. Elevated blood pressure 4. Type 2 diabetes mellitus 5. Edematous lower extremities Answer: 1, 2, 4 Explanation: Predisposing factors to vulvovaginal candidiasis (VVC) infections include pregnancy, glycosuria, and diabetes mellitus. Elevated blood pressure and edematous lower extremities is more likely to be associated with preeclampsia in the pregnant patient. Page Ref: 76 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

22) A patient is being assessed for recurrent vulvovaginal candidiasis (VVC) infections. What should the nurse instruct this patient to do to help reduce the incidence of infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Avoid douching 2. Use vaginal sprays 3. Wear cotton underwear 4. Avoid tight-fitting clothing 5. Apply cornstarch to the vulva Answer: 1, 3, 4 Explanation: Ways to prevent the recurrence of VVC include avoiding douching, wearing cotton underwear and avoiding tight-fitting clothing. Vaginal sprays should be avoided since they can irritate the vulva. Applying cornstarch to the vulva could encourage itching. Page Ref: 76—77 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

23) A patient and her partner are being treated for trichomoniasis. What should the nurse emphasize when teaching the couple about this infection? A) Avoid intercourse until symptom free B) Ensure a repeat test is completed in 3 months C) Limit alcohol intake while taking metronidazole D) Have annual screening for recurrence of the infection Answer: A Explanation: A) In trichomoniasis, partners should avoid intercourse until both are cured. Retesting for gonorrhea is recommended 3 months following treatment secondary to increasing prevalence and the potential for PID. Alcohol should be avoided, not limited, for 48 hours after taking metronidazole because of an effect similar to that of alcohol and disulfiram (Antabuse). Annual screening for sexually active individuals up to age 25 is recommended for chlamydia. Page Ref: 78 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to a woman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

24) A patient is being instructed on adverse effects of gonorrhea. For which reason should the nurse instruct the patient to contact the healthcare provider? A) Dysuria B) Urinary frequency C) Sharp abdominal pain D) Purulent, greenish-yellow vaginal discharge Answer: C Explanation: C) Women should be informed of signs that the infection is worsening, such as sharp abdominal pain, and be encouraged to seek further care. Dysuria, urinary frequency, and purulent, greenish-yellow vaginal discharge are manifestations of gonorrhea and do not indicate that the infection is getting worse. Page Ref: 79—80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to a woman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

25) The nurse is preparing instructions for a patient newly diagnosed with genital herpes. What should the nurse encourage to promote healing of the lesions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Take sitz baths 2. Use vaginal sprays 3. Wear cotton underwear 4. Douche after intercourse 5. Wear loose fitting clothing Answer: 1, 3, 5 Explanation: Actions to promote healing of genital herpes lesions include taking sitz baths, wearing cotton underwear, and wearing loose fitting clothing. Vaginal sprays and douching after intercourse will not help heal genital herpes lesions. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to a woman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

26) A college student is distraught after being diagnosed with pediculosis pubis. What should the nurse instruct this student to do to help prevent future infections? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Both partners need to be treated 2. Take the prescribed medication for 10 days 3. Avoid all sexual contact until treated and cured 4. Wash bed linens in hot water and dry in a dryer for 20 minutes 5. Testing for other sexually transmitted infections is recommended Answer: 1, 3, 4, 5 Explanation: For pediculosis pubis, both partners need to be tested. All sexual contact should be avoided until treated and cured. Bed linens, towels, clothing, and other objects should be machine washed in hot water (at least 103°F) and dried in a hot dryer for 20 minutes. Both partners must be treated and tested for other STIs. The medication for pediculosis pubis is topical, and repeated if nits are still present. Page Ref: 81—82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to a woman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

27) While reviewing data, the nurse determines that a patient is at risk for pelvic inflammatory disease. Which information did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Age 23 2. Douches weekly 3. Smokes cigarettes 1 ppd 4. IUD inserted 2 months ago 5. Received HPV vaccination Answer: 1, 2, 4 Explanation: Pelvic inflammatory disease (PID) occurs most often in sexually active women under age 25. Other risk factors include regular douching and recent insertion of an intrauterine device. Smoking and receiving the HPV vaccination are not risk factors for the development of PID. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

28) After a pelvic examination, a patient is scheduled for tests to diagnose pelvic inflammatory disease. Which finding from the physical examination suggested to the nurse practitioner that further testing is required? A) Cervical tenderness B) Greenish vaginal discharge C) Open sores along the vagina D) Condylomata acuminata on the vulva Answer: A Explanation: A) Manifestations of pelvic inflammatory disease include cervical tenderness or the chandelier sign. Greenish vaginal discharge is associated with gonorrhea. Open sores along the vagina might be associated with genital herpes. Condylomata acuminata on the vulva are genital warts. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

29) The nurse is reviewing laboratory testing completed for a patient with suspected pelvic inflammatory disease. Which test result should the nurse identify as supporting this diagnosis? A) Decreased hematocrit level B) Elevated sedimentation rate C) Decreased hemoglobin level D) Elevated white blood cell count Answer: B Explanation: B) In pelvic inflammatory disease the woman may have an elevated sedimentation rate. Decreased hematocrit and hemoglobin levels would indicate bleeding. An elevated white blood cell count indicates an infection, which may or may not occur with pelvic inflammatory disease. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

30) A patient schedules an appointment to be seen in the community clinic for dysuria, urgency, frequency, blood in the urine, and low back pain. For which health problem should the nurse provide care for this patient? A) Cystitis B) Pyelonephritis C) Glomerulonephritis D) Asymptomatic bacteriuria Answer: A Explanation: A) The classic initial symptoms of cystitis include dysuria, urgency, frequency, low back pain and hematuria. Manifestations of acute pyelonephritis include a sudden onset with chills, high temperature, costovertebral angle tenderness or flank pain, nausea, vomiting, and general malaise. Manifestations of glomerulonephritis include periorbital edema, elevated blood pressure, and urinary changes. Asymptomatic bacteriuria has no characteristic manifestations. Page Ref: 85 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

31) The nurse is caring for a client diagnosed with cystitis. When teaching the client about selfcare techniques, which foods or beverages will the nurse advise the client to avoid? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Caffeine 2. Dairy products 3. Alcohol 4. Carbonated beverages 5. Acidic fruit juices Answer: 1, 3, 4 Explanation: The nurse should advise the client to avoid foods or beverages that are bladder irritants, such as caffeine, alcohol, or carbonated beverages. Dairy products and acidic fruit juices are not considered bladder irritants and would not be included when advising the client to avoid bladder irritants. Page Ref: 86 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

32) A patient treated for a urinary tract infection a month ago is experiencing symptoms of the same infection. What should the nurse suspect is the reason for the reoccurrence of the infection? A) Using oral contraceptives B) Wearing cotton underwear C) Cleansing from front to back D) Stopped antibiotics after 3 days Answer: D Explanation: D) Not completing a full course of prescribed antibiotics could cause remaining bacteria to grow, leading to another infection. Use of oral contraceptives is not a risk factor for the development of a urinary tract infection. Wearing cotton underwear and cleansing from front to back are actions that reduce the risk of developing urinary tract infections. Page Ref: 86 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

33) A patient seeks medical attention after being exposed to blood during a gang fight several weeks ago. For which types of hepatitis should the nurse anticipate that this patient will be tested? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A 2. B 3. C 4. D 5. E Answer: 2, 3, 4 Explanation: Hepatitis B, C, and D are transmitted through blood, body fluids, and blood products. Hepatitis A and E are transmitted through the oral-fecal route. Hepatitis A is also transmitted through contaminated food and water. Page Ref: 82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 6 Compare the different types of viral hepatitis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

34) The nurse is planning teaching for a patient diagnosed with hepatitis A. What should the nurse emphasize when instructing the patient about this disease process? A) It is a chronic illness B) It is not a chronic illness C) A vaccination is not available D) It occurs in East and South Asia Answer: B Explanation: B) Hepatitis A is self-limiting and is not a chronic condition. Hepatitis B, C, and D infections are chronic. There is a vaccination available for hepatitis A. Hepatitis E is common worldwide and occurs primarily in East and South Asia. Page Ref: 82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 6 Compare the different types of viral hepatitis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

35) The nurse suspects that a newly admitted patient is experiencing manifestations of hepatitis A. What assessment findings did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Rash 2. Fever 3. Jaundice 4. Joint pain 5. Gray-colored stool Answer: 2, 3, 5 Explanation: Hepatitis A is characterized by symptoms of fever, jaundice, and gray-colored bowel movements. A rash and arthritis are associated with hepatitis B, C, and D. Page Ref: 82 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 6 Compare the different types of viral hepatitis. MNL LO: Demonstrate use of the nursing process in the care of women with genital or urinary infections.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 6 Women's Health Problems 1) The nurse receives a phone call from a 25-year-old woman experiencing breast tenderness in the week prior to her menses, with palpable breast nodularity, without nipple discharge. What is the best response by the nurse? A) "Please make an appointment at the breast cancer center as soon as possible." B) "How much salty food do you regularly consume?" C) "As long as you don't have nipple discharge, it isn't a serious condition." D) "Eliminate caffeine and chocolate from your diet." Answer: B Explanation: A) Recommending that the client make an appointment at the breast cancer center is unnecessary and might frighten the client. B) The client is describing fibrocystic breast changes. A salt restriction with a mild diuretic taken the week before menstrual bleeding often improves the condition. C) Neither the absence nor presence of nipple discharge is an indicator of the seriousness of a breast condition. D) Research is inconclusive as to whether eliminating methylxanthines from the diet is effective at reducing the symptoms the client describes. Page Ref: 91 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Contrast the common benign and malignant breast disorders. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

2) A client describes breast swelling and tenderness. What piece of data would be most important for the nurse to gather initially? A) Timing of the symptoms B) Birth control method C) Method of breast self-examination D) Diet history Answer: A Explanation: A) The breast undergoes regular cyclical changes in response to hormonal stimulation. The nurse will want to determine when the swelling and tenderness occur within the menstrual cycle. B) The birth control method can contribute to the database, but does not have priority. C) The method of BSE can contribute to the database, but does not have priority. D) Diet history can contribute to the database, but does not have priority. Page Ref: 91 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessment of health and illness parameters in patient, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Contrast the common benign and malignant breast disorders. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

3) A client is concerned about her risk for breast cancer. Following the initial history, the nurse identifies which of the following as a high risk factor for breast cancer? A) History of late menarche and early menopause B) Sister who has had breast cancer C) Mother with fibrocystic breast disease D) Multiparity Answer: B Explanation: A) Early menarche combined with late menopause is a breast cancer risk. B) Family history of first-degree relative (mother, sister, or daughter) with breast cancer increases the risk of breast cancer with the number of first-degree relatives with breast cancer. C) Fibrocystic breast disease is not a breast cancer risk factor. D) Multiparity is not a breast cancer risk factor. Page Ref: 93 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Contrast the common benign and malignant breast disorders. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

4) A nurse is providing a client with instructions regarding breast self-examination (BSE). Which of the following statements by the client would indicate that the teaching has been successful? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "I should perform BSE 1 week prior to the start of my period." B) "When I reach menopause, I will perform BSE every 2 months." C) "Knowing the density of my breast tissue is important." D) "I should inspect my breasts while standing with my arms down at my sides." E) "I should inspect my breasts while in a supine position with my arms at my sides." Answer: C, D Explanation: A) BSE should be performed 1 week after the start of each menstrual period. B) BSE should be performed monthly, on the same day each month, during menopause. C) The effectiveness of BSE is determined by the woman's ability to perform the procedure correctly, by her knowledge of her own breast tissue, and by the density of her breast tissue. D) The breasts should be inspected while standing with arms at sides. E) Supine is not a correct position for BSE. Page Ref: 89—90 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Contrast the common benign and malignant breast disorders. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

5) The nurse is working with a woman who is undergoing chemotherapy for breast cancer. The client states, "First, the cancer seemed unreal. Now I feel like I can cope." What is the nurse's best response? A) "Women with breast cancer often go through several stages of adjustment." B) "Women with breast cancer cope better than their partners cope." C) "Women with breast cancer seek multiple opinions before starting treatment." D) "Women with breast cancer become angry after treatment begins." Answer: A Explanation: A) The course of adjustment confronting the woman with cancer has been described in four phases: shock, reaction, recovery, and reorientation. The client's statement indicates shock followed by reaction. B) Partners are often the primary support person during treatment, but might also have difficulty adapting to the diagnosis. C) Some clients seek multiple opinions; some do not. D) Anger is not a stage of adjustment. Page Ref: 94 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. C. 1. Value seeing healthcare situations "through patient's eyes." | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the emotional reactions a woman may experience in regard to a diagnosis of breast cancer. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

6) The nurse interviews a 28-year-old client with a new medical diagnosis of endometriosis. Which question asked by the nurse is appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Are you having hot flashes?" B) "Are you experiencing pain during intercourse?" C) "Is a vaginal discharge present?" D) "Are you having pain during your period?" E) "Have you noticed any skin rashes?" Answer: B, D Explanation: A) Hot flashes are not a symptom of endometriosis. B) The primary symptoms of endometriosis include dyspareunia. C) Vaginal discharge is not a symptom of endometriosis. D) The primary symptoms of endometriosis include dysmenorrhea. E) Skin rashes are not a symptom of endometriosis. Page Ref: 103 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Discuss the signs and symptoms, medical therapy, and implications for fertility of endometriosis. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

7) A woman with polycystic ovarian syndrome (PCOS) is prescribed clomiphene citrate for the treatment of infertility. Which statement does the nurse understand is true? A) The woman has abnormal ovaries B) The woman has low prolactin levels C) The woman's pituitary gland is intact D) The woman's thyroid gland is normal Answer: C Explanation: A) In order to qualify for treatment with clomiphene citrate, the woman must have normal ovaries. B) In order to qualify for treatment with clomiphene citrate, the woman must have normal prolactin levels. C) In order to qualify for treatment with clomiphene citrate, the woman must have an intact pituitary gland. D) A normal-functioning thyroid gland is not essential for the client who takes clomiphene citrate; therefore, this statement may not be true. Page Ref: 113 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX. 3.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Knowledge; 2. Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 12 Summarize the indications for the tests and associated treatments that are performed in an infertility workup. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

8) The nurse is teaching a client who has been diagnosed with vulvitis. Which statement by the client indicates that the nurse's instruction has not been effective? A) "I should stop having sexual intercourse." B) "Non-deodorized tampons could make this condition recur." C) "Wearing pantyhose daily will improve the problem." D) "A different brand of soap might eliminate the irritation." Answer: C Explanation: A) Intercourse can occur, but with adequate lubrication. B) Use of deodorized and heavily scented products that come in contact with the vulva (toilet paper, soap, bubble bath, pads, tampons, etc.) can cause the inflammation. C) Vulvitis is inflammation of the vulva. Tight clothing, especially if made of synthetic fibers, can predispose women to the condition. Pantyhose should not be worn. D) Use of deodorized and heavily scented products that come in contact with the vulva (toilet paper, soap, bubble bath, pads, tampons, etc.) can cause the inflammation. Page Ref: 96, 97 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Identify the implications of an abnormal finding during a pelvic examination. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

9) The 22-year-old client is scheduled for her first gynecologic examination. What can the nurse do to make the client more comfortable during this exam? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Create a trusting atmosphere. B) Show the client what the speculum looks like. C) Avoid telling the client what the exam involves. D) Ask the client why she has delayed her first Pap test this long. E) Provide a mirror for the client. Answer: A, B, E Explanation: A) It is important to create a trusting atmosphere and incorporate practices that help the client maintain a sense of control. B) Show the client all of the equipment to be used. C) To reduce fear and improve the client's sense of control, create a trusting atmosphere by explaining everything involved in the exam. D) Asking why the client has delayed her first Pap test is being judgmental, which does not foster a therapeutic relationship. E) Provide a mirror to increase learning about anatomy and to create a trusting atmosphere. Page Ref: 95 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Delineate the psychosocial responses a woman may experience when facing any of the common gynecologic procedures. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

10) The 12-year-old client reports that menarche occurred 5 months ago. She has had bleeding every day this month, and is very worried. The nurse should explain that the most common cause of this bleeding is which of the following? A) Dysfunctional uterine bleeding (DUB) B) Diabetes mellitus (DM) C) Pregnancy D) Von Willebrand's disease Answer: A Explanation: A) Adolescents often experience DUB during the first 2 years following menarche due to hypothalamic immaturity after menarche. B) Uterine bleeding is not a symptom of DM. C) Uterine bleeding is not a symptom of pregnancy. D) Although von Willebrand's disease can cause irregular uterine bleeding, it is quite rare. Page Ref: 101 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss abnormal uterine bleeding and abdominal masses. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

11) A nurse is teaching a class on the different types of uterine bleeding. The nurse explains that which of the following is one of the causes of abnormal uterine bleeding? A) Iron-deficiency anemia B) Polyps C) Heavy periods every 2 months D) Spotting between periods Answer: B Explanation: A) Iron-deficiency anemia is a symptom of abnormal uterine bleeding, not a cause. B) A classification system has been developed for the causes of AUB using the acronym PALMCOEIN. The P stands for Polyps. C) Heavy periods every 2 months could be one of the symptoms of abnormal uterine bleeding, not a cause. D) Spotting between periods is a symptom of abnormal uterine bleeding, not a cause. Page Ref: 102 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 5 Discuss abnormal uterine bleeding and abdominal masses. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

12) The nurse walks in to find the client crying after the physician informed her of her diagnosis of human papilloma virus (HPV). Which statement by the nurse conveys an attitude of acceptance toward the client with a sexually transmitted infection? A) "Don't worry about it. In a few weeks, with treatment, the lesions will disappear." B) "You seem upset. I'll get the doctor." C) "You seem upset. Can I help answer any questions?" D) "I think you need to see a therapist." Answer: C Explanation: A) This client needs a caring person to listen to her and convey acceptance of her. This statement does not convey this. B) The client does not need the doctor at this time. C) The nurse's attitude of acceptance and matter-of-factness conveys to the client that she is still an acceptable person who happens to have an infection. D) It is not up to the nurse to determine whether this client needs a therapist. Page Ref: 98 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. C. 8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Delineate the psychosocial responses a woman may experience when facing any of the common gynecologic procedures. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

13) The nurse obtains a health history from four clients. To which client should she give priority for teaching about cervical cancer prevention? A) Age 37, multiple partners B) Age 22, abstains from sexual intercourse C) Age 32, pregnant with twins D) Age 27, uses female condom Answer: A Explanation: A) Having multiple partners increases the client's risk of contracting sexually transmitted infections, including possible exposure to human papilloma virus (HPV). Contracting HPV increases the risk of abnormal cervical cell changes and cervical cancer. B) Practicing abstinence does not increase risks of cervical cancer. C) Pregnancy of any type does not increase risks of cervical cancer. D) Use of a female condom does not increase risks of cervical cancer. Page Ref: 98 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Teamwork: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Identify the implications of an abnormal finding during a pelvic examination. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

14) The nurse is about to tell a client that her Pap smear result was abnormal. Which statement should the nurse include? A) "The Pap smear is used to diagnose cervical cancer." B) "A loop electrosurgical excision procedure (LEEP) is needed." C) "Colposcopy to further examine your cervix is the next step." D) "Your cervix needs to be treated with cryotherapy." Answer: C Explanation: A) The Pap smear is a screening tool for cervical abnormalities; it is not diagnostic. B) Although LEEP (the removal of the surface tissue of the cervix) might be performed to treat cervical dysplasia or carcinoma in situ, this client has not had a diagnostic examination yet. C) Colposcopy is an examination of the cervix through a magnifying device. D) Cryotherapy, or freezing of the cervix, is one treatment option for precancerous cervical lesions. Page Ref: 100 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss the importance of an annual Pap smear and appropriate follow-up for an abnormal finding. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

15) The client's Pap smear result is ASC-US. Which statement is the best way for the nurse to explain this ASC-US result? A) "Abnormal cells of an unknown cause." B) "Cancer has invaded the upper cervix." C) "High-grade squamous intraepithelial lesion (HSIL), which includes CIN." D) "The focus of the Pap smear is the detection of high-risk pregnancy." E) "The cervical cells are abnormal and the reason why is severe dysplasia and carcinoma in situ." Answer: A Explanation: A) ASC-US stands for abnormal squamous cells of undetermined significance. The nurse should tell the client that these are abnormal cells of an unknown cause. Preferred management is HPV testing; if positive, refer for colposcopy; if negative, repeat HPV co-testing in 3 years. B) ASC-US does not indicate cancer. C) CIN refers to a lesion that may progress to invasive carcinoma (cancer). ASC-US does not indicate cancer. D) The focus of the Pap smear is the detection of high-grade cervical disease, especially cervical intraepithelial neoplasia (CIN). E) ASC-US stands for abnormal squamous cells of undetermined significance. The cervical cells are abnormal, but the reason why is unknown. Page Ref: 100 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss the importance of an annual Pap smear and appropriate follow-up for an abnormal finding. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

16) The nurse has presented a community education class on recommended health screenings for women. Which statement about the Pap smear by a class member indicates that additional teaching is necessary? A) "It is recommended for women 21 years of age and older." B) "It diagnoses cervical cancer." C) "Intercourse at a young age is a risk factor for an abnormal Pap smear." D) "Detects abnormal cells." Answer: B Explanation: A) Pap smear screening is recommended for all women 21 years of age and older. B) The focus of the Pap smear is the detection of high-grade cervical disease. It does not diagnose cervical cancer. C) Several factors put a woman at high risk for an abnormal Pap: intercourse at a young age, multiple partners, history of immunotherapy, long-term combined oral contraceptive (COC) use, smoking, and previous history of dysplasia. D) The purpose of the Papanicolaou smear (Pap smear) is to screen for the presence of cellular abnormalities by obtaining a sample containing cells from the cervix and the endocervical canal. Page Ref: 98 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patient or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Discuss the importance of an annual Pap smear and appropriate follow-up for an abnormal finding. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

17) Which client in the gynecology clinic should the nurse see first? A) 32-year-old taking gonadotropins, reporting extremity edema B) 15-year-old, no menses for past 4 months C) 18-year-old seeking information on contraception methods D) 31-year-old, taking progestins, reports increasing dyspareunia Answer: A Explanation: A) Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of ovulation induction by gonadotropin therapy, manifested by third-spacing. This client should be seen first. B) Secondary amenorrhea can be caused by pregnancy; teen pregnancy is a high risk. This client does not take priority of care. C) Unplanned pregnancy and sexually transmitted infections can be problematic in the future, but this client exhibits no signs or symptoms of a life-threatening condition at this time and does not need to be seen first. D) Although this client might have endometriosis, dyspareunia is not a life-threatening condition. Page Ref: 113 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 12 Summarize the indications for the tests and associated treatments that are performed in an infertility workup. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

18) The nurse is caring for a client diagnosed with endometriosis. Which statement by the client would require a need for perhaps another treatment option? A) "I am having many hot flashes since I had the Lupron injection." B) "The pain I experience with intercourse is becoming more severe." C) "I have vaginal dryness, reduced libido, and my clitoris has become larger since taking danazol. Is this normal?" D) "I've noticed I have not had my period on a regular basis since being on the GnRH analogs." Answer: C Explanation: A) Hot flashes are expected, and not a complication. B) Dyspareunia is a common symptom of endometriosis, and therefore is not a complication. C) Danazol is a testosterone derivative that suppresses ovulation and causes amenorrhea. It is intended for short-term therapy. Because of adverse effects, many clinicians have moved away from danazol to other treatment options. D) GnRH analogs suppress the menstrual cycle through estrogen antagonism. Page Ref: 103—104 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Discuss the signs and symptoms, medical therapy, and implications for fertility of endometriosis. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

19) The client diagnosed with endometriosis asks the nurse whether there are any long-term health risks associated with this condition. The nurse should include which statement in the client teaching about endometriosis? A) "There are no other health risks associated with endometriosis." B) "Pain with intercourse rarely occurs as a long-term problem." C) "You are at increased risk for ovarian and breast cancer." D) "Most women with this condition develop severe migraines." Answer: C Explanation: A) There are long-term health risks associated with endometriosis. B) Dyspareunia is a common symptom of endometriosis. C) An increased risk for cancer of the ovary and breast is associated with endometriosis. D) Endometriosis is not associated with increased migraines. Page Ref: 103—104 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Discuss the signs and symptoms, medical therapy, and implications for fertility of endometriosis. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

20) The client is undergoing lab work and ultrasound for a possible diagnosis of polycystic ovarian syndrome (PCOS). Which problem does the nurse expect to find in the client's history? A) Multiple first-trimester fetal losses B) Dyspareunia C) Vulvitis D) Oligomenorrhea Answer: D Explanation: A) First-trimester fetal loss is not associated with polycystic ovarian syndrome (PCOS). B) Dyspareunia is not associated with polycystic ovarian syndrome (PCOS). C) Vulvitis is not associated with polycystic ovarian syndrome (PCOS). D) Irregular menses, ranging from total absence of periods (amenorrhea) to intermittent or infrequent periods (oligomenorrhea) are the hallmarks of PCOS. Page Ref: 104—105 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Discuss the signs and symptoms, diagnosis criteria, treatment options, and health implications of polycystic ovarian syndrome. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

21) The client with polycystic ovarian syndrome (PCOS) has been prescribed metformin (Glucophage). The nurse tells the client that the medication will do which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Decrease your excessive hair growth." B) "Make it easier to lose weight." C) "Increase your acne." D) "Improve your chances of pregnancy." E) "Make your menstrual periods irregular." Answer: A, B, D Explanation: A) Polycystic ovarian syndrome (PCOS) treatment with metformin decreases hirsutism. B) Polycystic ovarian syndrome (PCOS) treatment with metformin improves weight loss success. C) Polycystic ovarian syndrome (PCOS) treatment with metformin decreases acne. D) Polycystic ovarian syndrome (PCOS) treatment with metformin increases ovulation and therefore menstrual regularity and fertility. E) Polycystic ovarian syndrome (PCOS) treatment with metformin increases ovulation and therefore menstrual regularity and fertility. Page Ref: 105 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Discuss the signs and symptoms, diagnosis criteria, treatment options, and health implications of polycystic ovarian syndrome. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

22) Abdominal hysterectomy is generally recommended for which condition? A) Severe endometriosis B) Removal of the ovaries C) Suspected or confirmed cancer removal D) Abnormal uterine bleeding Answer: A Explanation: A) Abdominal hysterectomy is recommended for severe endometriosis. B) Removal of the uterus through an abdominal incision is called a total abdominal hysterectomy (TAH), and removal of both fallopian tubes and ovaries is called a bilateral salpingooophorectomy (BSO); when both procedures are done at the same time it is termed a TAH-BSO. C) Total abdominal hysterectomy (TAH) is preferred when cancer is suspected or confirmed because it permits easier exploration of the abdomen and pelvis to determine the degree and extent of involvement. D) Vaginal hysterectomy is generally done for pelvic relaxation, abnormal uterine bleeding, or small fibroids. Page Ref: 106 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Contrast laparoscope-assisted vaginal hysterectomy and abdominal hysterectomy with regard to indications for use and the advantages and disadvantages of each procedure. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

23) Which of the following systems provides a uniform format and classification of terminology based on current understanding of cervical disease? A) Levonorgestrel intrauterine B) PALM-COEIN C) Bethesda D) BSE Answer: C Explanation: A) Levonorgestrel intrauterine system is for contraception and control of excessive menstrual bleeding by suppression of endometrial growth. B) PALM-COEIN is a classification system developed for the causes of AUB. C) The Bethesda System for classifying Pap smears is a standardized method of reporting cytologic Pap smear findings and is the most widely used method in the United States. D) BSE is the acronym for breast self-examination and is not considered a system. Page Ref: 98 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss the importance of an annual Pap smear and appropriate follow-up for an abnormal finding. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

24) The nurse is preparing teaching materials for female clients who wish to perform breast selfexamination. In which order should the nurse ensure that the teaching materials present the process of inspection? 1. Compare the breasts 2. Study the skin surface 3. Analyze for symmetry 4. Study the shape and direction 5. Look at color, thickening, edema, and venous patterns Answer: 1, 3, 4, 5, 2 Explanation: When inspecting the breasts, the breasts should be first compared, then analyzed for symmetry. Next the shape and direction should be studied, followed by looking at color, thickening, edema, and venous pattern. Lastly, the skin surface should be studied. Page Ref: 89—90 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Contrast the common benign and malignant breast disorders. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

25) During a routine physical examination a female patient asks the nurse what can be done to prevent the development of breast cancer. What should the nurse review with the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Exercise regularly 2. Discuss starting tamoxifen 3. Reduce the intake of red meat 4. Maintain a normal body weight 5. Reduce the intake of dietary fat Answer: 1, 3, 4, 5 Explanation: Actions to reduce modifiable risks for breast cancer include exercising regularly, reducing the intake of red meat, avoiding obesity, and reducing dietary fat. Women at high risk of breast cancer may choose to begin chemoprevention using tamoxifen. Page Ref: 92—93 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Contrast the common benign and malignant breast disorders. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

26) A female patient is anxious about having a pelvic examination. To help reduce the patient's fears in which order should the nurse explain that the examination will be performed? 1. The speculum is inserted 2. The speculum is removed 3. The perineum is inspected 4. The rectal examination is performed 5. The healthcare provider applies gloves 6. The bimanual examination is performed Answer: 5, 3, 1, 2, 6, 4 Explanation: For a pelvic examination, the examiner dons gloves for the procedure. Let the woman know that the examiner begins with an inspection of the external genitalia. The speculum is then inserted to allow visualization of the cervix and vaginal walls and to obtain specimens for testing. After the speculum is withdrawn the examiner performs a bimanual examination of the internal organs using the fingers of one hand inserted in the woman's vagina while the other hand presses over the woman's uterus and ovaries. The final step of the procedure is generally a rectal examination. Page Ref: 95—96 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 10 Delineate the psychosocial responses a woman may experience when facing any of the common gynecologic procedures. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

27) During an interview the nurse learns that a patient's sister was recently diagnosed with endometrial cancer. What should the nurse review to reduce the patient's risk for developing the same disease process? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Smoking cessation 2. Maintain a normal body mass index 3. Consider birth control without estrogen 4. Limit the intake of alcohol to one drink per day 5. Increase exercise to 30 minutes most days of the week Answer: 2, 3 Explanation: Risk factors for endometrial cancer include obesity and long-term use of unopposed estrogen. Smoking, alcohol, and limited exercise are not risk factors for the development of endometrial cancer. Page Ref: 102—103 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 6 Discuss the signs and symptoms, medical therapy, and implications for fertility of endometriosis. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

28) The nurse is reviewing data collected during a health history and physical assessment and suspects that the patient could be experiencing polycystic ovarian syndrome (PCOS). What information did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Body mass index 31 2. Hair loss and warm moist skin 3. Periods occur every 3 to 4 months 4. Fasting capillary blood glucose 123 mg/dL 5. Inability to become pregnant after 2 years of unprotected intercourse Answer: 1, 3, 4, 5 Explanation: The most common clinical signs and symptoms of PCOS include obesity since half of women with PCOS are clinically obese. Irregular menses is the hallmark of PCOS. Hyperinsulinemia is associated with PCOS. The majority of women with PCOS struggle with some degree of infertility. Hair loss and warm moist skin are not manifestations of PCOS. Page Ref: 104—105 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation; Nursing Process. Learning Outcome: 7 Discuss the signs and symptoms, diagnosis criteria, treatment options, and health implications of polycystic ovarian syndrome. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

29) A patient receiving chemotherapy for breast cancer writes in a journal during the treatments and reads devotional material. Which phase of psychologic adjustment should the nurse identify that this patient is experiencing? A) Shock B) Denial C) Reaction D) Recovery Answer: C Explanation: A) Reaction occurs in conjunction with the initiation of treatment. Coping mechanisms become evident during this phase, and may include things like journaling and reading devotional material. Shock generally extends from the discovery of the lump through the process of diagnosis. Denial of the reality of the illness is a common response by the woman during the periods of diagnosis and treatment. Recovery begins during convalescence following the completion of medical treatment. B) Reaction occurs in conjunction with the initiation of treatment. Coping mechanisms become evident during this phase, and may include things like journaling and reading devotional material. Shock generally extends from the discovery of the lump through the process of diagnosis. Denial of the reality of the illness is a common response by the woman during the periods of diagnosis and treatment. Recovery begins during convalescence following the completion of medical treatment. C) Reaction occurs in conjunction with the initiation of treatment. Coping mechanisms become evident during this phase, and may include things like journaling and reading devotional material. Shock generally extends from the discovery of the lump through the process of diagnosis. Denial of the reality of the illness is a common response by the woman during the periods of diagnosis and treatment. Recovery begins during convalescence following the completion of medical treatment. D) Reaction occurs in conjunction with the initiation of treatment. Coping mechanisms become evident during this phase, and may include things like journaling and reading devotional material. Shock generally extends from the discovery of the lump through the process of diagnosis. Denial of the reality of the illness is a common response by the woman during the periods of diagnosis and treatment. Recovery begins during convalescence following the completion of medical treatment. Page Ref: 94 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation. Learning Outcome: 2 Describe the emotional reactions a woman may experience in regard to a diagnosis of breast cancer. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility. 29 Copyright © 2020 Pearson Education, Inc.

30) During a pelvic examination, a patient is diagnosed with a Bartholin gland cyst. For which treatment should the nurse prepare this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Pelvic ultrasound B) Antibiotic therapy C) Exploratory laparotomy D) Incision and drainage of the cyst E) Culture and sensitivity of the discharge Answer: B, D, E Explanation: A) Treatment of a Bartholin gland cyst involves antibiotic therapy, incision and drainage of the abscess, and culture and sensitivity of the discharge. A pelvic ultrasound and exploratory laparotomy are not indicated for this health problem. B) Treatment of a Bartholin gland cyst involves antibiotic therapy, incision and drainage of the abscess, and culture and sensitivity of the discharge. A pelvic ultrasound and exploratory laparotomy are not indicated for this health problem. C) Treatment of a Bartholin gland cyst involves antibiotic therapy, incision and drainage of the abscess, and culture and sensitivity of the discharge. A pelvic ultrasound and exploratory laparotomy are not indicated for this health problem. D) Treatment of a Bartholin gland cyst involves antibiotic therapy, incision and drainage of the abscess, and culture and sensitivity of the discharge. A pelvic ultrasound and exploratory laparotomy are not indicated for this health problem. E) Treatment of a Bartholin gland cyst involves antibiotic therapy, incision and drainage of the abscess, and culture and sensitivity of the discharge. A pelvic ultrasound and exploratory laparotomy are not indicated for this health problem. Page Ref: 97 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 3 Identify the implications of an abnormal finding during a pelvic examination. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

31) A patient is demonstrating manifestations of acute cervicitis. Which laboratory test should the nurse expect to be completed for this patient? A) Sedimentation rate B) Blood test for VDRL C) White blood cell count D) Vaginal smear for STIs Answer: D Explanation: A) Acute inflammation of the cervix is usually the result of infection from Neisseria gonorrhoeae or Chlamydia trachomatis. A vaginal smear for STIs will most likely be done. Sedimentation rate, blood test for VDRL, and white blood cell count are not indicated in the diagnosis of acute cervicitis. B) Acute inflammation of the cervix is usually the result of infection from Neisseria gonorrhoeae or Chlamydia trachomatis. A vaginal smear for STIs will most likely be done. Sedimentation rate, blood test for VDRL, and white blood cell count are not indicated in the diagnosis of acute cervicitis. C) Acute inflammation of the cervix is usually the result of infection from Neisseria gonorrhoeae or Chlamydia trachomatis. A vaginal smear for STIs will most likely be done. Sedimentation rate, blood test for VDRL, and white blood cell count are not indicated in the diagnosis of acute cervicitis. D) Acute inflammation of the cervix is usually the result of infection from Neisseria gonorrhoeae or Chlamydia trachomatis. A vaginal smear for STIs will most likely be done. Sedimentation rate, blood test for VDRL, and white blood cell count are not indicated in the diagnosis of acute cervicitis. Page Ref: 97 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 3 Identify the implications of an abnormal finding during a pelvic examination. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

32) The nurse is caring for a female client with a history of pelvic inflammatory disease (PID) who reports having difficulty conceiving after unprotected sex for over 2 years. Which deviation from the norm does the nurse recognize is most likely the cause of the client's infertility? A) Non-patent fallopian tube B) Unfavorable cervical mucus C) Absence of ovulation D) Abnormal endometrial preparation Answer: A Explanation: A) Women with a history of pelvic inflammatory disease (PID) have the risk of developing infertility. Specifically, obstruction and non-patent fallopian tubes often occur in PID and are a common source of infertility among women with the disease. Unfavorable cervical mucus, absence of ovulation, and abnormal endometrial preparation may all lead to infertility; however, these are not most common among women diagnosed with PID. B) Women with a history of pelvic inflammatory disease (PID) have the risk of developing infertility. Specifically, obstruction and non-patent fallopian tubes often occur in PID and are a common source of infertility among women with the disease. Unfavorable cervical mucus, absence of ovulation, and abnormal endometrial preparation may all lead to infertility; however, these are not most common among women diagnosed with PID. C) Women with a history of pelvic inflammatory disease (PID) have the risk of developing infertility. Specifically, obstruction and non-patent fallopian tubes often occur in PID and are a common source of infertility among women with the disease. Unfavorable cervical mucus, absence of ovulation, and abnormal endometrial preparation may all lead to infertility; however, these are not most common among women diagnosed with PID. D) Women with a history of pelvic inflammatory disease (PID) have the risk of developing infertility. Specifically, obstruction and non-patent fallopian tubes often occur in PID and are a common source of infertility among women with the disease. Unfavorable cervical mucus, absence of ovulation, and abnormal endometrial preparation may all lead to infertility; however, these are not most common among women diagnosed with PID. Page Ref: 108 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 11 Compare the essential components of fertility with the possible causes of infertility. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

33) The nurse takes a telephone call from a women's health clinic patient. What information should cause the nurse to suspect that the patient is experiencing a cystocele? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Bloody urine B) Low back pain C) Onset of stress incontinence D) Feeling of fullness in the perineum E) Feels like something "fell out" of the vagina Answer: C, D, E Explanation: A) Manifestations of a cystocele include symptoms of stress urinary incontinence (SUI), pelvic pressure and the perception of something "falling out" of the vagina. Hematuria and low back pain are not manifestations of a cystocele. B) Manifestations of a cystocele include symptoms of stress urinary incontinence (SUI), pelvic pressure and the perception of something "falling out" of the vagina. Hematuria and low back pain are not manifestations of a cystocele. C) Manifestations of a cystocele include symptoms of stress urinary incontinence (SUI), pelvic pressure and the perception of something "falling out" of the vagina. Hematuria and low back pain are not manifestations of a cystocele. D) Manifestations of a cystocele include symptoms of stress urinary incontinence (SUI), pelvic pressure and the perception of something "falling out" of the vagina. Hematuria and low back pain are not manifestations of a cystocele. E) Manifestations of a cystocele include symptoms of stress urinary incontinence (SUI), pelvic pressure and the perception of something "falling out" of the vagina. Hematuria and low back pain are not manifestations of a cystocele. Page Ref: 105 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 8 Compare the signs and symptoms and treatment options of the three forms of pelvic relaxation–cystocele, rectocele, and uterine relaxation. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

34) A patient with a rectocele is experiencing progressive pain and constipation. What should the nurse expect to be indicated for this patient? A) Enemas B) Surgery C) Laxatives D) Antibiotics Answer: B Explanation: A) Surgery is often indicated for a rectocele. Enemas, laxatives, and antibiotics may help treat the symptoms but will not cure the problem. B) Surgery is often indicated for a rectocele. Enemas, laxatives, and antibiotics may help treat the symptoms but will not cure the problem. C) Surgery is often indicated for a rectocele. Enemas, laxatives, and antibiotics may help treat the symptoms but will not cure the problem. D) Surgery is often indicated for a rectocele. Enemas, laxatives, and antibiotics may help treat the symptoms but will not cure the problem. Page Ref: 105 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 8 Compare the signs and symptoms and treatment options of the three forms of pelvic relaxation–cystocele, rectocele, and uterine relaxation. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

35) A 38-year-old female is scheduled for a laparoscopic-assisted vaginal hysterectomy (LAVH) for severe endometriosis with the removal of both ovaries. What should the nurse expect to be prescribed for this patient postoperatively? A) Corticosteroid therapy B) Mineralocorticoid therapy C) Estrogen replacement therapy D) Progesterone replacement therapy Answer: C Explanation: A) Supplemental estrogen replacement therapy is recommended in a premenopausal woman having both fallopian tubes and ovaries removed. Corticosteroid and mineralocorticoid therapies are indicated for adrenal gland dysfunction. Progesterone replacement therapy is not indicated for this patient's health problem. B) Supplemental estrogen replacement therapy is recommended in a premenopausal woman having both fallopian tubes and ovaries removed. Corticosteroid and mineralocorticoid therapies are indicated for adrenal gland dysfunction. Progesterone replacement therapy is not indicated for this patient's health problem. C) Supplemental estrogen replacement therapy is recommended in a premenopausal woman having both fallopian tubes and ovaries removed. Corticosteroid and mineralocorticoid therapies are indicated for adrenal gland dysfunction. Progesterone replacement therapy is not indicated for this patient's health problem. D) Supplemental estrogen replacement therapy is recommended in a premenopausal woman having both fallopian tubes and ovaries removed. Corticosteroid and mineralocorticoid therapies are indicated for adrenal gland dysfunction. Progesterone replacement therapy is not indicated for this patient's health problem. Page Ref: 106 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 9 Contrast laparoscope-assisted vaginal hysterectomy and abdominal hysterectomy with regard to indications for use and the advantages and disadvantages of each procedure. MNL LO: Demonstrate use of the nursing process in the care of women genital or breast disorders, or infertility.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 7 Social Issues 1) There have been a number of historical trends that have contributed to the existing wage gap, including which of the following? A) There was a perception that men were the sole breadwinners. B) Women who were competitive in the work environment were viewed positively. C) Women in past generations generally were not limited to certain occupations. D) Increase in societal importance of women's intellectual traits. Answer: A Explanation: A) Historically, there was a perception that men were the sole breadwinners, thus higher salaries for men were justified to support a family. B) Historically, women who were competitive in the work environment were viewed negatively. C) Women in past generations generally were limited to certain occupations. D) There was an increase in societal importance focusing on women's appearance, with intellectual traits being viewed less favorably. Page Ref: 124 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. C. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: V. 8. Discuss the implications of healthcare policy on issues of access, equity, affordability, and social justice in healthcare delivery. | NLN Competencies: Context and Environment: Appreciate the influence of systems of healthcare outcomes. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify contributing factors that perpetuate the gender wage gap and economic inequality for women. MNL LO: Demonstrate understanding of social issues affecting women.

2) The nurse is planning a community educational presentation for people living below the poverty level. The nurse knows that which of the following is the largest population in this socioeconomic category? A) Adults in communal living situations B) Young married couples under the age of 20 C) Single women with children D) Single adults Answer: C Explanation: A) Adults living together are not usually below the poverty level. B) Young married couples are not the most likely to encounter poverty. C) Of households headed by single mothers, 40% live in poverty. D) Single adults are not the most likely to encounter poverty. Page Ref: 121 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: V. 8. Discuss the implications of healthcare policy on issues of access, equity, affordability, and social justice in healthcare delivery. | NLN Competencies: Context and Environment: Appreciate the influences of systems on healthcare outcomes. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the meaning of the phrase feminization of poverty and its impact on women and their families. MNL LO: Demonstrate understanding of social issues affecting women.

3) The community clinic nurse manager is working on a long-term budget. The manager understands that in the next few years, Medicaid is expected to pay for fewer births. This is, in part, because of which of the following? A) The U.S. economy is becoming stronger. B) More women are able to pay for private insurance. C) New public policies are providing other forms of payment. D) Rules for Medicaid have been changed. Answer: D Explanation: A) The strength of the economy is not a factor in Medicaid regulations. B) Private insurance is expensive, and not affordable to poor women who would be eligible for Medicaid. C) Although some states are implementing affordable healthcare options, not all states have chosen to do so. D) Women receiving Temporary Assistance for Needy Families (TANF) do not automatically receive Medicaid services when they become pregnant. Page Ref: 124 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. C. 13. Acknowledge the tension that may exist between patient rights, and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: V. 3. Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services. | NLN Competencies: Context and Environment: Appreciate the influence of systems on healthcare outcomes. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Discuss the impact of poverty on women's access to healthcare. MNL LO: Demonstrate understanding of social issues affecting women.

4) The nurse working at a homeless shelter is studying case statistics. Of the total homeless population served at the shelter, which group would the nurse's statistics likely uncover as the fastest-growing group? A) Unemployed women B) Families with children C) The mentally ill D) The elderly Answer: B Explanation: A) Unemployment is one aspect of this trend, but unemployed women are not the fastest-growing group. B) In 2012, the number of homeless individuals fell slightly, by 0.4%, with the exception of homeless families. C) The mentally ill are one part of this equation, but are not the fastest-growing group. D) The elderly are part of the group living in the shelters, but are not the fastest-growing group. Page Ref: 123 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: II. B. 6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice. | AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal, and political factors influencing healthcare delivery and practice. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the impact of poverty on women's access to healthcare. MNL LO: Demonstrate understanding of social issues affecting women.

5) The nurse working with a client who is seeking a family and medical leave knows that the employee must meet which eligibility requirement of the Family and Medical Leave Act (FMLA) of 1993? A) Work at least 40 hours per week B) Have been employed for at least 1 month C) Work for a company with fewer than 50 employees D) Parental leave for childbirth or adoption by her employer Answer: D Explanation: A) Employees must work at least 25 hours per week to be eligible. B) Employees must have been in their position for at least 1 year. C) FMLA applies only to companies with 50 or more employees. D) The Family and Medical Leave Act mandates parental leave for childbirth or adoption but applies only to companies with 50 or more employees. Page Ref: 125 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 6. Describe strategies to empower patients or families in all aspects of the healthcare process. | AACN Essentials Competencies: V. 4. Examine legislative and regulatory processes relevant to the provision of healthcare. | NLN Competencies: Context and Environment: Healthcare economic policy; reimbursement structures; accreditation standards; staffing models and productivity; supply chain models. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the implications of the Family and Medical Leave Act (FMLA) of 1993 on maternity and paternity leave and how this has impacted families. MNL LO: Demonstrate understanding of social issues affecting women.

6) The pregnant client employed at a factory asks the nurse whether exposure to chemicals can cause harm to her fetus. The nurse should advise the client that exposure to which substance can lead to neurological damage? A) Lead B) Latex C) Formaldehyde D) Benzene Answer: A Explanation: A) Women exposed to lead during pregnancy are at risk for spontaneous abortion, prematurity, low birth weight, intrauterine growth restriction, and brain, kidney, and nervous system dysfunction. B) Exposure to latex is not known to cause neurological damage. C) Exposure to formaldehyde is not known to cause neurological damage. D) Exposure to benzene is not known to cause neurological damage. Page Ref: 127 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Identify potential adverse outcomes associated with environmental hazards in the workplace or the home of a woman of childbearing age. MNL LO: Demonstrate understanding of social issues affecting women.

7) Pesticide exposure can be linked to a variety of adverse health outcomes, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased risk of cancer B) Endocrine abnormalities C) Liver damage D) Birth defects E) Cardiovascular diseases Answer: A, B, C, D Explanation: A) Pesticide exposure can be linked to a variety of adverse health outcomes, including an increased risk of cancer. B) Pesticide exposure can be linked to a variety of adverse health outcomes, including endocrine abnormalities. C) Pesticide exposure can be linked to a variety of adverse health outcomes, including liver damage. D) Pesticide exposure can be linked to a variety of adverse health outcomes, including birth defects. E) Cardiovascular diseases in not one of the adverse health outcomes linked to pesticide exposure. Page Ref: 127—128 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: VII. 2. Conduct a health history, including environmental exposure and family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Identify potential adverse outcomes associated with environmental hazards in the workplace or the home of a woman of childbearing age. MNL LO: Demonstrate understanding of social issues affecting women.

8) Which of the following federal departments actively investigates and prosecutes individuals who cross state lines to avoid paying child support, and now intercepts delinquent parents' income tax refunds? A) U.S. Department of Health and Human Services B) U.S. Department of Labor C) U.S. Department of Justice D) U.S. Equal Employment Opportunity Commission Answer: C Explanation: A) The U.S. Department of Health and Human Services does not investigate and prosecute individuals who cross state lines to avoid paying child support. B) The U.S. Department of Labor keeps track of labor statistics. C) The U.S. Department of Justice actively investigates and prosecutes individuals who cross state lines to avoid paying child support, and now intercepts delinquent parents' income tax refunds. D) The U.S. Equal Employment Opportunity Commission receives complaints from pregnant women who were turned down for jobs, denied transfers to positions for which they were qualified, or fired unjustly. Page Ref: 122 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. A. 4. Examine how the safety, quality, and cost effectiveness of healthcare can be improved through the active involvement of patients and families. | AACN Essentials Competencies: V. 1. Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments; including local, state, national, and global healthcare trends. | NLN Competencies: Context and Environment: Healthcare economic policy; reimbursement structures; accreditation standards; staffing models and productivity; supply chain models. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss the meaning of the phrase feminization of poverty and its impact on women and their families. MNL LO: Demonstrate understanding of social issues affecting women.

9) The nurse manager is preparing an educational in-service for staff nurses about elder abuse. The nurse manager develops a hypothetical situation: A wheelchair-bound client who lives with her daughter has experienced hunger because she cannot reach the cupboards to make lunch. Which category of elder abuse does this example describe? A) Psychologic abuse B) Physical abuse C) Neglect D) Financial abuse Answer: C Explanation: A) Psychologic abuse is usually verbal. B) Physical abuse involves some degree of pain and injury. C) Neglect is a failure on the part of a caregiver, or any person having custody of an elder, to provide reasonable care, which is the degree of care that a reasonable person would provide. D) Financial abuse involves money. Page Ref: 130 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Identify the four different types of elder abuse and the detrimental impact they have on older women. MNL LO: Demonstrate understanding of social issues affecting women.

10) Psychologic elder abuse includes, but is not limited to, which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Verbal assaults B) Humiliation C) Desertion D) Intimidation E) Failure to provide reasonable care Answer: A, B, D Explanation: A) Psychologic abuse includes verbal assaults. B) Psychologic abuse includes humiliation. C) Abandonment is the desertion of an elder by any person responsible for the care and custody of that elder. D) Psychologic abuse includes intimidation. E) Failure on the part of a caregiver, or any person having custody of an elder, to provide reasonable care, is consider neglect. Page Ref: 130 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Identify the four different types of elder abuse and the detrimental impact they have on older women. MNL LO: Demonstrate understanding of social issues affecting women.

11) The community health nurse manager is reviewing the charts of female elderly clients. Which issue are these clients most likely to experience? A) Adequate financial resources to purchase medications B) Senior services that provide transportation to healthcare appointments C) Multiple medications prescribed by different physicians D) Medicare that covers healthcare costs so no out-of-pocket expenses occur Answer: C Explanation: A) Older women, particularly those who are poor, face multiple barriers in obtaining adequate healthcare services, including excessive medical costs not covered by Medicare. B) Not all elderly have adequate access to transportation for healthcare. C) Polypharmacy, which means multiple medicines, is a common problem in the elderly population. Elderly women (as well as elderly men) often have multiple healthcare providers with different specialties who provide pharmacologic intervention. D) Lack of private health insurance coverage and excessive medical costs not covered by Medicare can be barrier in obtaining adequate healthcare services. Page Ref: 131 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: V. B. 6. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss possible adverse outcomes that may occur as a result of aging on a woman's health and healthcare. MNL LO: Demonstrate understanding of social issues affecting women.

12) The nurse recognizes that what are the most common disabilities in women? A) Asthma and headaches B) Arthritis or rheumatism C) Adverse kidney and nervous system functioning D) Cardiovascular diseases Answer: B Explanation: A) Asthma and headaches are health conditions associated with air pollution. B) The most common disabilities in women are arthritis or rheumatism and the incidence of disability increases with age. C) Adverse kidney and nervous system functioning are effects of lead exposure. D) Cardiovascular diseases are health conditions associated with air pollution. Page Ref: 131 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: V. B. 6. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Identify the five types of disability and their impact on quality of life for disabled women. MNL LO: Demonstrate understanding of social issues affecting women.

13) A home care nurse is looking over the charts of four elderly female clients. The nurse knows that which client has the highest risk for developing diabetes and heart disease? A) A woman who is 55 and white B) A woman who is 60 and from a middle-class background C) All women over 55 D) A woman over 65 who is African American Answer: D Explanation: A) Minority and low-income women 65 years old and older are more likely than white, higher income women to have serious health problems. B) Minority and low-income women 65 years old and older are more likely than white, higher income women to have serious health problems. C) By age 65, not age 55, half of all women have developed two or more chronic diseases. D) Minority and low-income women 65 years old and older are more likely than white, higher income women to have serious health problems. Page Ref: 131 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Discuss possible adverse outcomes that may occur as a result of aging on a woman's health and healthcare. MNL LO: Demonstrate understanding of social issues affecting women.

14) The nurse at a women's clinic is reviewing a new client health information questionnaire. Which question does she find to be insulting and discriminatory toward lesbian clients? A) Who should be contacted in case of emergency? B) What method of birth control do you use? C) How often do you drink alcohol? D) Do you feel safe in your relationship? Answer: B Explanation: A) Asking who should be contacted in an emergency is not an insulting or discriminatory question. Emergency contact is important for all clients. B) The assumption that all women are in need of contraception for birth control is often cited as a reason that lesbian women may conceal their sexual orientation. C) Lesbians should be assessed for chemical dependency like all clients. D) Asking whether the client feels safe in her relationship and assessing for domestic partner violence are common interventions for all clients who come into the clinic. Page Ref: 135 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Explain the implications of various barriers that lesbian, bisexual, and transgender women face and how they can negatively impact healthcare access and outcomes. MNL LO: Demonstrate understanding of social issues affecting women.

15) Lesbian, transgendered, and bisexual women are at greater risk for health and social disparities, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased suicide risk B) Increased risk of homelessness C) Lack of screening for female-related cancers D) Lack of screening for lung cancers E) Increased divorce rates Answer: A, B, C Explanation: A) Healthy People 2020 recognizes that health disparities continue to exist for lesbian, gay, bisexual, and transgendered individuals, which includes increased suicide risk. B) Healthy People 2020 recognizes that health disparities continue to exist for lesbian, gay, bisexual, and transgendered individuals, which includes increased risk of homelessness. C) Healthy People 2020 recognizes that health disparities continue to exist for lesbian, gay, bisexual, and transgendered individuals, which includes lack of screening for female-related cancers. D) Lack of screening for lung cancer is not a specific risk factor for this demographic. E) Increased divorce rates is not a specific factor for this demographic. Page Ref: 133—134 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Explain the implications of various barriers that lesbian, bisexual, and transgender women face and how they can negatively impact healthcare access and outcomes. MNL LO: Demonstrate understanding of social issues affecting women.

16) The nurse is working with a group of recent immigrants from a country in which female genital mutilation (FGM) is practiced. In order to be effective in teaching about gynecologic care in the U.S., the nurse must keep which issues in mind? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Women might undergo FGM willingly to support the status quo of society. B) Women might undergo the procedure to be considered for marriage. C) Women who immigrate to other countries feel a sense pride once the procedure has been performed. D) Women might undergo the procedure to gain greater sexual pleasure. E) Women might undergo the procedure to lose their virginity. Answer: A, B Explanation: A) The procedure is performed by various ethnic groups for a variety of reasons, including perceived improved social acceptance. B) The procedure is performed by various ethnic groups for a variety of reasons, including marriageability. C) Women who immigrate to other countries may feel a sense of shame or embarrassment once the procedure has been performed. D) The procedure is performed by various ethnic groups for a variety of reasons, including the reduction of female sexual desire. E) Women might undergo the procedure to preserve their virginity. Page Ref: 135 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 11 Discuss the cultural and healthcare implications of female genital mutilation. MNL LO: Demonstrate understanding of social issues affecting women.

17) The community nurse is conducting health assessments at the homeless shelter and notes that the majority of clients are female. What should the nurse identify as reasons for the percentage of women who are homeless? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Unemployment 2. Substance abuse 3. Recent prison release 4. Lack of family support 5. Inadequate child support Answer: 1, 2, 3, 4 Explanation: Factors that increase the risk of female homelessness include unemployment, substance abuse, recent prison release and lack of family support. Inadequate child support is not identified as a factor that increases the risk of female homelessness. Page Ref: 123 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice: conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 6 Specify the factors that commonly contribute to many older women's economic vulnerability. MNL LO: Demonstrate understanding of social issues affecting women.

18) While visiting the home of a single patient who is raising school-age children, the nurse becomes concerned that the quality of care for the children after school is less than adequate. What did the nurse observe that led to this conclusion? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Children fighting in the front yard 2. Youngest child failing spelling and arithmetic 3. Middle child received an A on a writing assignment 4. Youngest child received a black eye from a child in school 5. Oldest child riding the bicycle in the street without a helmet Answer: 1, 2, 4, 5 Explanation: Low-quality childcare is associated with increased peer arguments, lower cognitive and language scores, bullying, and risky or impulsive behavior. Higher academic scores are associated with mothers who have college educations. Page Ref: 122 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 3 Discuss the impact of poverty on women's access to healthcare. MNL LO: Demonstrate understanding of social issues affecting women.

19) At the end of a routine examination, a 68-year-old female asks the nurse what she should observe to determine if she should obtain custody of her two preschool-age grandchildren. What factors should the nurse tell this patient to look for? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Parental divorce 2. Long work hours 3. Drug or alcohol abuse 4. Intimate partner violence 5. Use of public transportation Answer: 1, 3, 4 Explanation: The most common reasons why grandparents obtain guardianship of grandchildren include parental divorce, drug or alcohol abuse, and intimate partner violence. Long work hours and use of public transportation are not reasons for grandparents to obtain guardianship of grandchildren. Page Ref: 127 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 6 Specify the factors that commonly contribute to many older women's economic vulnerability. MNL LO: Demonstrate understanding of social issues affecting women.

20) An older patient is demonstrating a new onset of confusion and forgetfulness. While reviewing the patient's medical records, the nurse suspects these new manifestations are druginduced. Which medications did the nurse identify as causing changes in cognitive functioning in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Antihistamine for allergies 2. Antidepressant for nerve pain 3. Antibiotic for bronchial infection 4. Anticoagulant for atrial fibrillation 5. Antihypertensive for high blood pressure Answer: 1, 2 Explanation: Certain drugs can cause cognitive impairment, especially when diminished kidney and liver function is present. Drugs that alter the central nervous system include antihistamines and antidepressants. These drugs may cause forgetfulness, confusion, disorientation, and inability to concentrate. Antibiotics, anticoagulants, and antihypertensives are not identified as causing cognitive impairment. Page Ref: 131 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 8 Discuss possible adverse outcomes that may occur as a result of aging on a woman's health and healthcare. MNL LO: Demonstrate understanding of social issues affecting women.

21) While conducting a health interview, the nurse suspects that a middle-aged female client has undiagnosed learning disabilities. What did the nurse observe to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Difficulty reading instructions 2. Illegible signature on treatment forms 3. Difficulty tying shoes when eyeglasses are not being worn 4. Inability to hear normal conversation through the right ear 5. Inability to select correct paper money to pay the insurance co-pay Answer: 1, 2, 5 Explanation: Learning disabilities can inhibit educational attainment and employment. Learning disabilities include dyslexia, which can hinder reading, writing, and spelling; dysgraphia, which manifests with poor handwriting; and dyscalculia, which includes difficulty with processing math. The inability to tie shoes without wearing eyeglasses and not hearing through the right ear are physical issues that do not necessarily impact learning. Page Ref: 132 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 9 Identify the five types of disability and their impact on quality of life for disabled women. MNL LO: Demonstrate understanding of social issues affecting women.

22) The nurse is concerned that a clinic patient is at risk for experiencing poverty. Which information did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Of African-American descent 2. Attends church on Sunday mornings 3. Completed only up to 10th grade 4. Raising 2 children under the age of 10 alone 5. Works as a clothing assistant in a retail store Answer: 1, 3, 4 Explanation: Factors that contribute to the feminization of poverty include being a member of an ethnic minority, not having sufficient education, and raising children as a single mother. Attending church and working in a retail store do not contribute to the feminization of poverty. Page Ref: 121 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 1 Discuss the meaning of the phrase feminization of poverty and its impact on women and their families. MNL LO: Demonstrate understanding of social issues affecting women.

23) While attending a community fair the nurse is surprised to learn the number of women who are homemakers, teachers, and nurses. What impact should the nurse recognize that this has on these individuals' income? A) Potential for longer lifespan B) Overall lower income than men C) Reduced risk for chronic illnesses D) Increased risk for health problems Answer: B Explanation: B) Historical trends that have contributed to an existing wage gap include being limited to occupations such as child care, teaching, and nursing, which by virtue of being femaledominated professions pay lower salaries. The professions of homemakers, teachers, and nurses will not impact lifespan and chronic illness, or increase the risk for health problems. Page Ref: 124—125 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 2 Identify contributing factors that perpetuate the gender wage gap and economic inequality for women. MNL LO: Demonstrate understanding of social issues affecting women.

24) A female is offered a position as a manager with a major city hotel that offers flexibility with childcare and family issues. What should this individual also investigate financially before accepting this position? A) Number of sick days B) Expectations to work holidays C) Number of overtime hours expected to work every month D) Wages that are commensurate with those of male employee managers Answer: D Explanation: D) One reason for wage discrepancy is that women accept lower salaries in exchange for provisions such as flexibility for childcare responsibilities and family-related issues. This person needs to investigate the wages she will receive before accepting this position. The number of sick days, expectations to work holidays, and overtime hours would have a higher impact on work-life balance than on finances. Page Ref: 124—125 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 2 Identify contributing factors that perpetuate the gender wage gap and economic inequality for women. MNL LO: Demonstrate understanding of social issues affecting women.

25) A patient requiring back surgery wants to take family/medical leave to recover but is not sure if she is eligible. What should the nurse review as eligibility requirements for this coverage? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Work more than 25 hours per week 2. Have been in the job for at least 1 year 3. Be expected to return to work within 4 weeks 4. Be willing to accept a lower-paying position upon return 5. Have provisions to self-pay for health insurance while off from work Answer: 1, 2 Explanation: Limitations to the Family Medical Leave Act (FMLA) include that employees must work at least 25 hours per week to be eligible and must have been in their position for at least 1 year. The maximum amount of leave allowed for FMLA is 12 weeks. The Act provides job security for the person to return to their former position, or one that is considered comparable. Health insurance benefits are covered while on leave. Page Ref: 125 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 4 Describe the implications of the Family and Medical Leave Act (FMLA) of 1993 on maternity and paternity leave and how this has impacted families. MNL LO: Demonstrate understanding of social issues affecting women.

26) The elderly parent of an employee at an insurance company sustains a myocardial infarction and needs assistance for several weeks after returning home from the hospital. What option should the employee consider to cover her absence while caring for her parent? A) Sick days B) Personal days C) Vacation days D) Family medical leave Answer: D Explanation: D) The Family and Medical Leave Act (FMLA) offers twelve weeks of unpaid leave to care for a parent who is in recovery from an illness. The employee does not need to take sick days, personal days, or vacation days to care for her parent. Page Ref: 125 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Describe the implications of the Family and Medical Leave Act (FMLA) of 1993 on maternity and paternity leave and how this has impacted families. MNL LO: Demonstrate understanding of social issues affecting women.

27) During a routine prenatal visit the nurse suspects that a patient in the 14th week of gestation is affected by environmental pollution. What assessment findings caused the nurse to come to this conclusion? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Headache 2. Scratchy throat 3. Chest wheezing 4. Abdominal pain 5. Itchy burning eyes Answer: 1, 2, 3, 5 Explanation: Health conditions associated with air pollution include headache, throat irritation, asthma, and eye irritation. Abdominal pain is not a health condition associated with air pollution. Page Ref: 128 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 5 Identify potential adverse outcomes associated with environmental hazards in the workplace or the home of a woman of childbearing age. MNL LO: Demonstrate understanding of social issues affecting women.

28) An older female patient is concerned about the finances needed to run her home. What event in this person's life should the nurse realize is causing her financial concern? A) Change in the number of prescribed medications B) Recent death of spouse after a long and costly illness C) Participation in activities at the community center D) Relocation of older children to another city Answer: B Explanation: B) A husband's long, costly illness and the decrease or loss of his pension following his death can negatively impact a woman's financial resources. There is no information about how the patient's medications have changed. She could be prescribed less. Participating in activities and having adult children move away would not directly impact this older person's financial status. Page Ref: 129—130 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 6 Specify the factors that commonly contribute to many older women's economic vulnerability. MNL LO: Demonstrate understanding of social issues affecting women.

29) An older person contacts the emergency medical service at 11 PM to report that she has been left sitting in her wheelchair all day after her caregiver left in the morning to buy groceries. What type of elder abuse is this person experiencing? A) Abandonment B) Physical abuse C) Financial abuse D) Psychological abuse Answer: A Explanation: A) Abandonment is the desertion of an elder by any person responsible for the care and custody of that elder, under circumstances in which a reasonable person would continue to provide care. There is no evidence that the older person is experiencing physical, financial, or psychological abuse. Page Ref: 130 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 7 Identify the four different types of elder abuse and the detrimental impact they have on older women. MNL LO: Demonstrate understanding of social issues affecting women.

30) The nurse determines that a patient in the clinic has a learning disability. What did the nurse assess to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Dyslexia 2. Dysgraphia 3. Hearing loss 4. Osteoarthritis 5. Bilateral cataracts Answer: 1, 2 Explanation: Learning disabilities can inhibit educational attainment and employment and include dyslexia and dysgraphia. Hearing loss and bilateral cataracts are sensory changes that would not necessarily impact learning. Osteoarthritis is not a learning disability. Page Ref: 132 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 9 Identify the five types of disability and their impact on quality of life for disabled women. MNL LO: Demonstrate understanding of social issues affecting women.

31) A 24-year-old patient with an intellectual disability at 30 weeks' gestation asks when it is safe to have an abortion. How should the nurse respond to this patient? A) "Have you been hiding your pregnancy?" B) "The safe time to end a pregnancy has passed." C) "Is it safe for me to assume that you don't want to have this baby?" D) "I guess you didn't realize that an abortion should have occurred months ago." Answer: C Explanation: C) The nurse should explain about the safe time to end a pregnancy in a more appropriate way. The patient has an intellectual disability and may not understand when an abortion can be performed. Asking if the patient is hiding the pregnancy is inappropriate. Asking if the patient does not want to have the baby is appropriate if the patient is asking for information about an abortion. Saying that the patient didn't realize that an abortion should have occurred months ago would be inappropriate because the patient has an intellectual disability. Page Ref: 131—132 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 9 Identify the five types of disability and their impact on quality of life for disabled women. MNL LO: Demonstrate understanding of social issues affecting women.

32) An older female patient with a known intellectual disability is newly diagnosed with osteoporosis and admitted with a fractured hip after falling in the home. What should the nurse realize could have contributed to this patient's health problem? A) Importance of resting during the day B) Need to reduce the amount of physical activity C) Understanding home environmental safety needs D) Reducing the oral intake of protein and carbohydrates Answer: C Explanation: C) Understanding home environmental safety needs could have been an issue with the patient with an intellectual disability. Resting, reducing physical activity, and altering the intake of protein and carbohydrates would not be beneficial for the patient with osteoporosis. Page Ref: 133 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 9 Identify the five types of disability and their impact on quality of life for disabled women. MNL LO: Demonstrate understanding of social issues affecting women.

33) The nurse notes that a lesbian client who recently found a breast lump on self-examination has not had a mammogram for 10 years. When asked about this delay the client states that she was not made to feel comfortable during the last mammogram. What should the nurse recognize is the underlying problem that this client is describing? A) Social barrier B) Emotional barrier C) Fear of finding a health problem D) Discomfort with the examination Answer: A Explanation: A) Since the patient is lesbian and did not feel comfortable during her last mammogram, the nurse suspects that the patient experienced discrimination and social barriers related to the client's sexual orientation. Lesbian women are at greater risk for health and social disparities such as lack of screening for female-related cancers (breast cancer and cervical cancer). There is no information to support fear of finding a health problem, or discomfort with the examination. Although the client is likely emotional over the experience, the underlying problem described is a social barrier or discrimination. Page Ref: 134 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 10 Explain the negative implications of homophobia for lesbian and bisexual women and how it can negatively impact healthcare access and outcomes. MNL LO: Demonstrate understanding of social issues affecting women.

34) A lesbian female is surprised to learn of contracting the human papillomavirus. What should the nurse explain to this patient? A) "Are you telling me everything about your sexual orientation?" B) "It is rare for this infection to occur in women such as yourself." C) "Is it possible that your partner has been having intercourse with a man?" D) "Exposure to vaginal secretions can increase the risk of sexually transmitted infections." Answer: D Explanation: D) Lesbian sexual contact can transmit a number of STIs and the virus that causes cervical cancer, because it involves exposure to vaginal secretions. Women's health services in particular have not shown acceptance of lesbian status, as demonstrated by asking if the patient has been truthful about sexual orientation, stating that the infection is rare in people like the patient, and suggesting that the patient's partner is having intercourse with a man. Page Ref: 135 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 10 Explain the negative implications of homophobia for lesbian and bisexual women and how it can negatively impact healthcare access and outcomes. MNL LO: Demonstrate understanding of social issues affecting women.

35) A patient with female genital mutilation is being prepared for a gynecologic examination. What cultural implications should the nurse keep in mind when assisting with this examination? A) Maintain a nonjudgmental attitude B) The procedure was performed by choice C) The patient is at increased risk for genital infection D) The procedure was performed to increase sexual satisfaction Answer: A Explanation: A) Women who immigrate to other countries may feel a sense of shame or embarrassment once the procedure has been performed. The nurse needs to maintain a nonjudgmental attitude to support this patient's cultural needs. Most female genital mutilations are not performed by choice. They can increase the patient's risk for genital infection however this would not support the patient's cultural needs. Female genital mutilation is performed to reduce sexual satisfaction. Page Ref: 135 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation. Learning Outcome: 11 Discuss the cultural and healthcare implications of female genital mutilation. MNL LO: Demonstrate understanding of social issues affecting women.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 8 Violence Against Women 1) The client has been a victim of a violent, sadistic rape. She is crying and asks the nurse, "Why would someone do something like that?" The nurse should explain that which of the following is the primary purpose of sadistic rape? A) Take pleasure from the victim's struggle and pain B) Express feelings of rage C) Feel a sense of power or mastery D) Relieve intolerable anxiety Answer: A Explanation: A) In sadistic rape, the assailant has an antisocial personality and delights in torture and mutilation. In this type of rape, the victim and assailant are generally strangers, and the assault is planned. Sadistic rapes cause the most injuries, including homicide. B) In anger rape, the sexual assault is used to express feelings of rage and to retaliate for what the attacker perceives as wrongs against him. These perceived wrongs most often have nothing to do with the rape victim. Considerable brutality and degradation can characterize this type of rape. Attacks on older women often are a form of anger rape. C) In power rape, the purpose of the assault is control or mastery. The assailant uses sexual intercourse to place a woman in a powerless position so that he can feel dominant, potent, and strong. He often believes that his victim enjoys the assault, and he exerts only the amount of force necessary to subdue his victim. Often power rape is a planned stranger attack, but most acquaintance rapes are also power rapes. The vast majority of all rapes are motivated by this need for power and control. D) Anxiety is not associated with a type of rape. Page Ref: 150 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Crisis Intervention Standards: QSEN Competencies: I. C. 9. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Identify the phases of the rape trauma syndrome. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

2) The nurse is teaching an in-service educational presentation about working with battered women. The nurse should explain that it is often frustrating for nurses to work with battered women for which reasons? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) There is little the nurse can really do to help. B) Healthcare policies and practices are not supportive of abused women. C) Both husband and wife must agree to therapy. D) These women might return to the abusive situation. E) Women often believe that they are the cause of the abuse. Answer: D, E Explanation: A) Healthcare providers can play a critical role in identifying and reducing violence, even in homicide prevention efforts. B) Since 1980, there have been a number of notable changes in healthcare policy and practices aimed at responding to violence against women. C) The abuser must seek behavior change therapy to accomplish permanent change. D) Women often believe that escape is futile, or escape and then return when the crisis is over. E) Women are often convinced by the abusers that it is their own behavior that causes the abuse. Page Ref: 142—143 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. C. 5. Recognize personally held attitudes about working with patients from different ethnic, cultural, and social backgrounds. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Identify the phases of the cycle of violence. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

3) The nurse is planning a community education presentation on battering. Which statement about battering should the nurse include? A) Battering occurs in a small percentage of the population. B) Battering is mainly a lower-class, blue-collar problem. C) Battered women are at greatest risk for severe violence when they leave the batterer. D) If the batterer stops drinking, the violence usually stops. Answer: C Explanation: A) The statistics on reported cases underrepresent the true incidence. As many as one in three women may be the victim of assault by her partner in her lifetime; however, it is a widely underreported crime. B) Domestic violence occurs among all sectors of society. It happens to women of all socioeconomic statuses, races, ethnicities, and religious faiths. C) Battered women are at greatest risk for injury or domestic homicide when they leave the abuser. D) Battered women sometimes think that the abuse will stop if their partners stop drinking or using drugs. Unfortunately, this usually does not happen. Page Ref: 142 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify factors that contribute to domestic violence. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

4) The nurse is interviewing a client who has admitted to being a victim of domestic violence. What is the most typical description of how the domestic violence developed in a relationship? A) "He changed overnight. Everything was fine, and all of a sudden he flipped out and beat me up; he nearly killed me." B) "It was severe from the beginning. As soon as we got married, he began hitting me and threatening to kill me." C) "We've both always dated other people. I thought that was understood. He was as emotionally abusive in the beginning as he is now." D) "I don't know when it started, really. It was gradual. First, just yelling, blaming, and shoving. Then the beatings started; and now they're more frequent." Answer: D Explanation: A) Domestic violence does not begin suddenly, and will always escalate. B) Typically, these forms of abuse begin slowly and subtly after some form of commitment, such as engagement, onset of a sexual relationship, or marriage. C) Typically, these forms of abuse begin slowly and subtly after some form of commitment, such as engagement, onset of a sexual relationship, or marriage. D) Typically, these forms of abuse begin slowly and subtly after some form of commitment, such as engagement, onset of a sexual relationship, marriage, pregnancy, or first childbirth. Page Ref: 140—141 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify factors that contribute to domestic violence. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

5) The nurse is presenting a session on intimate partner violence. Which statement by a client indicates a need for further education? A) "My daughter is not to blame for the violence in her marriage." B) "Everyone experiences anger and hitting in a relationship." C) "Abusers can be either husbands or boyfriends or girlfriends." D) "The 'honeymoon period' follows an episode of violence." Answer: B Explanation: A) This statement recognizes that the blame for her assault lies with her assailant, not with the victim. B) Violence is not a normal part of intimate relationships. Domestic violence, also called intimate partner violence (IPV), is defined as a pattern of coercive behaviors and methods used to gain and maintain power and control by one individual over another in an adult intimate relationship. This statement indicates that the client has likely been a victim of domestic violence herself. C) Batterers come from all racial, ethnic, and religious groups and all professions, occupations, and socioeconomic strata. Batterers can also be either male or female. D) An acute episode of battering is followed by the tranquil phase, or honeymoon period, which is characterized by extremely loving, kind, and contrite behaviors by the batterer. Page Ref: 140—141 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Describe the factors that contribute to the occurrence of domestic violence and sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

6) When a woman seeks care for an injury, the nurse should be alert to which clues of abuse? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Defensive injuries B) Immediate reporting of symptoms or seeking care for injuries C) Lack of eye contact D) Providing too much detailed information about the injury E) Vague complaints without accompanying pathology Answer: A, C, E Explanation: A) Defensive injuries may be a sign of abuse. B) Delayed reporting of symptoms or seeking care for injuries may be a sign of abuse, not immediate reporting and seeking care. C) Lack of eye contact may be a sign of abuse. D) Hesitation in providing detailed information about the injury and how it occurred may be a sign of abuse. E) Vague complaints without accompanying pathology may be a sign of abuse. Page Ref: 144, 146 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. C. 1. Value seeing healthcare situations "through patients' eyes." | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Specify physical and psychological signs that may indicate a woman is in an abusive relationship. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

7) A woman has come to the emergency department with multiple bruises on her body and a small laceration over her upper lip. She says she fell down the stairs while doing housework. Which observation would most cause the nurse to suspect that the client has been a victim of battering? A) The client is hesitant to provide details about how the injuries occurred. B) The client was accompanied to the emergency department by her mother instead of her partner. C) The client has sought care quickly after the incident. D) The client does not seem to be in pain. Answer: A Explanation: A) Hesitation to provide detailed information about the injury and how it occurred is a common sign of abuse. B) Who accompanies the client to the emergency department is not a significant sign for abuse. C) Often a woman delays seeking care when there has been abuse. D) Pain level is not indicative of abuse. The experience of pain and how it is expressed is often a cultural issue. Page Ref: 144 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Specify physical and psychological signs that may indicate a woman is in an abusive relationship. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

8) The client with limited English language skills has a black eye and bruises across her face and arms. The client's husband has been acting as an interpreter for her, and answers all of the questions the nurse asks, often without talking to his wife first. The nurse suspects the client has been a victim of domestic abuse. What should the nurse do next? A) Ask the husband whether he has beaten his wife. B) Ask the husband to have a female friend come in with his wife. C) Provide written materials in English for the client to read at home. D) Ask the husband to step out of the room, and obtain an interpreter. Answer: D Explanation: A) Asking the abuser whether he has abused his spouse is useless, as most abusers see their behavior as appropriate. B) Asking the husband to have a female friend come with his wife is not the best action for the nurse to take next. C) Written proficiency develops after verbal fluency; therefore, written materials in English are inappropriate for this client. D) Screening for women experiencing domestic violence must be done privately. An interpreter should also be provided as necessary. Page Ref: 144 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate the role of the nurse in caring for women who have experienced partner abuse. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

9) If a woman returns to an abusive situation, the nurse should encourage her to develop an exit, or safety, plan for herself and her children, if she has any. What should the plan include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Identify friends and family who know about the situation and will help her. B) Call the police if violence begins. C) Pack a change of clothes for herself and the children. D) Have a plan for where she will go. E) Have a planned escape route. Answer: A, C, D, E Explanation: A) She should identify friends and family who know about the situation and will help her. Ask that she establish a code word for danger with those family and friends. B) She should ask a neighbor to call the police if violence begins. C) She should pack a change of clothes for herself and the children, including toilet articles and an extra set of car and house keys stored away from her house with a friend or neighbor. D) She should have a plan for where she will go, regardless of the day or time. E) She should have a planned escape route and emergency telephone numbers she can call. Page Ref: 147 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Describe the needs that women with abusive partners and their children may have beyond the healthcare setting. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

10) The nurse has been talking to a woman about the reorganization phase following a rape. Which response would indicate that the client understands this phase? A) "By using denial and suppression in this phase, I will eventually be able to accept what has happened to me." B) "During this time, I won't talk much about the rape, because I am examining my inward feelings regarding the rape." C) "During this time, I will repeatedly replay the role of the victim until I come to terms with the experience." D) "My perception of a normal sexual relationship will be similar to my perception prior to the rape." Answer: C Explanation: A) Denial and suppression indicate the client is experiencing the outward adjustment phase of rape trauma syndrome. B) Denial and suppression indicate the client is experiencing the outward adjustment phase of rape trauma syndrome. C) During reorganization, a victim adjusts her self-concept to include the rape. D) Sexual relationships often develop dysfunction after rape. Page Ref: 151 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Identify the phases of the rape trauma syndrome. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

11) Among women who have been sexually assaulted, which of the following are the most frequently diagnosed sexually transmitted infections (STIs)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Bacterial vaginosis B) HIV C) Chlamydia D) Syphilis E) Gonorrhea Answer: A, C, E Explanation: A) Among women who have been sexually assaulted, trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed sexually transmitted infections (STIs). B) HIV is not one of the most frequently diagnosed STIs following a sexual assault. C) Among women who have been sexually assaulted, trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed sexually transmitted infections (STIs). D) Syphilis is not one of the most frequently diagnosed STIs following a sexual assault. E) Among women who have been sexually assaulted, trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed sexually transmitted infections (STIs). Page Ref: 153 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health and illness. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

12) When a woman who has been raped is admitted to the emergency department, the nurse caring for the woman knows that which of the following is the priority nursing intervention? A) Explaining exactly what will need to be done to preserve legal evidence B) Assuring the woman that everything will be all right C) Creating a safe, secure environment for her D) Contacting family members Answer: C Explanation: A) The legal interventions would not take priority over safety at this time. B) Assuring the woman that everything will be all right is not the first priority nursing intervention in caring for a survivor of a sexual assault. C) The first priority in caring for a survivor of a sexual assault is to create a safe, secure environment. D) Contacting family members is important, but is not the priority nursing intervention. Page Ref: 153 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 6. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

13) What is the most important aspect of care for the nurse to remember when screening a woman for partner abuse? A) Ensuring privacy and confidentiality B) Conveying warmth and empathy C) Asking specific, direct questions about abuse D) Clarifying her myths about battering Answer: A Explanation: A) Screening for women experiencing domestic violence must be done privately, with only the nurse and the client present, in a safe and quiet place. B) Warmth and empathy are helpful, but confidentiality is more important. C) General questions about possible abuse both will facilitate trust building and are more likely to obtain accurate information, but privacy to obtain this information is the first priority. D) Clarifying myths is not essential during screening. Page Ref: 144 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate the role of the nurse in caring for women who have experienced partner abuse. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

14) A client comes to the reproductive health clinic and reports that she woke up in a strange room this morning, her perineal area is sore, and she can't clearly remember what happened the previous evening. The client says she is afraid that she was a victim of a drug-facilitated sexual assault. Which statement should the nurse include when discussing this possibility with the client? A) "Drinking alcohol can lead to uninhibited sexual behavior, which is not the same as rape." B) "Some men use drugs mixed into a drink to subdue a potential victim prior to a rape." C) "It is rare that a woman doesn't remember what happened if she is actually raped." D) "We need to check for forensic evidence of rape before we can be sure what happened." Answer: B Explanation: A) Although one effect of alcohol consumption is decreased inhibition, which can lead to less cautious sexual behavior, if a woman is drugged, the sexual act is nonconsensual and is therefore classified as rape. B) Drug-facilitated sexual assault occurs when a drug such as Rohypnol, which dissolves easily and is odorless, is slipped into the drink of an unsuspecting woman. C) Rohypnol, which dissolves easily and is odorless, can be slipped into the drink of an unsuspecting woman and causes amnesia of the attack. D) Forensic evidence is collected for possible legal prosecution of the attacker, but the absence of collectable evidence does not eliminate the possibility of rape. Page Ref: 150 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

15) The emergency department nurse is admitting a client who has been sexually assaulted. The nurse is explaining how the physical evidence will be collected. Which statement by the client indicates that teaching has been effective? A) "All the evidence will be kept in a locked cupboard until the police arrive." B) "You collect urine samples to make sure the rapist did not get me pregnant." C) "The evidence you collect might be able to identify the rapist." D) "Blood samples are taken to help identify whether the rapist had HIV." Answer: C Explanation: A) The evidence must remain in the hands of the nurse until handed directly to the police. B) Urine should be collected in cases in which a drug-facilitated sexual assault is suspected. C) DNA can be obtained from collected evidence to identify the rapist. D) Blood is drawn to test for syphilis and to determine the woman's blood type, and additional blood may be drawn for a pregnancy test. Page Ref: 152 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Summarize the procedures for collecting and preserving physical evidence of sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

16) The nurse is preparing an educational seminar about the frequency of intimate partner violence against females. Using the chart below, which age group should the nurse identify as experiencing the most intimate partner violence in 2010?

A) 12-17 B) 18-24 C) 25-34 D) 35-49 Answer: B Explanation: B) The group experiencing the most intimate partner violence against women in 2010 is the solid green line which represents the 25-34 age group. The solid red line is the 12-17 age groups. The dotted red line is the 18-24 age group. The dotted blue line is the 35-49 age group. And the solid orange line is the 50 or older age group. Page Ref: 140 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 1 Describe the factors that contribute to the occurrence of domestic violence and sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

17) The nurse is helping a victim of domestic violence create a safety plan. In which order should the nurse recommend that the steps of the plan be completed? 1. Decide where to go regardless of the day or time 2. Establish a code word that is shared with family and friends 3. Have money, identification, and bank account information prepared 4. Determine a planned escape route with emergency telephone numbers 5. Pack a change of clothes, toilet articles, and keys stored away from the home Answer: 5, 3, 1, 2, 4 Explanation: The patient should pack a change of clothes including toilet articles and an extra set of car and house keys stored away from her house with a friend or neighbor; have money, identification papers, and bank account information prepared; have a plan for where she will go, regardless of the day or time; establish a code word for danger that is shared with family and friends; and have a planned escape route and emergency telephone numbers. Page Ref: 147 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 5 Delineate the role of the nurse in caring for women who have experienced partner abuse. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

18) A female comes into the emergency department seeking treatment for possible rape. The patient recalls having a cocktail with friends at a local club but woke up in an alley three blocks away from the business. For which date rape drugs should the nurse prepare to have this patient tested? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Atropine 2. Ketamine 3. Scopolamine 4. Flunitrazepam 5. Gamma hydroxybutyrate Answer: 2, 3, 4, 5 Explanation: Flunitrazepam (Rohypnol), a potent sedative-hypnotic has received considerable attention as the "date rape drug of choice" since the late 1990s. Typically, Rohypnol, which dissolves easily and is odorless, is slipped into the drink of an unsuspecting woman. Gamma hydroxybutyrate (GHB), ketamine, and scopolamine have also been identified as date rape drugs that are used to incapacitate a woman. Atropine is not identified as being a date rape drug. Page Ref: 150 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

19) The nurse is participating in the collection of evidence from a victim of rape. In which order should the evidence be collected from this victim? 1. Oral swabs are obtained 2. Blood samples are drawn for syphilis 3. Hair samples and fingernail scrapings taken 4. Clothing is removed and bagged for evidence 5. Swabs of body stains and secretions are taken Answer: 4, 5, 1, 3, 2 Explanation: When collecting evidence from a rape victim, the victim's clothing is removed and placed in a paper bag. Swabs of body stains and secretions are taken. Then oral swabs are obtained. Hair samples and fingernail scrapings are taken. Blood samples are then drawn to evaluate for syphilis. Page Ref: 152—153 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

20) The nurse is identifying a plan to help a rape victim work through the phases of recovery. In which order should the nurse perform the following actions to help this victim? 1. Clarify the victim's feelings 2. Establish a trusting relationship 3. Acknowledge the victim's success 4. Provide advocacy as requested by the victim 5. Allow the victim to grieve and express feelings Answer: 5, 4, 2, 1, 3 Explanation: The order in which nursing actions should be provided to a victim during the phases of rape recovery include allowing the victim to grieve and express feelings during the acute phase; provide advocacy as identified by the victim during the outward adjustment phase; establish a trusting relationship and clarify the victim's feelings during the reorganizational phase; and acknowledge the victim's success during the integration and recovery phase. Page Ref: 154 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

21) The nurse is preparing a female client for a scheduled pelvic examination. During the health history interview, the client states, "My husband constantly criticizes me and calls me stupid. I am afraid that he will begin to hit me one of these days." Which type of intimate partner violence is the client experiencing based on the assessment data? A) Sexual abuse B) Physical abuse C) Economic abuse D) Emotional abuse Answer: D Explanation: A) Sexual abuse is forced sex, including vaginal, oral, or anal intercourse. This type of abuse also includes sexually demeaning treatment, forced use of objects, or forcing a woman to have sex with someone else against her will. B) Physical abuse may include acts such as pushing, shoving, slapping, hitting with a fist or object, kicking, choking, threatening with a gun or knife, or using a gun or knife against a woman. This type of abuse can also include forcing alcohol or drug use or denying a partner medical care. C) Economic abuse would include preventing a spouse or significant other from getting or keeping a job; making a spouse or significant other ask for money; controlling a spouse or significant other's money; destruction of property; or making all financial decisions for the spouse or significant other. D) Emotional abuse includes constant criticism, name calling, and unreasonable demands from a spouse or significant other. This type of abuse also includes damaging a spouse or significant other's relationship with a child and others who matter to him or her. Page Ref: 140 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Specify physical and psychological signs that may indicate a woman is in an abusive relationship. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

22) The nurse is teaching a class about domestic violence to enhance education within the community. Which statement regarding the cycle of violence should the nurse include in the presentation? A) "The tension-building phase lasts a few hours." B) "The batterer often feels remorse during the tension-building phase." C) "The acute battery incident is often triggered by an external event, such as the loss of a job." D) "The acute battery incident often finds the victim hoping the relationship will change for the better." Answer: C Explanation: A) The length of the tension-building phase of the cycle of violence varies considerably across individual cases and can range from weeks to years. It is often the acute battery incident that lasts a few hours. B) The batterer often feels remorse during the tranquil phase or honeymoon period, not the tension-building phase. C) An acute battery incident is often triggered by an external event for the abuser, such as the loss of a job. D) The victim of abuse often hopes the relationship will improve in the tension-building phase, not during the acute battery incident. Page Ref: 143 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Teaching and Learning. Learning Outcome: 3 Identify the phases of the cycle of violence. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

23) Which is a known characteristic of domestic violence batterers? A) Feeling inferior to others B) Working in a low-paying job C) Having a low socioeconomic status D) Being diagnosed with posttraumatic stress disorder Answer: A Explanation: A) Domestic violence batterers often have feelings of insecurity, inferiority, powerlessness, and helplessness that conflict with their assumptions of male supremacy. B) Batterers come from all occupations, not just from low-paying jobs. C) Batterers come from all socioeconomic strata. D) A diagnosis of posttraumatic stress disorder is not a known characteristic of domestic violence batterers. Page Ref: 143—144 Cognitive Level: Remembering Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Caring. Learning Outcome: 4 Summarize the characteristics of batterers and perpetrators of sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

24) The nurse is conducting a health maintenance assessment for a female client. Which neurologic data would cause the nurse to further assess for intimate partner abuse? A) Anxiety B) Depression C) Weight gain D) Tension headaches Answer: D Explanation: A) Anxiety is a psychiatric, not neurologic, assessment finding that would cause the nurse to further assess for intimate partner abuse. B) Depression is a psychiatric, not neurologic, assessment finding that would cause the nurse to further assess for intimate partner abuse. C) Weight gain is a constitutional, not neurologic, assessment finding that would cause the nurse to further assess for intimate partner abuse. D) Tension headaches are a neurologic assessment finding that would cause the nurse to further assess for intimate partner abuse. Page Ref: 144 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Specify the physical and psychological signs that may indicate a woman is in an abusive relationship. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

25) The nurse is conducting a health maintenance assessment for a new female client who recently moved to the city. Which finding would indicate the need for further assessment for intimate partner violence? A) A miscarriage two years ago noted during the reproductive history. B) A sprained ankle one year ago noted during the health history interview. C) A history of delaying treatment for a concussion and fractured extremity. D) A scar noted on the abdomen from a previous surgery during the physical examination. Answer: C Explanation: A) A miscarriage two years ago that is noted in the reproductive history would not cause the nurse to further assess the client for intimate partner abuse. B) Sprains and strains are not associated with intimate partner abuse. C) A client who delays treatment for a concussion or fractured extremity would indicate the need for further assessment for intimate partner violence. D) A scar from an old injury, not from a surgical procedure, would indicate the need for further assessment for intimate partner violence. Page Ref: 144 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Specify the physical and psychological signs that may indicate a woman is in an abusive relationship. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

26) The nurse is providing care to a female client who presents in the emergency department (ED) with multiple bruises and lacerations. The nurse suspects the client is the victim of domestic violence. Which action by the nurse is appropriate? A) Reporting the incident to the police to enhance safety B) Documenting domestic violence in the medical record C) Avoiding photographs of the injuries to prevent embarrassment D) Communicating the level of confidentiality that can be expected Answer: D Explanation: A) Reporting domestic violence may be mandatory in some states. However, it is important to note that reporting domestic violence may increase the client's risk for further abuse, not enhance the client's safety. B) The nurse would document the client's injuries in the medical record and use the term "probable battering." To protect the client's confidentiality and safety, it is critical that the nurse not refer to domestic violence or abuse on any discharge papers. C) Photographs of the client's injuries can be of great value along with documentation of the extent of the injuries and noting of the client's exact words in the medical record. D) It is important for the nurse to explain the assessment process to the client and communicate the level of confidentiality that can be expected. Page Ref: 146 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate the role of the nurse in caring for women who have experienced partner abuse. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

27) Which action by the nurse is appropriate when providing care to a female client who is the victim of domestic violence? A) Providing adequate time for the client to tell her story B) Reporting the incident to the police to protect the client C) Telling the spouse about the client's accusations of abuse D) Stressing to the client that the abuse could have been avoided Answer: A Explanation: A) The nurse should allow the client adequate time to work through her story, problems, and situation at her own pace. B) The nurse would not report the incident to the police to protect the client. Reporting the abuse is associated with the risk for further abuse towards the client. C) It is not appropriate for the nurse to tell the client's spouse about the accusations of abuse. This is a breach of confidentiality. D) It is not therapeutic for the nurse to stress to the client that the abuse could have been avoided. Page Ref: 147 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate the role of the nurse in caring for women who have experienced partner abuse. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

28) The nurse is helping a victim of domestic abuse to develop a safety plan. Which client action would require intervention by the nurse? A) Asking a neighbor to call police if violence begins B) Establishing a code word for danger with family and friends C) Keeping a bag packed in the home in case the need to leave arises D) Having a planned escape route and emergency phone numbers if violence occurs Answer: C Explanation: A) Asking a neighbor to call the police if violence begins is an appropriate client action that would not require intervention from the nurse. B) Establishing a code word for danger with family and friends is an appropriate client action that would not require intervention from the nurse. C) Keeping a bag packed in the home if the need arises to leave would require intervention from the nurse. The bag should be kept at the home of a neighbor or family member. If the abuser finds the bag the client's risk for injury may increase. D) Having a planned escape route and emergency phone numbers if violence occurs is an appropriate client action that would not require intervention from the nurse. Page Ref: 147 Cognitive Level: Evaluating Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe the needs that women with abusive partners and their children may have beyond the healthcare setting. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

29) The nurse is providing care to a female client who is the victim of domestic violence. Which referral by the nurse is most appropriate? A) Group therapy B) Physical therapy C) Nutrition therapy D) Occupational therapy Answer: A Explanation: A) Victims of domestic violence require counseling and advocacy from the nurse. The most appropriate referral for this client is group therapy. B) Physical therapy is not an appropriate referral for this client. C) Nutrition therapy is not an appropriate referral for this client. D) Occupational therapy is not an appropriate referral for this client. Page Ref: 149 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe the needs that women with abusive partners and their children may have beyond the healthcare setting. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

30) Which myth regarding rape will the community health nurse include in a teaching session within the community? A) Rape is a type of sexual assault. B) Women lie about rape as an act of revenge. C) Both men and women can be victims of rape. D) Rape is one of the most underreported violent crimes. Answer: B Explanation: A) Rape is a type of sexual assault. This is not a myth regarding rape. B) One myth regarding rape is that women lie about rape as an act of revenge. This is appropriate for the nurse to include in the teaching session. C) Both men and women can be victims of rape. This is not a myth regarding rape. D) Rape is one of the most underreported violent crimes. This is not a myth regarding rape. Page Ref: 149—150 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Teaching and Learning. Learning Outcome: 1 Describe the factors that contribute to the occurrence of domestic violence and sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

31) A female client presents in the emergency department (ED) after being sexually assaulted at a party. Which assessment finding indicates that the client may have been drugged? A) Attending the party with a large group of friends B) Accepting a beverage from a stranger at the party C) Dancing and kissing several men during the party D) Drinking large amounts of alcohol during the party Answer: B Explanation: A) Attending a party with a large group of friends is not an assessment finding that would indicate the client may have been drugged. B) Accepting a drink from someone else or drinking a drink that was left unattended would indicate the client may have been drugged. C) Dancing and kissing several men during the party is not an assessment finding that would indicate the client may have been drugged. D) Drinking large amounts of alcohol at the party is not an assessment finding that would indicate the client may have been drugged. Having one or two drinks and then suddenly feeling very drunk would be an indicator that the client had been drugged. Page Ref: 150 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Describe the factors that contribute to the occurrence of domestic violence and sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

32) The nurse is providing care to a client who is the victim of sexual assault. Which assessment finding does the nurse anticipate during the disorganization phase of rape trauma syndrome? A) Anxiety B) Insomnia C) Dyspepsia D) Depression Answer: A Explanation: A) Anxiety is an expected clinical manifestation that occurs during the disorganization phase of rape trauma syndrome. B) Insomnia is an expected clinical manifestation that often occurs during the reorganization phase of rape trauma syndrome. C) Dyspepsia is an expected clinical manifestation that often occurs during the reorganization phase of rape trauma syndrome. D) Depression is an expected clinical manifestation that often occurs during the reorganization phase of rape trauma syndrome. Page Ref: 151 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify the phases of the rape trauma syndrome. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

33) The nurse is assisting with the collection of evidence for a female client who is the victim of sexual assault. Which actions by the nurse are appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Drawing blood to test for gonorrhea 2. Placing each piece of clothing in a plastic bag 3. Pulling hair from the head and pubic region as evidence 4. Collecting a urine sample if drug-facilitated rape is suspected 5. Obtaining informed consent prior to photographing the injured areas Answer: 3, 4, 5 Explanation: When collecting evidence for a female client who is the victim of sexual assault, the nurse will assist in pulling hair from the head and pubic region as evidence, collect a urine sample if drug-facilitated rape is suspected, and obtain informed consent prior to photographing the areas of injury. The nurse would draw blood to test for syphilis, not gonorrhea. The nurse would place each piece of the client's clothing into a paper bag, which is sealed and labeled. A plastic bag is not appropriate. Page Ref: 152—153 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Summarize the procedures for collecting and preserving physical evidence of sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

34) The nurse is providing care for a female client who is the victim of sexual assault. Which sexually transmitted infections (STIs) does the nurse anticipate medication prescriptions to prevent? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Syphilis 2. Gonorrhea 3. Chlamydia 4. Bacterial vaginosis 5. Herpes simplex virus Answer: 2, 3, 4 Explanation: A client who is the victim of sexual assault is at the greatest risk for contracting gonorrhea, chlamydia, and bacterial vaginosis. The nurse would anticipate medication prescriptions for these STIs. While the client is also at risk for syphilis and herpes simplex virus, these STIs are not as common; therefore, the nurse would not anticipate medication prescriptions for these STIs. Page Ref: 153 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Summarize the procedures for collecting and preserving physical evidence of sexual assault. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

35) The nurse is planning care for a client who is the victim of rape. Which psychosocial nursing diagnoses does the nurse include in the client's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fear 2. Fatigue 3. Powerlessness 4. Risk for infection 5. Readiness for enhanced knowledge Answer: 1, 3 Explanation: When planning the psychosocial care for a client who is the victim of rape, the nurse would include the nursing diagnoses of fear and powerlessness in the plan of care. Fatigue, risk for infection, and readiness for enhanced knowledge are not diagnoses that the nurse would include in the plan of care for a client who is the victim of rape. Page Ref: 153 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

36) The nurse is providing care to a female client in the acute phase of recovery following a sexual assault. Which nursing actions are appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Clarifying feelings 2. Creating a safe environment 3. Supporting advocacy efforts 4. Establishing a trusting relationship 5. Providing care for significant others Answer: 2, 5 Explanation: During the acute phase of recovery following a sexual assault, the appropriate nursing actions include creating a safe environment and providing care for significant others. Clarifying feelings is an appropriate nursing action during the reorganizational phase of recovery following a sexual assault. Supporting advocacy efforts is an appropriate nursing action during the integration and recovery phases of recovery following a sexual assault. Establishing a trusting relationship is an appropriate nursing action during the outward adjustment phase following a sexual assault. Page Ref: 154 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Discuss the nurse's role as patient advocate with domestic violence and sexual assault survivors. MNL LO: Demonstrate use of the nursing process in the care of women experiencing violence.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 9 Reproductive Physiology, Conception, and Fetal Development 1) The nurse is preparing a class on reproduction. What is the cell division process called that results in two identical cells, each with the same number of chromosomes as the original cell? A) Meiosis B) Mitosis C) Oogenesis D) Gametogenesis Answer: B Explanation: A) Meiosis is a process of cell division that leads to the development of ova and sperm. B) Mitosis results in the production of diploid body (somatic) cells, which are exact copies of the original cell. C) Oogenesis is the process that produces the female gamete, called an ovum (egg). D) Gametogenesis is the process by which germ cells, or gametes (ova and sperm), are produced. Page Ref: 170 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) sciences, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 6 Compare the processes by which ova and sperm are produced. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

2) The female and male reproductive organs are homologous, which means what? A) They are believed to cause vasoconstriction and muscular contraction B) They are fundamentally similar in function and structure C) They are rich in sebaceous glands D) They are target organs for estrogenic hormones Answer: B Explanation: A) Efferent sympathetic motor nerves are believed to cause vasoconstriction and muscular contraction. B) The female and male reproductive organs are homologous; that is, they are fundamentally similar in function and structure. C) The labia minora are rich in sebaceous glands. D) The female internal reproductive organs are target organs for estrogenic hormones. Page Ref: 169 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) sciences, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

3) The nurse explains to a preconception class that if only a small volume of sperm is discharged into the vagina, an insufficient quantity of enzymes might be released when they encounter the ovum. In that case, pregnancy would probably not result, because of which of the following? A) Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus. B) The block to polyspermy (cortical reaction) would not occur. C) The fertilized ovum would be unable to implant in the uterus. D) Sperm would be unable to penetrate the zona pellucida of the ovum. Answer: D Explanation: A) Peristalsis of the fallopian tube is not a factor in this stage of fertilization. B) A block to polyspermy would indicate that the ovum had already been penetrated by a fertilizing sperm, which would occur later in the fertilization process. C) The ovum has not yet been fertilized in this example. D) About a thousand acrosomes must rupture to clear enough hyaluronic acid for even a single sperm to penetrate the ovum's zona pellucida successfully. If only a small amount of sperm were released, there most likely would be an insufficient quantity of acrosomes to penetrate the zona pellucida of the ovum and allow fertilization. Page Ref: 170 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Analyze the components of the process of fertilization as to how each may affect conception. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

4) The nurse is creating a handout on reproduction for teen clients. Which piece of information should the nurse include in this handout? A) The fertilized ovum is called a gamete. B) Prior to fertilization, the sperm are zygotes. C) Ova survive 12-24 hours in the fallopian tube if not fertilized. D) Sperm survive in the female reproductive tract up to a week. Answer: C Explanation: A) Ova and sperm are gametes; a fertilized ovum is a zygote. B) Sperm are gametes (as are ova); a zygote is a fertilized ovum. C) Ova are considered fertile for about 12 to 24 hours after ovulation. D) Sperm can survive in the female reproductive tract for 48 to 72 hours but are believed to be healthy and highly fertile for only about the first 24 hours. Page Ref: 172 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Analyze the components of the process of fertilization as to how each may affect conception. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

5) What are the three functions of the fallopian tubes? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Provide transport for the ovum from the ovary to the uterus B) Serve as a warm, moist, nourishing environment for the ovum or zygote C) Secrete large amounts of estrogens D) Provide a site for fertilization to occur E) Support and protect the pelvic contents Answer: A, B, D Explanation: A) The fallopian tubes provide transport for the ovum from the ovary to the uterus. B) The fallopian tubes serve as a warm, moist, nourishing environment for the ovum or zygote. C) The ovaries, not the fallopian tubes, secrete large amounts of estrogens. D) The fallopian tubes provide a site for fertilization to occur. E) The female bony pelvis, not the fallopian tubes, supports and protects the pelvic contents. Page Ref: 161 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts form liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

6) What are the three functions of cervical mucosa? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Form the relatively fixed axis of the birth passage B) Provide lubrication for the vaginal canal C) Provide nourishment and protective maternal antibodies to infants D) Provide an alkaline environment to shelter deposited sperm from the acidic vaginal secretions E) Act as a bacteriostatic agent Answer: B, D, E Explanation: A) The female boney pelvis forms the relatively fixed axis of the birth passage. B) The cervical mucosa provides lubrication for the vaginal canal. C) The breasts provide nourishment and protective maternal antibodies to infants. D) The cervical mucosa provides an alkaline environment to shelter deposited sperm from the acidic vaginal secretions. E) The cervical mucosa acts as a bacteriostatic agent. Page Ref: 161 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

7) A pregnant woman tells the nurse-midwife, "I've heard that if I eat certain foods during my pregnancy, the baby will be a boy." The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time? A) At the time of ejaculation B) At the time of fertilization C) At the time of implantation D) At the time of differentiation Answer: B Explanation: A) Ejaculation is the release of sperm from the male, and does not necessarily cause a pregnancy. B) Fertilization is the point at which the sex of the zygote is determined. C) Implantation is when the fertilized ovum is implanted in the uterine endometrium. The sex of the zygote has already been determined at this stage. D) Differentiation refers to a cell division process. Page Ref: 172 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Analyze the components of the process of fertilization as to how each may affect conception. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

8) The nurse is explaining the difference between meiosis and mitosis. Which statements would be best? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Meiosis is the division of a cell into two exact copies of the original cell. B) Mitosis is splitting one cell into two, each with half the chromosomes of the original cell. C) Meiosis is a type of cell division by which gametes, or the sperm and ova, reproduce. D) Mitosis occurs in only a few cells of the body. E) Meiotic division leads to cells that halve the original genetic material. Answer: C, E Explanation: A) Meiosis creates two cells that have half of the chromosomes of the original cell. B) Mitosis creates two cells that are exact copies of the original cell. C) Meiosis is a special type of cell division by which diploid cells give rise to gametes (sperm and ova). D) Mitosis makes growth and development possible. In mature individuals it is the process by which our body cells continue to divide and replace themselves. E) Meiosis creates two cells that contain half the genetic material of the parent cell. Page Ref: 170 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe the strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Compare the processes by which ova and sperm are produced. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

9) The true moment of fertilization occurs when what happens? A) Cortical reaction occurs B) Nuclei unite C) Spermatozoa propel themselves up the female tract D) Sperm surrounding the ovum release their enzymes Answer: B Explanation: A) At the moment of penetration by a fertilizing sperm, the zona pellucida undergoes a reaction that prevents additional sperm from entering a single ovum, known as the block to polyspermy. This cellular change is mediated by release of materials from the cortical granules, organelles found just below the ovum's surface, and is called the cortical reaction. B) The true moment of fertilization occurs as the nuclei unite. Their individual nuclear membranes disappear, and their chromosomes pair up to produce the diploid zygote. C) Fertilization has not yet occurred when the spermatozoa are still in the female reproductive tract. D) This is part of the acrosomal reaction and occurs prior to fertilization. Page Ref: 172 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Analyze the components of the process of fertilization as to how each may affect conception. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

10) Student nurses in their obstetrical rotation are learning about fertilization and implantation. The process of implantation is characterized by which statements? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The trophoblast attaches itself to the surface of the endometrium. B) The most frequent site of attachment is the lower part of the anterior uterine wall. C) Between days 7 and 10 after fertilization, the zona pellucida disappears, and the blastocyst implants itself by burrowing into the uterine lining. D) The lining of the uterus thins below the implanted blastocyst. E) The cells of the trophoblast grow down into the uterine lining, forming the chorionic villi. Answer: A, C, E Explanation: A) During implantation, the trophoblast attaches itself to the surface of the endometrium for further nourishment. B) The most frequent site of attachment is the upper part of the posterior uterine wall. C) Between days 7 and 10 after fertilization, the zona pellucida disappears, and the blastocyst implants itself by burrowing into the uterine lining and penetrating down toward the maternal capillaries until it is completely covered. D) The lining of the uterus thickens, not thins. E) The cells of the trophoblast grow down into the thickened lining, forming the chorionic villi. Page Ref: 170—173 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Analyze the components of the process of fertilization as to how each may affect conception. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

11) The nurse is creating a poster for pregnant mothers. Which description of fetal development should the nurse include? A) Four primary germ layers form from the blastocyst. B) After fertilization, the cells only become larger for several weeks. C) Most organs are formed by 8 weeks after fertilization. D) The embryonic stage is from fertilization until 5 months. Answer: C Explanation: A) Three primary germ layers form from the blastocyst: ectoderm, mesoderm, and endoderm. B) After fertilization, the cells reproduce by mitosis, resulting in more cells, not larger cells. C) Most organs are formed during the embryonic stage, which lasts from the 15th day after fertilization until the end of the 8th week after conception. D) The embryonic stage ends before the fifth month. Page Ref: 182—183 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

12) A client tells you that her mother was a twin, two of her sisters have twins, and several cousins either are twins or gave birth to twins. The client, too, is expecting twins. Because there is a genetic predisposition to twins in her family, there is a good chance that the client will have what type of twins? A) Dizygotic twins B) Monozygotic twins C) Identical twins D) Nonzygotic twins Answer: A Explanation: A) Studies indicate that dizygotic twins tend to occur in certain families, perhaps because of genetic factors that result in elevated serum gonadotropin levels leading to double ovulation. B) Monozygotic twins, known also as identical twins, are not familial. C) Identical twins, known also as monozygotic twins, are not familial. D) Nonzygotic twins do not exist. Page Ref: 176 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

13) The nurse is caring for a client pregnant with twins. Which statement indicates that the client needs additional information? A) "Because both of my twins are boys, I know that they are identical." B) "If my twins came from one fertilized egg that split, they are identical." C) "If I have one boy and one girl, I will know they came from two eggs." D) "It is rare for both twins to be within the same amniotic sac." Answer: A Explanation: A) Not all same-sex twins are identical or monozygotic, because fraternal, or dizygotic, twins can be the same gender or different genders. B) Identical, or monozygotic, twins develop from a single fertilized ovum. They are of the same sex and have the same phenotype (appearance). C) The only way to have twins of different sexes is if they come from two separate fertilized ova. D) If the amnion has already developed approximately 8 to 12 days after fertilization, division results in two embryos with a common amniotic sac and a common chorion (monochorionicmonoamniotic placenta). This type occurs rarely. Page Ref: 176—177 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

14) A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following? A) Estrogen B) Human chorionic gonadotropin (hCG) C) Progesterone D) Luteinizing hormone Answer: B Explanation: A) Estrogen and progesterone are ovarian hormones. B) If the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete human chorionic gonadotropin (hCG), which is needed to maintain the corpus luteum. C) Estrogen and progesterone are ovarian hormones. D) Luteinizing hormone is excreted by the anterior pituitary gland. Page Ref: 180 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Summarize the actions of the hormones that affect reproductive functioning. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

15) A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. This is most likely due to a lack of which hormone? A) Estrogen B) Progesterone C) FSH D) LH Answer: B Explanation: A) Estrogens are associated with characteristics contributing to femaleness. B) Progesterone is often called the hormone of pregnancy because it inhibits uterine contractions and relaxes smooth muscle to cause vasodilation, allowing pregnancy to be maintained. C) FSH is a hormone secreted by the pituitary gland, and its lack would not affect the ability of the uterus to be prepared for implantation of the fertilized ovum. D) LH is a hormone secreted by the pituitary gland, and its lack would not affect the ability of the uterus to be prepared for implantation of the fertilized ovum. Page Ref: 163 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 2 Summarize the actions of the hormones that affect reproductive functioning. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

16) The nurse is presenting a community education session on female hormones. Which statement from a participant indicates the need for further information? A) "Estrogen is what causes females to look female." B) "The presence of some hormones causes other to be secreted." C) "Progesterone is present at the end of the menstrual cycle." D) "Prostaglandin is responsible for achieving conception." Answer: D Explanation: A) Estrogens are associated with characteristics contributing to femaleness, including breast alveolar lobule growth and duct development. B) It is true that the presence of some hormones causes other to be secreted. .XXC It is true that the proportions of progesterone and estrogen control the events of both ovarian and menstrual cycles. D) Prostaglandin is not related to conception. Prostaglandin production increases during follicular maturation and has basic regulatory functions in cells. Page Ref: 163 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Summarize the actions of the hormones that affect reproductive functioning. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

17) The student nurse encounters a 15-year-old girl who reports that she has no pubic or axillary hair and has not yet experienced growth of her breasts. The student asks the nurse about the physiology of this occurrence. The nurse explains that the client probably lacks which hormone? A) Testosterone B) Progesterone C) Estrogen D) Prolactin Answer: C Explanation: A) Testosterone is responsible for the development of secondary sex characteristics in males. B) Progesterone and prolactin do not accomplish this change. C) Estrogens influence the development of secondary sex characteristics in females. D) Progesterone and prolactin do not accomplish this change. Page Ref: 163 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Summarize the actions of the hormones that affect reproductive functioning. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

18) What is the function of the scrotum? A) Produce testosterone, the primary male sex hormone B) Deposit sperm in the female vagina during sexual intercourse so that fertilization of the ovum can occur C) Provide a reservoir where spermatozoa can survive for a long period D) Protect the testes and the sperm by maintaining a temperature lower than that of the body Answer: D Explanation: A) The interstitial cells produce testosterone, the primary male sex hormone. B) The primary reproductive function of the penis is to deposit sperm in the female vagina during sexual intercourse so that fertilization of the ovum can occur. C) The epididymis provides a reservoir where spermatozoa can survive for a long period. D) The function of the scrotum is to protect the testes and the sperm by maintaining a temperature lower than that of the body. Page Ref: 167 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes for care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 5 Identify the structures and functions of the male reproductive system. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

19) Ovarian hormones include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Estrogens B) Progesterone C) Parathyroid hormone D) Luteinizing hormone E) Testosterone Answer: A, B, E Explanation: A) Ovarian hormones include the estrogens, progesterone, and testosterone. B) Ovarian hormones include the estrogens, progesterone, and testosterone. C) Ovarian hormones do not include the parathyroid hormone. D) Ovarian hormones do not include the luteinizing hormone, although the ovary is sensitive to it. E) Ovarian hormones include the estrogens, progesterone, and testosterone. Page Ref: 162 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Summarize the actions of the hormones that affect reproductive functioning. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

20) A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what? A) Menstruation is about to begin. B) Ovulation will occur soon. C) Ovulation has occurred. D) She is pregnant, and will not menstruate. Answer: C Explanation: A) A temperature increase does not occur when menstruation is about to begin. B) A temperature increase does not occur before ovulation has occurred. C) In some women, ovulation is accompanied by mid-cycle pain, known as mittelschmerz. This pain may be caused by a thick tunica albuginea or by a local peritoneal reaction to the expelling of the follicular contents. Body temperature increases about 0.3°C to 0.6°C (0.5°F to 1°F) 24 to 48 hours after the time of ovulation. D) Pregnancy can be detected through the presence of human chorionic gonadotropin hormone. Page Ref: 165 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: How (a) science, (b) the evidence on which practice is based, and (c) informatics are developed, and by whom; the relationships between research and science building, and between research and EBP. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

21) The nurse teaching the phases of the menstrual cycle should include that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and extensive vascular changes occur in which phase? A) Menstrual phase B) Proliferative phase C) Secretory phase D) Ischemic phase Answer: D Explanation: A) In the menstrual phase, estrogen levels are low, cervical mucus is scant, viscous, and opaque, and endometrium is shed. B) In the proliferative phase, endometrium and myometrium thickness increases and estrogen peaks just before ovulation. C) In the secretory phase, estrogen drops sharply, and progesterone dominates; vascularity of the entire uterus increases; and tissue glycogen increases, making the uterus ready for implantation. D) In the ischemic phase, the corpus luteum begins to degenerate, and as a result, both estrogen and progesterone levels fall. Small blood vessels rupture, and the spiral arteries constrict and retract, causing a deficiency of blood in the endometrium, which becomes pale. Page Ref: 160 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

22) The nurse is preparing a handout on the ovarian cycle to a group of middle school girls. Which information should the nurse include? A) The hormone human chorionic gonadotropin stimulates ovulation. B) Irregular menstrual cycles have varying lengths of the luteal phase. C) The ovum leaves its follicle during the follicular phase. D) There are two phases of the ovarian cycle: luteal and follicular. Answer: D Explanation: A) Human chorionic gonadotropin (hCG) is secreted by a fertilized ovum, and does not stimulate ovulation. B) In women whose menstrual cycles vary, usually it is only the length of the follicular phase that varies, while the luteal phase is of fixed length. C) The luteal phase begins when the ovum leaves its follicle. D) The ovarian cycle has two phases: the follicular phase (days 1 to 14) and the luteal phase (days 15 to 28 in a 28-day cycle). Page Ref: 164 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Identify the two phases of the ovarian cycle and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

23) The nurse teaching a high school class explains that during the menstrual cycle, the endometrial glands begin to enlarge under the influence of estrogen and cervical mucosal changes occur; the changes peak at ovulation. In which phase of the menstrual cycle does this occur? A) Menstrual B) Proliferative C) Secretory D) Ischemic Answer: B Explanation: A) Menstruation occurs during the menstrual phase. B) The proliferative phase begins when the endometrial glands begin to enlarge under the influence of estrogen and cervical mucosal changes occur; the changes peak at ovulation. C) The secretory phase occurs after ovulation. D) The ischemic phase occurs if fertilization does not occur. Page Ref: 163—164 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

24) The nurse is preparing a presentation on the menstrual cycle for a group of high school students. Which statement should the nurse include in this presentation? A) "The menstrual cycle has five distinct phases that occur during the month." B) "One hormone controls the phases of the menstrual cycle." C) "The secretory phase occurs when a woman is most fertile." D) "Menstrual cycle phases vary in order from one woman to another." Answer: C Explanation: A) There are four phases of the menstrual cycle. B) Four hormones control ovulation and, therefore, the menstrual cycle. C) During the secretory phase, the vascularity of the entire uterus increases greatly, providing a nourishing bed for implantation. D) Although the length of the menstrual cycle might vary, the phases of the menstrual cycle always occur in the same order. Page Ref: 165, 167 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

25) The nurse is preparing a handout for female adolescents on the menstrual cycle. What phase of the cycle occurs if fertilization does not take place? A) Menstrual B) Proliferative C) Secretory D) Ischemic Answer: D Explanation: A) Menstruation occurs during the menstrual phase. Some endometrial areas are shed, whereas others remain. B) The proliferative phase begins when the endometrial glands enlarge, the blood vessels become prominent and dilated, and the endometrium increases in thickness. C) The secretory phase follows ovulation. D) The ischemic phase occurs if fertilization does not occur. Page Ref: 160 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

26) Which statement by a pregnant client to the nurse would indicate that the client understood the nurse's teaching? A) "Because of their birth relationship, fraternal twins are more similar to each other than if they had been born singly." B) "Identical twins can be the same or different sex." C) "Congenital abnormalities are more prevalent in identical twins." D) "Identical twins occur more frequently than fraternal twins." Answer: C Explanation: A) Fraternal twins are not more similar to each other than if they had been born singly. B) Identical, or monozygotic twins, have identical chromosomal structures, and, therefore, are always the same sex. C) Monozygotic twinning is considered a random event and occurs in approximately 3 to 4 per 1000 live births. Congenital anomalies are more prevalent and both twins may have the same malformation. D) Dizygotic, or fraternal, twins occur more frequently than do monozygotic twins. Page Ref: 177 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 12 Identify the factors that influence congenital malformations of the organ systems and the resulting congenital malformations. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

27) The nurse is reviewing the process of fertilization with a group of high school students. Which structure should the nurse identify as the location where fertilization of the ovum occurs?

A) A B) B C) C D) D Answer: B Explanation: B) Fertilization of the secondary oocyte by a spermatozoon usually occurs in the ampulla, which comprises the outer two thirds of the fallopian tube. Choice 1 is the infundibulum. Choice 3 is the intrauterine part of the fallopian tube. Choice 4 is the ovarian ligament. Page Ref: 161 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Analyze the components of the process of fertilization as to how each may affect conception. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

28) The nurse educator is teaching student nurses what a fetus will look like at various weeks of development. Which descriptions would be typical of a fetus at 20 weeks' gestation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The fetus has a body weight of 435-465 g. B) Nipples appear over the mammary glands. C) The kidneys begin to produce urine. D) Nails are present on fingers and toes. E) Lanugo covers the entire body. Answer: A, B, D, E Explanation: A) A fetus at 20 weeks' gestation has a body weight of 435-465 g. B) A fetus at 20 weeks' gestation has nipples appear over the mammary glands. C) Kidneys of a fetus begin to produce urine at 12 weeks' gestation. D) A fetus at 20 weeks' gestation has nails present on fingers and toes. E) A fetus at 20 weeks' gestation has lanugo that covers the entire body. Page Ref: 183 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

29) The nurse is reviewing the female reproductive cycle with a group of high school students. Which part of the following diagram identifies the menstrual phase of this cycle?

A) A B) B C) C D) D Answer: D Explanation: D) Choice 4 identifies the menstrual phase of the female reproductive cycle. Choice 1 identifies the proliferative phase of the cycle. Choice 2 identifies the secretory phase of the cycle. Choice 3 identifies the ischemic phase of the cycle. Page Ref: 164 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

30) During health class the school nurse is reviewing the anatomy of the male reproductive system. Which structure should be identified as the location of sperm production?

A) A B) B C) C D) D Answer: A Explanation: A) The testes sit in the scrotum. Choice 2 is the epididymis. Choice 3 is the symphysis pubis. Choice 4 is the ejaculatory duct. Page Ref: 167—168 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Identify the structures and functions of the male reproductive system. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

31) Where in the illustration below is the isthmus of the fallopian tube located?

A) A B) B C) C D) D Answer: A Explanation: A) Each fallopian tube may be divided into three parts: the isthmus, the ampulla, and the infundibulum or fimbria. The fallopian tube isthmus is straight and narrow, with a thick muscular wall and an opening (lumen) 2-3 mm in diameter. It is just before the intrauterine part of the fallopian tube. Page Ref: 159 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

32) The nurse is working with a client who has experienced a fetal death in utero at 20 weeks. The client asks what her baby will look like when it is delivered. Which statement by the nurse is best? A) "Your baby will be covered in fine hair called lanugo." B) "Your child will have arm and leg buds, not fully formed limbs." C) "A white, cheesy substance called vernix caseosa will be on the skin." D) "The genitals of the baby will be ambiguous." Answer: A Explanation: A) Downy fine hair called lanugo covers the body of a 20-week-old fetus. B) Limb buds have developed by 35 days post-fertilization. C) Vernix caseosa forms at about 24 weeks. D) Male and female external genitals appear similar until end of ninth week. At 16 weeks, sex determination is possible. Page Ref: 183 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

33) The nurse is presenting a class to pregnant clients. The nurse asks, "The fetal brain is developing rapidly, and the nervous system is complete enough to provide some regulation of body function on its own, at which fetal development stage?" It is clear that education has been effective when a participant makes which response? A) "The 17th-20th week" B) "The 25th-28th week" C) "The 29th-32nd week" D) "The 33rd-36th week" Answer: B Explanation: A) The nervous system function is not developed between the 17th and 20th weeks of gestation. B) Between the 25th and 28th week, the brain is developing rapidly, and the nervous system is complete enough to provide some degree of regulation of body functions. C) The complexity of the nervous system develops long before the 29th-32nd week. D) The complexity of the nervous system develops long before the 33rd-36th week. Page Ref: 183 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

34) A pregnant client who is at 14 weeks' gestation asks the nurse why the doctor used to call her baby an embryo, and now calls it a fetus. What is the best answer to this question? A) "Fetus is the term used from the ninth week of gestation onward." B) "We call a baby a fetus when it is larger than an embryo." C) "An embryo is a baby from conception until the eighth week." D) "The official term for a baby in utero is really zygote." Answer: A Explanation: A) The fetal stage begins in the ninth week. B) The embryonic stage ends with the eighth week, regardless of size. C) The preembryonic stage is from conception until day 15. D) A zygote is a fertilized ovum. Page Ref: 185 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

35) Which term will the nurse use when teaching a client information regarding the entire female external genitalia? A) Vulva B) Clitoris C) Mons pubis D) Perineal body Answer: A Explanation: A) The vulva is the term the nurse will use when documenting information about the entire female external genitalia. B) The clitoris is a structure included in the female external genitalia. This term is not used when referring to the entire female external genitalia. C) The mons pubis is a structure included in the female external genitalia. This term is not used when referring to the entire female external genitalia. D) The perineal body is a structure included in the female external genitalia. This term is not used when referring to the entire female external genitalia. Page Ref: 158 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Teaching and Learning. Learning Outcome: 1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

36) Which statement regarding cervical mucus is accurate during ovulation and appropriate to include in an educational session with the client? A) Cervical mucus is thicker during ovulation. B) Cervical mucus is opaque during ovulation. C) Cervical mucus is clearer during ovulation. D) Cervical mucus is acidic during ovulation. Answer: C Explanation: A) Cervical mucus is thinner, not thicker, during ovulation. B) Cervical mucus is clearer, not opaque, during ovulation. C) Cervical mucus is clearer during ovulation. D) Cervical mucus is alkaline, not acidic, during ovulation. Page Ref: 161 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. Nursing/Integrated Concepts: Teaching and Learning. Learning Outcome: 4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. MNL LO: Demonstrate understanding of reproductive physiology, conception, and fetal development.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 10 Reproductive Genetics 1) The nurse is reviewing preconception questionnaires in charts. Which couple are the most likely candidates for preconceptual genetic counseling? A) Wife is 30 years old, husband is 31 years old B) Wife and husband are both 29 years old, first baby for husband, wife has a normal 4-year-old C) Wife's family has a history of hemophilia D) Single 32-year-old woman is using donor sperm Answer: C Explanation: A) An age under 35 is not a risk factor for genetic abnormalities. B) An age under 35 is not a risk factor for genetic abnormalities. C) For families in which the woman is a known or possible carrier of an X-linked disorder, such as hemophilia, the risk of having an affected male fetus is 25%. D) Sperm donors are screened for genetic disorders, and men with a possible genetic problem are not accepted for sperm donation. Page Ref: 201 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team. | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Identify couples who may benefit from preconceptual genetic counseling and testing, including those with special reproductive concerns. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

2) A couple is at the clinic for preconceptual counseling. Both parents are 40 years old. The nurse knows that the education session has been successful when the wife makes which statement(s)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "We are at low risk for having a baby with Down syndrome." B) "Our children are more likely to have genetic defects." C) "Children born to parents our age have sex-linked disorders." D) "The tests for genetic defects can be done early in pregnancy." E) "It will be almost impossible for us to conceive a child." Answer: B, D Explanation: A) The risk for trisomy 21 (Down syndrome) is 1 in 385. B) Women 35 or older are at greater risk for having children with chromosome abnormalities. C) Sex-linked disorders are not related to the age of either parent. D) Genetic testing such as amniocentesis and chorionic villus sampling are done in the first trimester. E) Fertility decreases somewhat after age 35, but being over 35 does not mean that conception is impossible. Page Ref: 201 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Identify couples who may benefit from preconceptual genetic counseling and testing, including those with special reproductive concerns. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

3) A newborn has been diagnosed with a disorder that occurs through an autosomal recessive inheritance pattern. The parents ask the nurse, "Which of us passed on the gene that caused the disorder?" What should the nurse tell them? A) The female B) The male C) Neither D) Both Answer: D Explanation: A) It is not a sex-linked disorder or an abnormal chromosome disorder. B) It is not a sex-linked abnormality. C) In an autosomal recessive inherited disorder, both parents are carriers of the abnormal gene. D) An affected individual can have clinically normal parents, but both parents are generally carriers of the abnormal gene. Page Ref: 196—197 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care; (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Identify the characteristics of autosomal dominant, autosomal recessive, X-linked (sex-linked) recessive, and multifactorial inheritance disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

4) Couples at risk for having a detectable single gene or chromosomal anomaly may wish to undergo which procedure? A) Preimplantation genetic screening (PGS) B) Preimplantation genetic diagnosis (PGD) C) Intracytoplasmic sperm injection (ICSI) D) Gamete intrafallopian transfer (GIFT) Answer: B Explanation: A) Preimplantation genetic screening (PGS) is a term used when the embryos are screened for aneuploidy for the purpose of increasing the likelihood of a viable pregnancy with normal chromosomes. B) Preimplantation genetic diagnosis (PGD) is a term used when one or both genetic parents carry a gene mutation and testing is performed to determine whether that mutation or unbalanced chromosomal compliment has been passed to the oocyte or embryo. C) Intracytoplasmic sperm injection (ICSI) is a microscopic procedure to inject a single sperm into the outer layer of an ovum so that fertilization will occur. D) Gamete intrafallopian transfer (GIFT) involves the retrieval of oocytes by laparoscopy. Page Ref: 202 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 3 Identify couples who may benefit from preconceptual genetic counseling and testing, including those with special reproductive concerns. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

5) The couple at 12 weeks' gestation has been told that their fetus has sickle cell disease. Which statement by the couple indicates that they are adequately coping? A) "We knew we were both carriers of sickle cell disease. We shouldn't have tried to have a baby." B) "If we had been healthier when we conceived, our baby wouldn't have this disease now." C) "Taking vitamins before we got pregnant would have prevented this from happening." D) "The doctor told us there was a 25% chance that our baby would have sickle cell disease." Answer: D Explanation: A) Self-blame and judgment do not indicate adequate coping. B) Preconception health and nutrition do not affect transmission of an autosomal recessive trait. Self-blame and judgment do not indicate adequate coping. C) Preconception health and nutrition do not affect transmission of an autosomal recessive trait. D) A true statement indicates adequate coping. When both parents are carriers of an autosomal recessive disease, there is a 25% risk for each pregnancy that the fetus will be affected. Page Ref: 196—197 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 9. Assess level of patient's decisional conflict and provide access to resources. | AACN Essentials Competencies: IX. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Identify the characteristics of autosomal dominant, autosomal recessive, X-linked (sex-linked) recessive, and multifactorial inheritance disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

6) A pregnant client asks the nurse, "What is this "knuckle test" that is supposed to tell whether my baby has a genetic problem?" What does the nurse correctly explain? A) "In the first trimester, the nuchal translucency measurement is used to improve the detection rate for Down syndrome and trisomy 18." B) "You will need to ask the physician for an explanation." C) "It tests for hemophilia A or B." D) "It tests for Duchenne muscular dystrophy." Answer: A Explanation: A) Screening tests, such as nuchal translucency ultrasound are designed to gather information about the risk that the pregnancy could have chromosome abnormalities or open spina bifida. B) This is not an appropriate response. The nurse must be aware of laboratory tests performed during pregnancy to intelligently answer clients' questions. C) DNA testing tests for hemophilia. D) DNA testing tests for Duchenne muscular dystrophy. Page Ref: 198 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and, (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Compare prenatal and postnatal diagnostic procedures used to determine the presence of genetic disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

7) A nurse counsels a couple on sex-linked disorders. Both the man and the woman are carriers of the disorder. They ask the nurse how this disorder will affect any children they might have. What is the nurse's best response? A) "If you have a daughter, she will not be affected." B) "Your son will be affected because the father has the disorder." C) "There is a 25% chance that your son will have the disorder because the mother has the disorder." D) "There is a 50% chance that your son will be a carrier only." Answer: D Explanation: A) There is a 50% chance that a carrier mother will pass the abnormal gene to each of her daughters, who will become carriers. B) Fathers affected with a sex-linked disorder cannot pass the disorder to their sons, but all of their daughters become carriers of the disorder. C) Because it is sex-linked, there will be more than a 25% chance that a son would be a carrier only. D) There is a 50% chance that a carrier mother will pass the normal gene on to each of her sons, who will be unaffected. Page Ref: 197 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Identify the characteristics of autosomal dominant, autosomal recessive, X-linked (sex-linked) recessive, and multifactorial inheritance disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

8) A 58-year-old father and a 45-year-old mother gave birth to a baby boy 2 days ago. The nurse assesses a single palmar crease and low-set ears on the newborn. The nurse plans to counsel the couple about which chromosomal abnormality? A) Trisomy 13 B) Trisomy 18 C) Trisomy 21 D) Trisomy 26 Answer: C Explanation: A) A single palmar crease and low-set ears are not characteristics of trisomy 13. B) A single palmar crease and low-set ears are not characteristics of trisomy 18. C) A single palmar crease and low-set ears are characteristics of trisomy 21 (Down syndrome). D) Trisomy 26 is not a chromosomal abnormality. Page Ref: 192 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 10. Engage patients or designates surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Compare prenatal and postnatal diagnostic procedures used to determine the presence of genetic disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

9) Which couples may benefit from prenatal diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Couples including women under the age of 35 B) Couples with an unbalanced translocation C) Couples with a family history of a known or suspected single-gene disorder D) Couples including women with a teratogenic risk secondary to an exposure or maternal health condition E) Family history of birth defects and/or intellectual disability Answer: C, D, E Explanation: A) Women age 35 or over at time of birth may benefit from prenatal diagnosis. B) Couples with a balanced translocation (chromosomal abnormality) may benefit from prenatal diagnosis. C) Couples with a family history of known or suspected single-gene disorder (e.g., cystic fibrosis, hemophilia A or B, Duchenne muscular dystrophy) may benefit from prenatal diagnosis. D) Women with a teratogenic risk secondary to an exposure or maternal health condition (e.g., diabetes, seizure disorder) may benefit from prenatal diagnosis. E) Family history of birth defects and/or intellectual disability (mental retardation) (e.g., neural tube defects, congenital heart disease, cleft lip and/or palate) may benefit from prenatal diagnosis. Page Ref: 198—199 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Compare prenatal and postnatal diagnostic procedures used to determine the presence of genetic disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

10) A family has the following inherited disorder. What information should the nurse review with this family? A) There are various degrees of presentation B) The disorder will become milder in subsequent generations C) This is seen in consanguineous mating D) There is no male-to-male transmission Answer: A Explanation: A) Autosomal dominant inherited disorders have varying degrees of presentation. This is an important factor when counseling families concerning autosomal dominant disorders. Although a parent may have a mild form of the disease, the child may have a more severe form. There is no evidence to support autosomal dominant inherited disorders will become milder in subsequent generations. Autosomal recessive inherited disorders are seen more when there is a history of consanguineous mating. No male-to-male transmission is associated with X-linked recessive inheritance disorders. Page Ref: 196 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Identify the characteristics of autosomal dominant, autosomal recessive, X-linked (sex-linked) recessive, and multifactorial inheritance disorders. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

11) A married couple of Ashkenazi Jewish descent is pregnant with their first child. For which genetic health problems should the nurse provide teaching in anticipation of further testing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cystic fibrosis 2. Beta-thalassemia 3 Canavan disease 4. Tay-Sachs disease 5. Familial dysautonomia Answer: 1, 3, 4, 5 Explanation: Genetic screening for individuals of Ashkenazi Jewish descent includes cystic fibrosis, Canavan disease, Tay-Sachs disease, and familial dysautonomia. Beta-thalassemia is a genetic disorder seen in individuals of Greek or Italian descent. Page Ref: 203 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Identify couples who may benefit from preconceptual genetic counseling and testing, including those with special reproductive concerns. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

12) The nurse is providing care to several pregnant clients at an OB-GYN clinic. Which client might benefit from prenatal diagnostic testing? A) Paternal age of 35 years B) Maternal age of 30 years C) Family history of anxiety D) Family history of cystic fibrosis Answer: D Explanation: A) Advanced paternal age is not a reason for prenatal diagnostic testing. B) Advanced maternal age is a reason for prenatal diagnostic testing; however, advanced maternal age is considered at the age of 35 years, not 30 years. C) A family history of anxiety is not a reason for prenatal diagnostic testing. D) Cystic fibrosis is an example of a single-gene disorder. This client would benefit from prenatal diagnostic testing. Page Ref: 202 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Identify couples who may benefit from preconceptual genetic counseling and testing, including those with special reproductive concerns. MNL LO: Demonstrate understanding of reproductive genetics, screening, and management for women at risk for genetic disorders.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 11 Physical and Psychologic Changes of Pregnancy 1) A client with a normal prepregnancy weight asks why she has been told to gain 25-35 pounds during her pregnancy while her underweight friend was told to gain more weight. What should the nurse tell the client the recommended weight gain is during pregnancy? A) 25-35 pounds, regardless of a client's prepregnant weight B) More than 25-35 pounds for an overweight woman C) Up to 40 pounds for an underweight woman D) The same for a normal weight woman as for an overweight woman Answer: C Explanation: A) The recommended total weight gain during pregnancy for a woman of normal weight before pregnancy is 25 to 35 pounds. B) For women who were overweight before becoming pregnant, the recommended gain is 15 to 25 pounds. C) Prepregnant weight determines the recommended weight gain during pregnancy. Underweight women are advised to gain 28-40 pounds. D) Women of normal weight should gain 25-35 pounds during pregnancy, whereas overweight women should limit their weight gain to 15-25 pounds during pregnancy. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Identify the anatomic and physiologic changes that occur during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

2) The nurse understands that a client's pregnancy is progressing normally when what physiologic changes are documented on the prenatal record of a woman at 36 weeks' gestation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The joints of the pelvis have relaxed, causing a waddling gait. B) The cervix is firm and blue-purple in color. C) The uterus vasculature contains one sixth of the total maternal blood volume. D) Gastric emptying time is delayed, and the client complains of constipation and bloating. E) Supine hypotension occurs when the client lies on her back. Answer: A, C, D, E Explanation: A) The sacroiliac, sacrococcygeal, and pubic joints of the pelvis relax in the later part of the pregnancy, presumably as a result of hormonal changes. This often causes a waddling gait. B) Cervical changes during pregnancy include softening and blue-purple discoloration. C) By the end of pregnancy, one sixth of the total maternal blood volume is contained within the vascular system of the uterus. D) Gastric emptying time and intestinal motility are delayed, leading to frequent complaints of bloating and constipation, which can be aggravated by the smooth muscle relaxation and increased electrolyte and water reabsorption in the large intestine. E) The enlarging uterus may exert pressure on the vena cava when the woman lies supine, causing a drop in blood pressure. This is called the vena caval syndrome, or supine hypotension. Page Ref: 208, 210, 211, 224 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

3) A client who is in the second trimester of pregnancy tells the nurse that she has developed a darkening of the line in the midline of her abdomen from the symphysis pubis to the umbilicus. What other expected changes during pregnancy might she also notice? A) Lightening of the nipples and areolas B) Reddish streaks called striae on her abdomen C) A decrease in hair thickness D) Small purplish dots on her face and arms Answer: B Explanation: A) Pigmentation of the skin increases in areas already hyperpigmented: areolae, nipples, vulva, perianal area, and linea alba. B) Striae, or stretch marks, are reddish, wavy, depressed streaks that may occur over the abdomen, breasts, and thighs as pregnancy progresses. C) A greater percentage of hair follicles go into the dormant phase, resulting in less hair shedding, which is perceived as thickening of the hair. D) Although bright-red elevations on the skin (vascular spider nevi) are a normal finding, petechiae are not. Page Ref: 208 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

4) The nurse is listening to the fetal heart tones of a client at 37 weeks' gestation while the client is in a supine position. The client states, "I'm getting lightheaded and dizzy." What is the nurse's best action? A) Assist the client to sit up. B) Remind the client that she needs to lie still to hear the baby. C) Help the client turn onto her left side. D) Check the client's blood pressure. Answer: C Explanation: A) Having the client sit up will not offer the best and fastest relief. B) Having the client lie still will not improve the situation, and is not therapeutic. C) During pregnancy the enlarging uterus may put pressure on the vena cava when the woman is supine, resulting in supine hypotensive syndrome. This pressure interferes with returning blood flow and produces a marked decrease in blood pressure with accompanying dizziness, pallor, and clamminess, which can be corrected by having the woman lie on her left side. D) The client is hypotensive because she is at the end of pregnancy and lying supine. Checking her blood pressure will not relieve the situation. Page Ref: 209 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

5) What is the increased vascularization causing the softening of the cervix known as? A) Hegar sign B) Chadwick sign C) Goodell sign D) McDonald sign Answer: C Explanation: A) Hegar sign is a softening of the isthmus of the uterus. B) Increased vascularization causes blue-purple discoloration of the cervix known as Chadwick sign. C) Increased vascularization causes the softening of the cervix known as Goodell sign. D) McDonald sign is an ease in flexing the body of the uterus against the cervix. Page Ref: 214 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Identify the anatomic and physiologic changes that occur during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

6) It is 1 week before a pregnant client's due date. The nurse notes on the chart that the client's pulse rate was 74-80 before pregnancy. Today, the client's pulse rate at rest is 90. What action should the nurse should take? A) Chart the findings. B) Notify the physician of tachycardia. C) Prepare the client for an electrocardiogram (EKG). D) Prepare the client for transport to the hospital. Answer: C Explanation: A) The pulse rate frequently increases during pregnancy, although the amount varies from almost no increase to an increase of 10 to 15 beats per minute. This is a normal response, and does not indicate a need for emergency measures or treatment. B) This pulse rate in a near-term client is not considered to be tachycardia. C) This pulse rate in a near-term client does not indicate a need for emergency measures or treatment. D) This client does not need to go to the hospital. Page Ref: 209 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

7) A client at 16 weeks' gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change? A) "Because of your pregnancy, you're not making enough red blood cells." B) "Because your blood volume has increased, your hematocrit count is lower." C) "This change could indicate a serious problem that might harm your baby." D) "You're not eating enough iron-rich foods like meat." Answer: B Explanation: A) The pregnancy would not cause a decrease in the production of red blood cells. B) Hemoglobin and hematocrit levels drop in early to mid-pregnancy as a result of pregnancyassociated hemodilution. Because the plasma volume increase (50%) is greater than the erythrocyte increase (25%), the hematocrit decreases slightly. C) This change is referred to as physiologic anemia of pregnancy, and is not harmful to the fetus. D) The decreased hematocrit does not mean that the woman is not eating enough iron-rich foods. It is recommended that an iron supplement during pregnancy of 27 milligrams of iron be taken daily, and iron can be found in most prenatal supplements. Page Ref: 209 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 1 Identify the anatomic and physiologic changes that occur during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

8) During her first months of pregnancy, a client tells the nurse, "It seems like I have to go to the bathroom every 5 minutes." The nurse explains to the client that this is because of which of the following? A) The client probably has a urinary tract infection. B) Bladder capacity increases throughout pregnancy. C) The growing uterus puts pressure on the bladder. D) Some women are very sensitive to body function changes. Answer: C Explanation: A) Increased frequency of urination in the first trimester of pregnancy does not indicate a urinary tract infection. B) Bladder capacity does not increase throughout pregnancy. C) During the first trimester, the growing uterus puts pressure on the bladder, producing urinary frequency until the second trimester, when the uterus becomes an abdominal organ. Near term, when the presenting part engages in the pelvis, pressure is again exerted on the bladder. D) Sensitivity is not the cause of an increased frequency of urination in the first trimester. Page Ref: 210 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

9) The nurse is assessing a client in the third trimester of pregnancy. What physiologic changes in the client are expected? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The client's chest circumference has increased by 6 cm during the pregnancy. B) The client has a narrowed subcostal angle. C) The client is using thoracic breathing. D) The client may have epistaxis. E) The client has a productive cough. Answer: A, C, D Explanation: A) The chest increase compensates for the elevated diaphragm. B) The diaphragm is elevated and the subcostal angle is increased as a result of pressure from the enlarging uterus. C) Breathing changes from abdominal to thoracic as pregnancy progresses. D) Epistaxis (nosebleeds) may occur and are primarily the result of estrogen-induced edema and vascular congestion of the nasal mucosa. E) A productive cough is never a normal finding. Page Ref: 209 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

10) The nurse has received a phone call from a multigravida who is 21 weeks pregnant and has not felt fetal movement yet. What is the best action for the nurse to take? A) Reassure the client that this is a normal finding in multigravidas. B) Suggest that she should feel for movement with her fingertips. C) Schedule an appointment for her with her physician for that same day. D) Tell her gently that her fetus is probably dead. Answer: C Explanation: A) A lack of fetal movement is unusual at 21 weeks, and should be checked. B) Fetal movement can be actively palpated by the client's physician or a trained examiner, but is unlikely to be self-detected by the mother at this stage. C) Quickening, or the mother's perception of fetal movement, occurs about 18 to 20 weeks after the LMP in a primigravida (a woman who is pregnant for the first time) but may occur as early as 16 weeks in a multigravida (a woman who has been pregnant more than once). D) The fetus may or may not have died after or about the 20th week of pregnancy; however, telling the client that the fetus might have died in utero without confirmation of this fact is nontherapeutic. Page Ref: 214 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

11) The client in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best? A) "Lack of menses and breast enlargement are presumptive signs of pregnancy." B) "The changes you are describing are definitely indicators that you are pregnant." C) "Lack of menses can be caused by many things. We need to do a pregnancy test." D) "You're probably not pregnant, but we can check it out if you like." Answer: C Explanation: A) Although a lack of menses and breast enlargement are presumptive signs of pregnancy, the nurse should not state this without explaining that these symptoms also can be caused by other conditions. B) This statement is false because amenorrhea and breast enlargement can be caused by other conditions. C) This is a true statement, and addresses that these changes could be caused by conditions other than pregnancy. D) While lack of menses and breast enlargement might not be caused by pregnancy, they likely are the result of pregnancy, and it is inappropriate for the nurse to suggest the client is not pregnant. Page Ref: 214 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

12) The nurse has completed a community presentation about the changes of pregnancy, and knows that the lesson was successful when a community member states that which of the following is one probable or objective change of pregnancy? A) "Enlargement of the uterus" B) "Hearing the baby's heart rate" C) "Increased urinary frequency" D) "Nausea and vomiting" Answer: A Explanation: A) An examiner can perceive the objective (probable) changes that occur in pregnancy. Enlargement of the uterus is a probable change. B) Hearing the fetal heart rate is a diagnostic, or positive, change of pregnancy. C) Increased urinary frequency is a subjective, or presumptive, change of pregnancy. D) Nausea and vomiting are subjective, or presumptive, changes of pregnancy. Page Ref: 215 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

13) A client who is experiencing her first pregnancy has just completed the initial prenatal examination with a certified nurse-midwife. Which statement indicates that the client needs additional information? A) "Because we heard the baby's heartbeat, I am undoubtedly pregnant." B) "Because I have had a positive pregnancy test, I am undoubtedly pregnant." C) "My last period was 2 months ago, which means I'm 2 months along." D) "The increased size of my uterus means that I am finally pregnant." Answer: C Explanation: A) Hearing the fetal heart rate is a positive, or diagnostic, change of pregnancy, so this statement would not indicate the need for further teaching. B) A positive pregnancy test is a positive, or diagnostic, indication of pregnancy. This statement would not indicate the need for further teaching. C) Amenorrhea is a subjective, or presumptive, change of pregnancy, and is not a reliable indicator of pregnancy in the early months. This statement requires additional teaching. D) Increased uterine size is an objective, or probable, change of pregnancy. Page Ref: 214 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations that foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

14) The adolescent client reports to the clinic nurse that her period is late, but her home pregnancy test is negative. What should the nurse explain that these findings most likely indicate? A) "This means you are not pregnant." B) "You might be pregnant, but it might be too early for your home test to be accurate." C) "We don't trust home tests. Come to the clinic for a blood test." D) "Most people don't use the tests correctly. Did you read the instructions?" Answer: B Explanation: A) Although it might be true that she is not pregnant, this is not the best statement because the pregnancy might be too early for a urine pregnancy test to detect. B) This is a true statement. Most home pregnancy tests have low false-positive rates, but the false-negative rate is slightly higher. Repeating the test in a week is recommended. C) This statement is not worded therapeutically. A clinic pregnancy test is usually a urine test. D) Although this statement gets at the need to read the instructions for the test, it is not worded therapeutically. Page Ref: 214 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. A. 1. Integrate multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidencebased care that respects patient and family preferences. | NLN Competencies: RelationshipCentered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Contrast the various types of pregnancy tests. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

15) The client is at 6 weeks' gestation, and is spotting. The client had an ectopic pregnancy 1 year ago, so the nurse anticipates that the physician will order which intervention? A) A urine pregnancy test B) The client to be seen next week for a full examination C) An antiserum pregnancy test D) An ultrasound Answer: C Explanation: A) Urine pregnancy tests are not quantifiable. B) It is not appropriate to wait until next week to see the client. C) A β-Subunit radioimmunoassay (RIA) uses an antiserum with specificity for the β-subunit of hCG in blood plasma. This test may not only detect pregnancy but also detect an ectopic pregnancy or trophoblastic disease. D) An ultrasound may be used to diagnose an ectopic pregnancy, but would not be needed now. Page Ref: 216 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Contrast the various types of pregnancy tests. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

16) A woman calls the clinic and tells a nurse that she thinks she might be pregnant. She wants to use a home pregnancy test before going to the clinic, and asks the nurse how to use it correctly. What information should the nurse give? A) The false-positive rate of these tests is quite high. B) If the results are negative, the woman should repeat the test in 2 weeks if she has not started her menstrual period. C) A negative result merely indicates growing trophoblastic tissue and not necessarily a uterine pregnancy. D) The client should follow up with a healthcare provider after taking the home pregnancy test. Answer: D Explanation: A) The false-positive rate of these tests is quite low. B) If the results are negative, the woman should repeat the test in 1 week if she has not started her menstrual period. C) A positive result merely indicates growing trophoblastic tissue and not necessarily a uterine pregnancy. D) It is important that clients remember that the tests are not always accurate and they should follow up with a healthcare provider. Page Ref: 216—217 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III. B. 3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and effectively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Contrast the various types of pregnancy tests. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

17) A prenatal educator is asking a partner about normal psychologic adjustment of an expectant mother during the second trimester of pregnancy. Which answer by the partner would indicate a typical expectant mother's response to pregnancy? A) "She is very body-conscious, and hates every little change." B) "She daydreams about what kind of parent she is going to be." C) "I haven't noticed anything. I just found out she was pregnant." D) "She has been having dreams at night about misplacing the baby." Answer: B Explanation: A) Psychologic adjustment to pregnancy is as significant as the physiologic changes. B) The second trimester brings increased introspection and consideration of how she will parent. She might begin to get furniture and clothing as concrete preparation, and may feel movement and be aware of the fetus as she begins to incorporate it into her identity. C) In the first trimester, pregnant women usually tell their partners of the pregnancy. This answer is incorrect. D) Psychologic adjustment to pregnancy is as significant as the physiologic changes. In the third trimester, dreams of misplacing the baby or being unable to get to the baby are common. Page Ref: 218 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preference and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Discuss the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

18) The partner of a client at 16 weeks' gestation accompanies her to the clinic. The partner tells the nurse that the baby just doesn't seem real to him, and he is having a hard time relating to his partner's fatigue and food aversions. Which statement would be best for the nurse to make? A) "If you would concentrate harder, you'd be aware of the reality of this pregnancy." B) "My husband had no problem with this. What was your childhood like?" C) "You might need professional psychological counseling. Ask your physician." D) "Many men feel this way. Feeling the baby move in a few weeks will help make it real to you." Answer: D Explanation: A) This is inappropriate for the nurse say. B) This is an inappropriate comment for the nurse to make. C) The partner's feelings are not indicative of psychological pathology. D) Initially, expectant fathers may have ambivalent feelings. The extent of ambivalence depends on many factors, including the father's relationship with his partner, his previous experience with pregnancy, his age, his economic stability, and whether the pregnancy was planned. The expectant father must first deal with the reality of the pregnancy and then struggle to gain recognition as a parent from his partner, family, friends, coworkers, society–and from his baby as well. Page Ref: 220—221 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preference, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

19) The client at 30 weeks' gestation with her first child is upset. She tells the prenatal clinic nurse that she is excited to become a mother, and has been thinking about what kind of parent she will be. But her mother has told her that she doesn't want to be a grandmother because she doesn't feel old enough, while her husband has said that the pregnancy doesn't feel real to him yet, and he will become excited when the baby is actually here. What is the most likely explanation for what is happening within this family? A) Her husband will not attach with this child and will not be a good father. B) Her mother is rejecting the role of grandparent, and will not help out. C) The client is not progressing through the developmental tasks of pregnancy. D) The family members are adjusting to the role change at their own paces. Answer: D Explanation: A) The expectant father must first deal with the reality of the pregnancy and then struggle to gain recognition as a parent from his partner, family, friends, coworkers, society–and from his baby as well. B) Younger grandparents leading active lives may not demonstrate as much interest as the young couple would like. C) This is a false statement. The client is at the stage of seeking acceptance of this child by others, which first will be her partner and other family members. D) This is a true statement. With each pregnancy, routines and family dynamics are altered, requiring readjustment and realignment. Page Ref: 217 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nursepatient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

20) The pregnant client at 14 weeks' gestation is in the clinic for a regular prenatal visit. Her mother also is present. The grandmother-to-be states that she is quite uncertain about how she can be a good grandmother to this baby because she works full time. Her own grandmother was retired, and was always available when needed by a grandchild. What is the nurse's best response to this concern? A) "Don't worry. You'll be a wonderful grandmother. It will all work out fine." B) "What are your thoughts on what your role as grandmother will include?" C) "As long as there is another grandmother available, you don't have to worry." D) "Grandmothers are supposed to be available. You should retire from your job." Answer: B Explanation: A) It is important to avoid clichés in order to promote effective therapeutic communication. B) Although relationships with parents can be very complex, the expectant grandparents often become increasingly supportive of the expectant couple, even if conflicts previously existed. But it can be difficult for even sensitive grandparents to know how deeply to become involved in the childrearing process. In some areas, classes for grandparents provide information about changes in birthing and parenting practices. C) It is important to avoid placing guilt on clients in order to promote effective therapeutic communication. D) It is important to avoid placing guilt on clients in order to promote effective therapeutic communication. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation and evaluation of care. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

21) Nurses who are interacting with expectant families from a different culture or ethnic group can provide more effective, culturally sensitive nursing care by doing what? A) Recognizing that ultimately it is the family's right to make a woman's healthcare choices. B) Obtaining a medical interpreter of the language the client speaks. C) Evaluating whether the client's healthcare beliefs have any positive consequences for her health. D) Accepting personal biases, attitudes, stereotypes, and prejudices. Answer: B Explanation: A) The nurse should recognize that ultimately it is the woman's right to make her own healthcare choices. B) The nurse should provide for the services of an interpreter if language barriers exist. C) The nurse should evaluate whether the client's healthcare beliefs have any potential negative consequences for her health. D) The nurse should identify personal biases, attitudes, stereotypes, and prejudices. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Affirm and value diversity. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Summarize cultural factors that may influence a family's response to pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

22) Which of the following is common in many non-Western cultures and is on the increase in the United States? A) Ceremonial rituals and rites B) Cultural assessment C) Cultural values D) Co-sleeping Answer: D Explanation: A) A universal tendency exists to create ceremonial rituals and rites around important life events. B) Healthcare professionals are becoming increasingly aware of the importance of addressing cultural, physiologic, and psychologic needs in the prenatal assessment in order to provide culture-specific healthcare during pregnancy. C) Identification of cultural values is useful in planning and providing culturally sensitive care. D) Some parents advocate cosleeping or bed sharing (one or both parents sleeping with their baby or young child). Cosleeping, which is common in many non-Western cultures, is on the increase in the United States. Page Ref: 222 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Affirm and value diversity. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Summarize cultural factors that may influence a family's response to pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

23) The introduction of a new baby into the family is often the beginning of which of the following? A) Sibling rivalry B) Inconsistent childrearing C) Toilet training D) Weaning Answer: A Explanation: A) Sibling rivalry results from children's fear of change in the security of their relationships with their parents, which comes with the birth of a sibling. B) Consistency is important in dealing with young children. They need reassurance that certain people, special things, and familiar places will continue to exist after the new baby arrives. C) Parents should know that the older, toilet-trained child may regress to wetting or soiling because he or she sees the new baby getting attention for such behavior. D) The older, weaned child may want to drink from the breast or bottle again after the new baby comes. Page Ref: 222 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Affirm and value diversity. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

24) A pregnant patient is observed lying in bed in the following position. Which health problem is this patient prone to developing?

A) Vena caval syndrome B) Physiologic anemia of pregnancy C) Physiologic leukocytosis D) Low iron level Answer: A Explanation: A) In vena caval syndrome the gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension. Physiologic anemia of pregnancy is caused by an increase in plasma volume (50%) that is greater than the erythrocyte increase (25%) causing the hematocrit to slightly decrease. This body position does not impact white blood cell production. This body posture does not impact iron levels. Iron levels are impacted by the volume of red blood cells. Page Ref: 209 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment; Nursing Process. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

25) During a routine assessment of a pregnant patient the nurse observes the following on the patient's abdomen. How should the nurse document this finding?

A) Striae B) Chloasma C) Linea nigra D) Vascular spider nevi

Answer: C Explanation: C) The linea alba refers to the midline of the abdomen from the pubic area to the umbilicus and above. During pregnancy increased pigmentation may cause this area to darken. It is then referred to as the linea nigra. Some women also develop facial chloasma (or melasma gravidarum), the "mask of pregnancy." This is an irregular pigmentation of the cheeks, forehead, and nose that occurs in many women during pregnancy and is accentuated by sun exposure. Striae, or stretch marks, are reddish, wavy, depressed streaks that may occur over the abdomen, breasts, and thighs as pregnancy progresses. They are caused by reduced connective tissue strength due to elevated adrenal steroid levels. Vascular spider nevi may develop on the chest, neck, face, arms, and legs. They are small, bright-red elevations of the skin radiating from a central body. They may be caused by increased subcutaneous blood flow in response to increased estrogen levels. Page Ref: 210 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Communication and Documentation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

26) A patient weighing 80 kg with a body mass index of 29.8 is 6 weeks pregnant. What should be this patient's maximum weight at the time of delivery? Answer: 89 kg Explanation: Women who are obese are advised to limit weight gain to 5 to 9 kg (11 to 20 lb). Since the patient weighs 80 kg at 6 weeks pregnant, the maximum amount she should weigh would be 80 kg + 9 kg = 89 kg. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

27) During a pelvic examination of a pregnant patient the following area is identified as being softened. How should the nurse document this finding?

A) Ladin sign B) Braun von Fernwald sign C) Piskacek's sign D) Goodell sign Answer: A Explanation: A) The Ladin sign is a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. The Braun von Fernwald sign is an irregular softening and enlargement at the site of implantation. Piskacek's sign is a tumorlike asymmetric enlargement of the uterus. Goodell sign is caused by increased vascularization, which softens the cervix. Page Ref: 216 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Communication and Documentation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

28) The nurse is evaluating the fundal height of a patient who is 20 weeks pregnant. Which height should the nurse expect to assess in this patient?

A) A B) B C) C D) D Answer: D Explanation: D) At 20 week's gestation the fundal height should be at the level of the patient's umbilicus. Choice 1 is the fundal height for 36 week's gestation. Choice 2 is the fundal height for 30 week's gestation. Choice 3 is the fundal height for 26 week's gestation. Page Ref: 216 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

29) A patient at 28 weeks' gestation asks the nurse why she has backaches. To help explain the changes, the nurse shows her a picture of the shape of her back. Which picture should the nurse use?

A) A B) B C) C D) D Answer: B Explanation: B) In the 28th week of gestation, the baby is becoming large enough that it is increasingly causing lordosis of the lumbosacral spine. Page Ref: 211 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

30) The nurse is providing prenatal care to an obese client who asks, "How much weight should I gain during my pregnancy?" Which response by the nurse is appropriate? A) "You should gain 15 to 25 pounds." B) "You should gain 25 to 35 pounds." C) "You should gain 11 to 20 pounds." D) "You should gain 28 to 40 pounds." Answer: C Explanation: A) An overweight client should gain 15 to 25 pounds during pregnancy. B) A pregnant client who has a normal weight before pregnancy should gain 25 to 35 pounds during pregnancy. C) An obese client who becomes pregnant should gain 11 to 20 pounds during pregnancy. D) An underweight client should gain 28 to 40 pounds during pregnancy. Page Ref: 212 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Teaching and Learning. Learning Outcome: 1 Identify the anatomic and physiologic changes that occur during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

31) The nurse is conducting an initial prenatal appointment for a client who believes she is pregnant. Which is considered a positive sign of pregnancy? A) Linea nigra B) Fetal heartbeat C) Breast tenderness D) Urinary frequency Answer: B Explanation: A) Linea nigra is a probable, not positive, sign of pregnancy. B) A fetal heartbeat is a positive sign of pregnancy. C) Breast tenderness is a probable, not positive, sign of pregnancy. D) Urinary frequency is a probable, not positive, sign of pregnancy. Page Ref: 217 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

32) The nurse is providing care to a client who is entering the second trimester of pregnancy. Which client statement does the nurse anticipate when assessing this client? A) "We picked out a name for a boy and for a girl." B) "We bought the baby's crib and car seat this past weekend." C) "I am so uncomfortable all the time and I can't seem to sleep at night." D) "I am angry with my husband for not showing more interest in my pregnancy." Answer: D Explanation: A) The nurse would expect this client statement during the third, not second, trimester of pregnancy. B) The nurse would expect this client statement during the third, not second, trimester of pregnancy. C) The nurse would expect this client statement during the third, not second, trimester of pregnancy. D) The nurse would expect this statement during the second trimester of pregnancy. Page Ref: 218 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

33) The nurse is providing care to a pregnant client who is experiencing an increase in white, thick, and "cottage-cheese-like" vaginal discharge. Based on this data, which diagnosis does the nurse anticipate for this client? A) Syphilis B) Gonorrhea C) Moniliasis D) Chlamydia Answer: C Explanation: A) The assessment data does not support the diagnosis of syphilis. B) The assessment data does not support the diagnosis of gonorrhea. C) Vaginal secretions during pregnancy are often thick, white and acidic which increase the client's risk for moniliasis, a common yeast infection during pregnancy. D) The assessment data does not support the diagnosis of chlamydia. Page Ref: 208 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

34) The nurse notes purplish stretch marks on the pregnant client's breasts during the physical assessment. Which term will the nurse use when documenting this finding in the medical record? A) Striae B) Colostrum C) Linea nigra D) Chadwick's sign Answer: A Explanation: A) Striae is the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. B) Colostrum is not the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. C) Linea nigra is not the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. D) Chadwick's sign is not the term used to document the purplish stretch marks that may be noted on the breasts during pregnancy. Page Ref: 208 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Communication and Documentation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

35) The nurse is assessing a pregnant client who reports nasal stuffiness and congestion. Which term will the nurse use to document this data in the medical record? A) Rales B) Epistaxis C) Rhinitis of pregnancy D) Pregnancy-induced asthma Answer: C Explanation: A) Rales is not the term the nurse uses to document nasal stuffiness and congestion that occurs during pregnancy. B) Epistaxis is not the term the nurse uses to document nasal stuffiness and congestion that occurs during pregnancy. C) Rhinitis of pregnancy is the term that the nurse will use when documenting nasal stuffiness and congestion that often occurs during pregnancy. D) Pregnancy-induced asthma is not the term the nurse uses to document nasal stuffiness and congestion that occurs during pregnancy. Page Ref: 209 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Communication and Documentation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

36) The nurse is assessing a pregnant client during a scheduled prenatal visit who reports dizziness and clamminess when lying in bed each morning. Which statement by the nurse is appropriate based on this data? A) "The doctor may order an amniocentesis to determine if the fetus is healthy." B) "This information indicates that you are developing gestational hypertension." C) "Be sure to sit up slowly and stay sitting for several minutes prior to getting up." D) "Try lying on your left side to enhance blood flow, which will help your symptoms." Answer: D Explanation: A) This data does not warrant an amniocentesis. B) This data does not support the diagnosis of gestational hypertension. C) This statement is appropriate for a client who is experiencing orthostatic hypotension and is not appropriate for the data assessed. D) The data suggests that the client is experiencing supine hypotension, which is often corrected by having the client lie on her left side. Page Ref: 209 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

37) The nurse is assessing a pregnant client in the second trimester of pregnancy during a scheduled prenatal visit. Which questions are appropriate during the assessment process? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Do you feel bloated?" 2. "Do you have hemorrhoids?" 3. "Are you experiencing heartburn?" 4. "Are you experiencing constipation?" 5. "Are you experiencing nausea and vomiting?" Answer: 1, 2, 3, 4 Explanation: Gastrointestinal symptoms that often occur during the second trimester of pregnancy include feeling bloated, the development of hemorrhoids, heartburn, and constipation. Nausea and vomiting are more common during the first trimester of pregnancy. Page Ref: 210 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. A. 1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman. MNL LO: Demonstrate understanding of the physical and physiological changes that occur during pregnancy.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 12 Antepartum Nursing Assessment 1) While completing the medical and surgical history during the initial prenatal visit, the 16year-old primigravida interrupts with "Why are you asking me all these questions? What difference does it make?" Which statement would best answer the client's questions? A) "We ask these questions to detect anything that happened in your past that might affect the pregnancy." B) "We ask these questions to see whether you can have prenatal visits less often than most clients do." C) "We ask these questions to make sure that our paperwork and records are complete and up to date." D) "We ask these questions to look for any health problems in the past that might affect your parenting." Answer: A Explanation: A) The course of a pregnancy depends on a number of factors, including the past pregnancy history (if this is not a first pregnancy), prepregnancy health of the woman, presence of disease/illness states, family history, emotional status, and past healthcare. B) Prenatal visits follow a set schedule for normal clients without complications. C) Paperwork is a lower priority than client care. D) The psychological history of a client, not the medical or surgical history, can indicate potential problems with parenting. Page Ref: 227—228 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Summarize the essential components of a prenatal history. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

2) A woman gave birth last week to a fetus at 18 weeks' gestation after her first pregnancy. She is in the clinic for follow-up, and notices that her chart states she has had one abortion. The client is upset over the use of this word. How can the nurse best explain this terminology to the client? A) "Abortion is the obstetric term for all pregnancies that end before 20 weeks." B) "Abortion is the word we use when someone has miscarried." C) "Abortion is how we label babies born in the second trimester." D) "Abortion is what we call all babies who are born dead." Answer: A Explanation: A) The term abortion means a birth that occurs before 20 weeks' gestation or the birth of a fetus-newborn who weighs less than 500 g. An abortion may occur spontaneously, or it may be induced by medical or surgical means. B) This explanation is only partially correct. C) This explanation is only partially correct. D) This is not a true statement. Page Ref: 227 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 1. Value seeing healthcare situations "through patients' eyes." | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and selfdetermination and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Define common obstetric terminology found in the history of maternity patients. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

3) The clinic nurse is compiling data for a yearly report. Which client would be classified as a primigravida? A) A client at 18 weeks' gestation who had a spontaneous loss at 12 weeks B) A client at 13 weeks' gestation who had an ectopic pregnancy at 8 weeks C) A client at 14 weeks' gestation who has a 3-year-old daughter at home D) A client at 15 weeks' gestation who has never been pregnant before Answer: D Explanation: A) A pregnant woman who has been pregnant before is called a multigravida. B) A pregnant woman who has been pregnant before is called a multigravida. C) A pregnant woman who has been pregnant before is called a multigravida. D) Primigravida means a woman who is pregnant for the first time. Page Ref: 227 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Define common obstetric terminology found in the history of maternity patients. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

4) The client has delivered her first child at 37 weeks. The nurse would describe this to the client as what type of delivery? A) Preterm B) Postterm C) Early term D) Near term Answer: C Explanation: A) Preterm births are those that occur between 20 weeks and 37 completed weeks. B) Postterm births are those that occur at 42 weeks and beyond. C) Early term births extend from 37 to 38 weeks' gestation. D) Near term is not terminology used to describe birth. Page Ref: 227 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Define common obstetric terminology found in the history of maternity patients. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

5) The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form? A) Where was the father of the baby born? B) Do genetic diseases run in the family of the baby's father? C) What is the name of the baby's father? D) Are you married to the father of the baby? Answer: B Explanation: A) The father's place of birth is not important information to include about the pregnancy. B) This question has the highest priority because it gets at the physiologic issue of inheritable genetic diseases that might directly impact the baby. C) Although it is helpful for the nurse to know the name of the baby's father to include him in the prenatal care, this is psychosocial information. D) Although the marital status of the client might have cultural significance, this is psychosocial information. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the value of the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Summarize the essential components of a prenatal history. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

6) A 25-year-old primigravida is at 20 weeks' gestation. The nurse takes her vital signs and notifies the healthcare provider immediately because of which finding? A) Pulse 88/minute B) Rhonchi in both bases C) Temperature 37.4°C (99.3°F) D) Blood pressure 122/78 mmHg Answer: B Explanation: A) The pulse will increase 10-15 beats/minute during pregnancy, with 60-90 beats/minute being the normal range. B) Any abnormal breath sounds should be reported to the healthcare provider. C) Temperature norms in pregnancy are slightly higher due to fetal metabolism: 36.2-37.6°C (97-99.6°F). D) A blood pressure less than or equal to 120/80 mmHg considered normal. Page Ref: 235 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Safety and Quality: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

7) The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings? A) Document the findings on the prenatal chart. B) Have the physician see the client today. C) Instruct the client to avoid direct sunlight. D) Analyze previous thyroid hormone lab results. Answer: B Explanation: A) While all of these findings should be documented on the prenatal chart, additional action is indicated. B) Mottling of the skin is indicative of possible anemia. These abnormalities must be reported to the healthcare provider immediately. C) Instructing the client to avoid direct sunlight is not necessary; rather, additional action is indicated. D) The thyroid gland increases in size during pregnancy due to hyperplasia. Additional action is indicated. Page Ref: 234 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Safety and Quality: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

8) The nurse begins a prenatal assessment on a 25-year-old primigravida at 20 weeks' gestation and immediately contacts the healthcare provider because of which finding? A) Pulse 88/minute B) Respirations 30/minute C) Temperature 37.4°C (99.3°F) D) Blood pressure 118/82 mmHg Answer: B Explanation: A) Pulse rate may increase 10-15 beats per minute during pregnancy, with an average of 60-100 beats per minute. B) Tachypnea is not a normal finding and requires medical care. C) A slightly higher temperature is an expected finding during pregnancy, ranging from 36.2°C37.6°C (97°F-99.6°F). D) A blood pressure of less than or equal to 120/80 mmHg is considered normal. Page Ref: 234 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

9) The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings? A) 12 weeks' gestation, with fetal heart tones heard by Doppler fetoscope B) 22 weeks' gestation, client reports no fetal movement felt yet C) 16 weeks' gestation, fundus three finger-breadths above umbilicus D) Marked edema Answer: A Explanation: A) This is an expected finding because fetal heart tones should be heard by 12 weeks using a Doppler fetoscope. B) At 22 weeks, no fetal movement is an abnormal finding. Fetal movement should be felt by 20 weeks. C) This is an abnormal finding. The fundus should be three finger-breadths above umbilicus at 28 weeks. D) This is an abnormal finding. There may be some edema of hands and ankles in late pregnancy, but marked edema could indicate preeclampsia. Page Ref: 237 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

10) What signs would indicate that a pregnant client's urinalysis culture was abnormal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) pH 4.6-8 B) Alkaline urine C) Cloudy appearance D) Negative for protein and red blood cells E) Hemoglobinuria Answer: B, C, E Explanation: A) Urine pH of 4.6-8 is within a normal, healthy range. B) Alkaline urine could indicate metabolic alkalemia, Proteus infection, or an old specimen. C) A cloudy appearance could indicate an infection. D) Positive findings could indicate contaminated specimen, UTI, or kidney disease. E) Hemoglobinuria would be indicated by an abnormal urine color. Page Ref: 239 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

11) The nurse receives a phone call from a client who claims she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the client's estimated date of delivery (EDD) be if she is pregnant? A) Nov. 13 B) Jan. 17 C) Jan. 10 D) Dec. 3 Answer: B Explanation: A) Nov. 13 is not correct according to Nagele's rule. B) The due date is Jan. 17. Nagele's rule is to add 7 days to the last menstrual period and subtract 3 months. The last menstrual period is April 10, therefore Jan. 17 is the EDD. C) Jan. 10 is not correct according to Nagele's rule. D) Dec. 3 is not correct according to Nagele's rule. Page Ref: 242 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Calculate the estimated date of birth using the common methods. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

12) The primigravida at 22 weeks' gestation has a fundal height palpated slightly below the umbilicus. Which of the following statements would best describe to the client why she needs to be seen by a physician today? A) "Your baby is growing too much and getting too big." B) "Your uterus might have an abnormal shape." C) "The position of your baby can't be felt." D) "Your baby might not be growing enough." Answer: D Explanation: A) At 22 weeks' gestation, the fundal height should be at about 22 cm. B) Uterine shape can be assessed only with diagnostic imaging techniques such as ultrasound or CT scan. C) The position of the baby is not noted until 36 weeks' gestation. D) The fundal height at 20-22 weeks should be about even with the umbilicus. At 22 weeks' gestation, a fundal height below the umbilicus and a uterine size that is inconsistent with length of gestation could indicate fetal demise. Page Ref: 243 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

13) The nurse is explaining to a new prenatal client that the certified nurse-midwife will perform clinical pelvimetry as a part of the pelvic exam. The nurse knows that teaching has been successful when the client makes which statement about the reason for the exam? A) "It will help us know how big a baby I can deliver vaginally." B) "Doing this exam is a part of prenatal care at this clinic." C) "My sister had both of her babies by cesarean." D) "I am pregnant with my first child." Answer: A Explanation: A) By performing a series of assessments and measurements, the examiner assesses the pelvis vaginally to determine whether the size and shape are adequate for a vaginal birth; this procedure is called clinical pelvimetry. B) Although this is a true statement, the estimation of the pelvis size is a better indication of the client's understanding. C) Stating that the client's sister had her babies by cesarean would not indicate that the client understood the teaching. D) Clinical pelvimetry is done with the first pregnancy, but the client's stating that this is her first child does not indicate that the client understood the teaching. Page Ref: 244 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

14) The nurse is assessing a newly pregnant client. Which finding does the nurse note as a normal psychosocial adjustment in this client's first trimester? A) An unlisted telephone number B) Reluctance to tell the partner of the pregnancy C) Parental disapproval of the woman's partner D) Ambivalence about the pregnancy Answer: D Explanation: A) An unlisted telephone number does not indicate psychosocial adjustment. B) Reluctance to tell the partner about the pregnancy might indicate that the client anticipates disapproval, and is not a normal psychosocial adjustment. C) Parental disapproval of the client's partner does not indicate psychosocial adjustment. D) Ambivalence toward a pregnancy is a common psychosocial adjustment in early pregnancy. Page Ref: 240 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Summarize the essential components of a prenatal history. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

15) The nurse is assessing a primiparous client who indicates that her religion is Judaism. Why is this information pertinent for the nurse to assess? A) Religious and cultural background can impact what a client eats during pregnancy. B) It provides a baseline from which to ask questions about the client's religious and cultural background. C) Knowing the client's beliefs and behaviors regarding pregnancy is not important. D) Clients sometimes encounter problems in their pregnancies based on what religion they practice. Answer: B Explanation: A) Although this can be true, much more than diet is impacted by religious and cultural background. B) Nurses have an obligation to be aware of other cultures and develop a culturally sensitive plan of care to meet the needs of the childbearing woman and her family. C) It is especially helpful if the nurse is familiar with common practices of various religious and cultural groups who reside in the community. D) How a client observes her religion occasionally will cause problems with pregnancy, but this is not the most important reason for obtaining this information. Page Ref: 240, 249 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination and his or her own power and self-healing processes. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Summarize the essential components of a prenatal history. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

16) What would the nurse include as part of a routine physical assessment for a second-trimester primiparous patient whose prenatal care began in the first trimester and is ongoing? A) Pap smear B) Hepatitis B screening (HBsAg) C) Fundal height measurement D) Complete blood count Answer: C Explanation: A) Pap smear is usually done at the initial prenatal appointment. B) Hepatitis B screening is done at the initial prenatal appointment. C) At each prenatal visit, the blood pressure, pulse, and weight are assessed, and the size of the fundus is measured. Fundal height should be increasing with each prenatal visit. D) Complete blood count is done at the initial prenatal appointment. Page Ref: 243 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

17) If a woman has the pre-existing condition of diabetes, the nurse knows that she would be prone to what high-risk factor when pregnant? A) Vasospasm B) Postpartum hemorrhage C) Episodes of hypoglycemia and hyperglycemia D) Cerebrovascular accident (CVA) Answer: D Explanation: A) Vasospasm would be a high-risk factor for a client with pre-existing cardiac disease. B) Postpartum hemorrhage would be a high-risk factor for a client with pre-existing hyperthyroidism. C) Episodes of hypoglycemia and hyperglycemia would be a high-risk factor for a client with pre-existing diabetes. D) Cerebrovascular accident (CVA) would be a high-risk factor for a client with pre-existing hypertension. Page Ref: 246—247 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

18) Which third-trimester client would the nurse suspect might be having difficulty with psychological adjustments to her pregnancy? A) A woman who says, "Either a boy or a girl will be fine with me" B) A woman who puts her feet up and listens to some music for 15 minutes when she is feeling too stressed C) A woman who was a smoker but who has quit at least for the duration of her pregnancy D) A woman who has not investigated the kind of clothing or feeding methods the baby will need Answer: D Explanation: A) Acceptance of gender is indicative of healthy adaptation to pregnancy. B) Using stress reduction techniques are indicative of healthy adaptation to pregnancy. C) Quitting smoking is indicative of healthy adaptation to pregnancy. D) By the third trimester, the client should be planning and preparing for the baby (for example, living arrangements, clothing, feeding methods). Page Ref: 253 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal patient. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

19) A nurse examining a prenatal client recognizes that a lag in progression of measurements of fundal height from week to week and month to month could signal what condition? A) Twin pregnancy B) Intrauterine growth restriction C) Hydramnios D) Breech position Answer: B Explanation: A) A sudden increase in fundal height could indicate twins. B) A lag in progression of measurements of fundal height from month to month could signal intrauterine growth restriction (IUGR). C) A sudden increase in fundal height could indicate hydramnios. D) A fetus in breech position would still have a normal fundal height measurement. Page Ref: 231 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

20) The nurse at the prenatal clinic has four calls to return. Which call should the nurse return first? A) Client at 32 weeks, reports headache and blurred vision. B) Client at 18 weeks, reports no fetal movement in this pregnancy. C) Client at 16 weeks, reports increased urinary frequency. D) Client at 40 weeks, reports sudden gush of fluid and contractions. Answer: A Explanation: A) Headache and blurred vision are signs of preeclampsia, which is potentially life-threatening for both mother and fetus. This client has top priority. B) Fetal movement should be felt by 19-20 weeks. The lack of fetal movement prior to 20 weeks is considered normal. This client is a lower priority. C) Increased urinary frequency is common during pregnancy as the increased size of the uterus puts pressure on the urinary bladder. D) A full-term client who is experiencing contractions and a sudden gush of fluid is in labor. Although laboring clients should be in contact with their provider for advice on when to go to the hospital, labor at full term is an expected finding. This client is a lower priority. Page Ref: 249 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

21) Screening for gestational diabetes mellitus (GDM) is typically completed between which of the following weeks of gestation? A) 36 and 40 weeks B) Before 20 weeks C) 24 and 28 weeks D) 30 and 34 weeks Answer: C Explanation: A) Screening for gestational diabetes mellitus (GDM) is not completed between 36 and 40 weeks' gestation. B) Screening for gestational diabetes mellitus (GDM) is not completed before 20 weeks' gestation. C) Screening for gestational diabetes mellitus (GDM) is typically completed between 24 and 28 weeks' gestation. D) Screening for gestational diabetes mellitus (GDM) is not completed between 30 and 34 weeks' gestation. Page Ref: 246 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the prenatal patient. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

22) A pregnant patient's first day of her last menstrual period was 6/14. What would be this patient's estimated date of birth? Answer: 3/21 Explanation: To determine estimated date of birth, subtract 3 months and add 7 days from the first day of the patient's last menstrual period. For this patient, this would be 6 - 3 or 3 and 14 + 7 or 21. The estimated date of birth would be 3/21. Page Ref: 242 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 4 Calculate the estimated date of birth using the common methods. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

23) The nurse is measuring the fundal height of a patient who is at 28 weeks' gestation using the following method. What would be considered a normal finding?

A) 22 cm B) 24 cm C) 28 cm D) 30 cm Answer: C Explanation: C) Fundal height in centimeters correlates well with weeks of gestation between 22 weeks and 34 weeks. At 28 weeks' gestation, fundal height is probably about 28 cm. Fundal heights of 22 and 24 cm could indicate restricted fetal growth. A fundal height of 30 cm may indicate the presence of twins, hydramnios, or a large for gestational age (LGA) fetus. Page Ref: 243 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

24) The nurse is explaining pelvic measurements to a patient who is 20 weeks pregnant. On the diagram, which measurement should the nurse identify as being the smallest for the fetus to pass during delivery?

A) A B) B C) C D) D Answer: B Explanation: B) The important anteroposterior diameters of the inlet for childbearing are the diagonal conjugate, the obstetric conjugate, and the conjugate vera, or true conjugate. The obstetric conjugate is the smallest and the most important anteroposterior diameter through which the fetus must pass. Plane of least pelvic dimension is not an important measurement for delivery. Page Ref: 244 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

25) A pregnant patient is having pelvic measurements made. Which approach should the examiner use to determine this patient's estimated length of the pubic ramus? A)

Answer: B Explanation: B) Choice 2 is an estimation of the length of the pubic ramus. Choice 1 is an estimation of the subpubic angle. Choice 3 is an estimation of the depth and inclination of the pubis. Choice 4 is an estimation of the contour of the subpubic angle. Page Ref: 247 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

26) During the examination of a patient who is pregnant 24 weeks, the healthcare provider performs the maneuver in the diagram below. What is being measured on this patient?

A) Subpubic angle B) Transverse diameter C) Anteroposterior sagittal diameter D) Height and angle of the symphysis pubis Answer: B Explanation: B) The transverse diameter of the outlet is measured by placing the fist between the ischial tuberosities. The subpubic angle is estimated by palpating the bony structure externally with two fingers placed side by side at the border of the symphysis. The height and inclination of the symphysis pubis are measured, and the contour of the pubic arch is estimated. Excessively long or angulated bone structure shortens the diameter of the obstetric conjugate. Height can be determined by placing the index finger of the gloved hand up to the superior border of the symphysis. The anteroposterior sagittal diameter is the most significant diameter of the outlet because it is the shortest diameter through which the infant must pass. The examiner uses two fingers to determine the contour of the pubic arch. This provides information on the width of the angle at which these bones come together. Page Ref: 246 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period. 27 Copyright © 2020 Pearson Education, Inc.

27) The nurse is collecting information during the health history assessment for the client profile during the initial prenatal visit. Which question is appropriate when assessing the current pregnancy? A) "What was the date of your last menstrual period?" B) "How many times have you been pregnant?" C) "What were your children's birth weights?" D) "How many living children do you have?" Answer: A Explanation: A) The nurse would ask the client for the date of the last menstrual period when assessing the current pregnancy as part of the client profile. B) The nurse would ask the client how many times she has been pregnant when assessing past pregnancies as part of the client profile. C) The nurse would assess the birth weights of the client's children when assessing past pregnancies as part of the client profile. D) The nurse would ask the client how many living children she has when assessing past pregnancies as part of the client profile. Page Ref: 241 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Summarize the essential components of a prenatal history. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

28) The nurse is assessing an obese pregnant client during a routine prenatal visit. Which is the priority assessment for this client? A) Complete blood count (CBC) B) Basic metabolic panel (BMP) C) Blood pressure D) Fetal heart rate Answer: C Explanation: A) While it is important to monitor the client's CBC to assess for anemia, this is not the priority assessment for this client. B) The BMP is not commonly monitored during pregnancy. A blood glucose level may be monitored, as the client's weight places her at risk for gestational diabetes mellitus. C) The blood pressure would be monitored closely at each prenatal visit due to the client's weight. Obese clients have a greater risk for gestational hypertension. This is the priority assessment for this client. D) While it is important to monitor the fetal heart rate during every prenatal visit, this is not the priority for this client. Page Ref: 251 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide client-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal client. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

29) The nurse is providing care to a pregnant client diagnosed with a urinary tract infection (UTI) during a routine prenatal visit. What will the nurse educate the client about based on this data? A) Gestational hypertension B) Gestational diabetes mellitus C) Preterm labor D) Anemia Answer: C Explanation: A) A diagnosis of a UTI during pregnancy does not increase the risk for gestational hypertension. B) A diagnosis of a UTI during pregnancy does not increase the risk for gestational diabetes mellitus. C) The nurse would provide teaching to the client regarding signs and symptoms associated with preterm labor, as the diagnosis of a UTI increases the risk for developing this complication of pregnancy. D) A diagnosis of a UTI during pregnancy does not increase the risk for anemia. Page Ref: 233 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide client-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal client. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

30) The nurse is preparing to assess the pregnant client's fundal height during a routine prenatal visit. Which nursing action is appropriate in this situation? A) Telling the client not to eat or drink for one hour after the procedure B) Asking the client to empty her bladder prior to the procedure C) Obtaining informed consent for the procedure D) Assessing blood pressure after the procedure Answer: B Explanation: A) It is not necessary for the client to abstain from eating or drinking for one hour after the procedure. This action might be appropriate for a client who is having a glucose tolerance test, not for one undergoing assessment of fundal height. B) It is appropriate for the nurse to ask the client to empty her bladder prior to assessing fundal height. A full bladder may impact the accuracy of the measurement. C) Informed consent is not needed, as assessing fundal height is not an invasive procedure. D) There is no reason to assess the client's blood pressure after measuring fundal height. Page Ref: 243 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Describe the essential measurements that can be determined by clinical pelvimetry. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

31) The nurse is explaining "quickening" to a client who is pregnant for the first time. Which client indicates the need for further education on this topic? A) "It will feel like butterflies in my stomach." B) "It might feel like I have gas." C) "It should occur during the second trimester of my pregnancy." D) "It is an indication that I am experiencing preterm labor." Answer: D Explanation: A) Quickening is often described as if there are butterflies in the stomach. This statement indicates appropriate understanding of the information presented. B) Quickening is often mistaken for gas. This statement indicates appropriate understanding of the information presented. C) Quickening often occurs during the second trimester of pregnancy, between 16 and 22 weeks' gestation. This statement indicates appropriate understanding of the information presented. D) Quickening is not an indication of preterm labor, but an expected finding during pregnancy. This statement indicates the need for further education. Page Ref: 243 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

32) The nurse is teaching a pregnant client the clinical manifestations associated with preterm labor. Which client statement indicates the need for further education? A) "Menstrual-like cramps are a sign of preterm labor." B) "A dull low backache is a sign of preterm labor." C) "Diarrhea is a sign of preterm labor." D) "Vomiting is a sign of preterm labor." Answer: D Explanation: A) Painful menstrual-like cramps are a sign of preterm labor. This statement indicates appropriate understanding of the information presented. B) A dull low backache is a sign of preterm labor. This statement indicates appropriate understanding of the information presented. C) Diarrhea is a sign of preterm labor. This statement indicates appropriate understanding of the information presented. D) Vomiting is not a clinical manifestation associated with preterm labor. This statement indicates the need for further education. Page Ref: 248 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

33) The nurse is conducting an initial prenatal assessment for a pregnant client. Which screenings should the nurse prepare the client for during this visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Complete blood count (CBC) B) Glucose tolerance test (GTT) C) ABO and Rh typing D) HIV screening E) Urinalysis Answer: A, C, D, E Explanation: A) A CBC is drawn during the initial prenatal visit. B) A GTT is not done until the second trimester of the pregnancy. C) ABO and Rh typing are drawn during the initial prenatal visit. D) An HIV screening is drawn during the initial prenatal visit. E) A urinalysis is conducted during the initial prenatal visit and for every subsequent prenatal visit. Page Ref: 252 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the prenatal patient. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

34) Which serum markers are assessed when conducting a quadruple screen? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Alpha-fetoprotein (AFP) B) Human chorionic gonadotropin (hCG) C) Unconjugated estriol (UE) D) Inhibin-A E) Glycated hemoglobin Answer: A, B, C, D Explanation: A) A quadruple screen assesses for the serum marker of AFP. B) A quadruple screen assesses for the serum marker of hCG. C) A quadruple screen assesses for the serum marker of UE. D) A quadruple screen assesses the serum marker of inhibin-A. E) A quadruple screen does not assess for glycated hemoglobin. Page Ref: 248 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the prenatal patient. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

35) The nurse is teaching the pregnant client about the symptoms of preeclampsia. Which clinical manifestations will the nurse include in the teaching session? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Dizziness B) Blurred vision C) Abdominal pain D) Vaginal bleeding E) Severe headache Answer: A, B, E Explanation: A) Dizziness is a clinical manifestation associated with preeclampsia. B) Blurred vision is a clinical manifestation associated with preeclampsia. C) Abdominal pain is a clinical manifestation of premature labor or abruptio placentae, not preeclampsia. D) Vaginal bleeding is a clinical manifestation of abruptio placentae or placenta previa, not preeclampsia. E) Severe headache is a clinical manifestation associated with preeclampsia. Page Ref: 249 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III. B. 3. Base individualized care plan on client values, clinical expertise and evidence. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Teaching and Learning. Learning Outcome: 7 Relate the danger signs of pregnancy to their possible causes. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the antepartum period.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 13 The Expectant Family: Needs and Care 1) The nurse is caring for a pregnant client. The client's husband has come to the prenatal visit. Which question is best for the nurse to use to assess the father's adaptation to the pregnancy? A) "What kind of work do you do?" B) "What furniture have you gotten for the baby?" C) "How moody has your wife been lately?" D) "How are you feeling about becoming a father?" Answer: D Explanation: A) What kind of work the husband does is not an indicator of his adaptation to the pregnancy. B) What furniture has been obtained is not an indicator of the father's adaptation to the pregnancy. C) The husband's perceptions of his wife's moodiness are not an indicator of the father's adaptation to the pregnancy. D) A husband's adaptation to pregnancy includes his feelings about impending fatherhood. Page Ref: 259 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Describe actions the nurse can take to help maintain the well-being of the expectant father or partner and siblings during a family's pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

2) The nurse is preparing a class for expectant fathers. Which information should the nurse include? A) Siblings adjust readily to the new baby. B) Sexual activity is safe for normal pregnancy. C) The expectant mother decides the feeding method. D) Fathers are expected to be involved in labor and birth. Answer: B Explanation: A) Siblings often have difficulty adapting to the arrival of a new baby. Parents who are unprepared for the older child's feelings of anger, jealousy, and rejection may respond inappropriately in their confusion and surprise. B) In a healthy pregnancy, there is no medical reason to limit sexual activity. C) Often, the father wants input in deciding on the feeding method. D) In some cultures, the father is not present at birth. The nurse should recognize the importance of birth practices that are part of a family's tradition and honor these practices when possible. Page Ref: 259 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Describe actions the nurse can take to help maintain the well-being of the expectant father or partner and siblings during a family's pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

3) The prenatal period should be used to expose the prospective parents to up-to-date, evidencebased information about which of the following topics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Breastfeeding B) Pain relief C) Obstetric complications and procedures D) Toddler care E) Antepartum adjustment Answer: A, B, C Explanation: A) The prenatal period should expose prospective parents to up-to-date, evidencebased information about breastfeeding. B) The prenatal period should expose prospective parents to up-to-date, evidence-based information about pain relief. C) The prenatal period should expose prospective parents to up-to-date, evidence-based information about obstetric complications and procedures. D) The prenatal period should expose prospective parents to up-to-date, evidence-based information about normal newborn care. E) The prenatal period should expose prospective parents to up-to-date, evidence-based information about postpartum adjustment. Page Ref: 267 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

4) A Navajo client who is 36 weeks pregnant meets with a traditional healer as well as her physician. What does the nurse understand this to mean? A) The client is seeking spiritual direction. B) The client does not trust her physician. C) The client will not adapt well to mothering. D) The client is experiencing complications of pregnancy. Answer: A Explanation: A) Navajo clients are aware of the mind-soul connection, and might try to follow certain practices to have a healthy pregnancy and birth. Practices could include focus on peace and positive thoughts as well as certain types of prayers and ceremonies. A traditional healer may assist them. B) Seeing a traditional healer does not indicate mistrust of the provider. C) Seeking a spiritual healer does not indicate the client's lack of parenting ability. D) Seeking a spiritual healer does not indicate any type of pathology or complications. Page Ref: 261 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 1. Value seeing healthcare situations "through patients' eyes." | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the significance of cultural considerations in managing nursing care during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

5) A Chinese woman who is 12 weeks pregnant reports to the nurse that ginseng and bamboo leaves help reduce her anxiety. How should the nurse respond to this client? A) Advise the client to give up the bamboo leaves but to continue taking ginseng. B) Advise the client to discuss all herbal remedies with the provider. C) Tell the client that the provider thinks the remedies have no scientific foundation. D) Assess where the client obtains her remedy, and investigate the source. Answer: B Explanation: A) The nurse should find out what medications and home remedies the client is using, and counsel the client regarding overall effects. B) The nurse should advise the client to discuss all medications (including herbal supplements) with the health care provider. C) It is not appropriate to tell the client that the provider thinks the remedies have no scientific foundation. D) It is outside the nurse's scope to assess the source of the herbs. Page Ref: 261 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the significance of cultural considerations in managing nursing care during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

6) The primiparous client has told the nurse that she is afraid she will develop hemorrhoids during pregnancy because her mother did. Which statement would be best for the nurse to make? A) "It is not unusual for women to develop hemorrhoids during pregnancy." B) "Most women don't have any problem until after they've delivered." C) "If your mother had hemorrhoids, you will get them, too." D) "If you get hemorrhoids, you probably will need surgery to get rid of them." Answer: A Explanation: A) Many pregnant women will develop hemorrhoids. Hemorrhoids are varicosities of the veins in the lower end of the rectum and anus. During pregnancy, the gravid uterus presses on the veins and interferes with venous circulation. As the pregnancy progresses, the straining that accompanies constipation can contribute to the development of hemorrhoids. B) It is not true that most women have no hemorrhoids until after the birth. Many women develop hemorrhoids during pregnancy. C) A family history does not automatically mean that a client will develop the condition. D) Hemorrhoids that occur in pregnancy or at birth usually become asymptomatic after the early postpartum period. Page Ref: 272 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage the patient or designated surrogates in active partnership that promotes health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify the common discomforts of pregnancy and their causes. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

7) Which statement, if made by a pregnant client, would indicate that she understands health promotion during pregnancy? A) "I lie down after eating to relieve heartburn." B) "I try to limit my fluid intake to 3 or 4 glasses each day." C) "I elevate my legs while sitting at my desk." D) "I am avoiding exercise to stay well rested." Answer: C Explanation: A) Heartburn is gastroesophageal reflux, and will be exacerbated by lying down. B) At least 8-10 glasses of fluids should be consumed each day to maintain the increased blood volume of pregnancy. C) Elevating the legs can help decrease lower leg edema. D) Regular mild to moderate exercise has many benefits for pregnant women. Page Ref: 271 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

8) The nurse is teaching an early pregnancy class for clients in the first trimester of pregnancy. Which statement by a client requires immediate intervention by the nurse? A) "When my nausea is bad, I will drink some ginger tea." B) "The fatigue I am experiencing will improve in the second trimester." C) "It is normal for my vaginal discharge to be green." D) "I will urinate less often during the middle of my pregnancy." Answer: C Explanation: A) Ginger helps nausea, and is safe for use during pregnancy. B) First-trimester fatigue is common; fatigue usually improves during the second trimester. C) Increased whitish vaginal discharge, called leukorrhea, is common in pregnancy. Green discharge is not a normal finding, and indicates a vaginal infection. D) Urinary frequency, a common discomfort of pregnancy, occurs early in pregnancy and again during the third trimester because of the pressure of the enlarging uterus on the bladder. Page Ref: 271 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

9) The nurse assessing a pregnant African American woman in the first trimester understands that a cultural practice is which of the following? A) Use of herbs like dandelion during pregnancy to increase lactation B) Drinking ginseng tea for faintness C) Eating clay to supply dietary minerals D) Consulting a spiritual advisor to ensure a healthy pregnancy and birth Answer: C Explanation: A) Use of dandelion is a practice of American Indians. B) Asian women who are pregnant often drink ginseng tea. C) African American pregnant women may be guided by their extended family into common practices such as geophagia, the ingestion of dirt or clay, which is believed to alleviate mineral deficiencies. D) Consulting a spiritual advisor is common among Navajo and many other Native American cultures. Page Ref: 262 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the significance of cultural considerations in managing nursing care during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

10) Remedies for back pain in pregnancy that are supported by research evidence and may safely be taught to any pregnant woman by the nurse include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Pelvic tilt B) Water aerobics C) Sit-ups D) Proper body mechanics E) Good posture is important because it allows more room for the stomach to function. Answer: A, B, D, E Explanation: A) The pelvic tilt can help restore proper body alignment and relieve back pain. B) Exercise is an effective treatment for lower back pain. Exercise in water seems to provide benefits while being physically comfortable for expectant mothers. C) Sit-ups require back-lying. Because of the pressure of the enlarging uterus on the vena cava, the woman should not lie flat on her back after about the fourth month. D) The use of proper posture and good body mechanics throughout pregnancy is important. E) Good posture is important because it allows more room for the stomach to function. Page Ref: 273 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

11) A client in her third trimester of pregnancy reports frequent leg cramps. What strategy would be most appropriate for the nurse to suggest? A) Point the toes of the affected leg B) Increase intake of protein-rich foods C) Limit activity for several days D) Flex the foot to stretch the calf Answer: D Explanation: A) Leg cramps are exacerbated by pointing the toes. B) Leg cramps often result from an imbalance in the calcium-phosphorus ratio, not from a lack of protein-rich foods. C) Leg cramps are not caused by excess activity. D) The nurse should advise the client to practice dorsiflexion of her feet to stretch the affected muscle. Page Ref: 273 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 7. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

12) The nurse in a prenatal clinic finds that four clients have called with complaints related to their pregnancies. Which call should the nurse return first? A) Pregnant woman at 7 weeks' gestation reporting nasal stuffiness B) Pregnant woman at 38 weeks' gestation experiencing rectal itching and hemorrhoids C) Pregnant woman at 15 weeks' gestation with nausea and vomiting and a 15-pound weight loss D) Pregnant woman at 32 weeks' gestation treating constipation with prune juice Answer: C Explanation: A) Nasal stuffiness is common in the first trimester as a result of increased estrogen. B) Hemorrhoids are common during pregnancy and often cause itching. C) The nurse should return this call first because this patient is the highest priority. A 15-pound weight loss is not an expected finding. Although some nausea is common, the woman who suffers from extreme nausea coupled with vomiting requires further assessment. D) Constipation during the third trimester is a common finding. Increased fluid and fiber from food sources are most effective in relieving constipation. Page Ref: 269 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the common discomforts of pregnancy and their causes. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

13) A 38-year-old client in her second trimester states a desire to begin an exercise program to decrease her fatigue. What is the most appropriate nursing response? A) "Fatigue should resolve in the second trimester, but walking daily might help." B) "Avoid a strenuous exercise regimen at your age. Drink coffee to combat fatigue." C) "Avoid an exercise regimen due to your pregnancy. Try to nap daily." D) "Fatigue will increase as pregnancy progresses, but running daily might help." Answer: A Explanation: A) Even mild to moderate exercise is beneficial during pregnancy. Regular exercise–at least 30 minutes of moderate exercise daily or at least most days of the week–is preferred. B) The age of 38 is not too old to begin an exercise routine. Nurses should advise women of common sources of caffeine, including coffee, tea, colas, and chocolate and suggest they limit their caffeine intake to about 300 mg/day. C) Mild to moderate exercise is beneficial during pregnancy. Scheduling activities to allow for napping is helpful. D) Jogging or running is acceptable for women already conditioned to these activities, as long as they avoid exercising at maximum effort and overheating. Page Ref: 270 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

14) The pregnant client in her second trimester states, "I didn't know my breasts would become so large. How do I find a good bra?" The best answer for the nurse to give would be which of the following? A) "Avoid cotton fabrics and get an underwire bra; they fit everyone best." B) "Just buy a bra one cup size bigger than usual, and it will fit." C) "Look for wide straps and cups big enough for all of your breast tissue." D) "There isn't much you can do for comfort. Try not wearing a bra at all." Answer: C Explanation: A) Cotton is comfortable during pregnancy when perspiration increases, because it does not retain heat and moisture. B) The client should be fitted for a well-fitting, supportive bra of an appropriate size. C) The nurse should instruct the client to get a bra that fits with straps that are wide and do not stretch, and a cup that holds all breast tissue comfortably. D) One can obtain a bra that fits and is comfortable. It is not necessary to be uncomfortable. Page Ref: 276 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

15) A pregnant client who swims 3-5 times per week asks the nurse whether she should stop this activity. What is the appropriate nursing response? A) "You should decrease the number of times you swim per week." B) "Continuing your exercise program would be beneficial." C) "You should discontinue your exercise program immediately." D) "You should consider a less strenuous type of exercise." Answer: B Explanation: A) There is no need to decrease the number of times the client swims per week, because mild to moderate exercise is beneficial during pregnancy. B) Mild to moderate exercise is beneficial during pregnancy. Regular exercise–at least 30 minutes of moderate exercise daily or at least most days of the week–is preferred. C) Non-weight-bearing exercises, such as swimming or cycling, are recommended because they decrease the risk of injury and provide fitness with comfort. D) A moderate, rhythmic exercise routine involving large muscle groups such as swimming, cycling, or brisk walking is best. Page Ref: 278 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

16) The nurse is presenting a class of important "dos and don'ts" during pregnancy, including travel considerations. What method of travel does the nurse recommend as most appropriate for a client in her 25th week of pregnancy? A) Automobile B) Airplane C) Train D) None; this client should not travel Answer: C Explanation: A) Travel by automobile can be especially fatiguing, aggravating many of the discomforts of pregnancy. The pregnant woman needs frequent opportunities to get out of the car and walk. B) Occasional flying is considered safe in the absence of any obstetric or medical complications. However, those women who have medical or obstetric complications, such as poorly controlled diabetes, sickle cell disease, or preeclampsia, and those women with placental abnormalities or who are at risk for preterm birth are advised to avoid flying during pregnancy. Before flying, the pregnant woman should check with her particular airline to see if it has any travel restrictions. C) As pregnancy progresses, travel by train is generally recommended for long distances. D) If medical or pregnancy complications are not present, there are no restrictions on travel. Pregnant women should avoid travel if there is a history of bleeding or preeclampsia, or if multiple births are anticipated. Page Ref: 259 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

17) After teaching a pregnant client about the effects of smoking on pregnancy, the nurse knows that the client needs further education when she makes which statement? A) "I am at increased risk for preeclampsia." B) "I am at increased risk for preterm birth." C) "I am at increased risk for placenta previa." D) "I am at increased risk for abruptio placentae." Answer: A Explanation: A) Smoking is not associated with increased risk for preeclampsia. B) Smoking is associated with increased risk for preterm birth. C) Smoking is associated with increased risk for placenta previa. D) Smoking is associated with increased risk for abruptio placentae. Page Ref: 284 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

18) Which of the following drugs and drug categories can cause multiple fetal central nervous system (CNS), facial, and cardiovascular anomalies? A) Category C: Zidovudine B) Category B: Penicillin C) Category X: Isotretinoin D) Category A: Vitamin C Answer: C Explanation: A) Zidovudine does not cause multiple fetal central nervous system (CNS), facial, and cardiovascular anomalies. B) Penicillin does not cause multiple fetal central nervous system (CNS), facial, and cardiovascular anomalies. C) Isotretinoin (Accutane), the acne medication, can cause multiple central nervous system (CNS), facial, and cardiovascular anomalies. D) Vitamin C does not cause multiple fetal central nervous system (CNS), facial, and cardiovascular anomalies. Page Ref: 283 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Promote communication and open reporting as a priority in healthcare. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

19) The prenatal client in her third trimester tells the clinic nurse that she works 8 hours a day as a cashier and stands when at work. What response by the nurse is best? A) "No problem. Your baby will be fine." B) "Do you get regular breaks for eating?" C) "Your risk of poor pregnancy outcomes may be higher." D) "Standing might increase ankle swelling." Answer: C Explanation: A) Standing more than 3 hours a day increases the risk of preterm labor. To be therapeutic in communication, avoid false reassurance. B) Although breaks for eating are important for pregnant employees, it is more important to tell the client about the increased risks associated with standing more than 3 hours a day. C) Pregnant women who are employed in jobs that require prolonged standing (more than 3 hours) may be at risk for poor pregnancy outcomes. D) Although this is true, it is less important than teaching the client about the risks of preterm labor from standing more than 3 hours a day. Page Ref: 277 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

20) The pregnant client has asked the nurse what kinds of medications cause birth defects. Which statement would best answer this question? A) "Birth defects are very rare. Don't worry; your doctor will watch for problems." B) "To be safe, don't take any medication without talking to your doctor." C) "Too much vitamin C is one of the most common issues." D) "Almost all medications will cause birth defects in the first trimester." Answer: B Explanation: A) The nurse should avoid giving a "don't worry" answer to ensure therapeutic communication, but it is appropriate to instruct the client to check with her caregiver about medications. B) The nurse should remind the client of the need to check with her caregiver about medications. If a woman has taken a drug in category D or X, she should be informed of the risks associated with that drug and of alternatives. C) Vitamin C is cited as a category A drug, as long as its use does not exceed the recommended dietary allowance. It has demonstrated no associated fetal risk. D) Not all medications are teratogenic. Page Ref: 283 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

21) Absolute contraindications to exercise while pregnant include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Abruptio placentae B) Placenta previa after 26 weeks' gestation C) Preeclampsia-eclampsia D) Cervical insufficiency (cerclage) E) Intrauterine growth restriction (IUGR) Answer: B, C, D Explanation: A) Abruptio placentae is not an absolute contraindication to exercise. B) Placenta previa after 26 weeks' gestation is an absolute contraindication to exercise. C) Preeclampsia-eclampsia is an absolute contraindication to exercise. D) Cervical insufficiency (cerclage) is an absolute contraindication to exercise. E) Intrauterine growth restriction (IUGR) is not an absolute contraindication to exercise. Page Ref: 278 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

22) Intercourse is contraindicated if the pregnancy is vulnerable because of which diagnosis? A) Gestational diabetes B) Cervical insufficiency (cerclage) C) Abruptio placentae D) Placenta previa Answer: D Explanation: A) Intercourse is not contraindicated if the pregnancy is vulnerable because of the diagnosis of gestational diabetes. B) Intercourse is not contraindicated if the pregnancy is vulnerable because of the diagnosis of cervical insufficiency (cerclage). C) Intercourse is not contraindicated if the pregnancy is vulnerable because of the diagnosis of abruptio placentae. D) Intercourse is contraindicated if the pregnancy is vulnerable because of the diagnosis of threatened spontaneous abortion, placenta previa, or the risk of preterm labor. Page Ref: 281 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Identify some of the concerns that an expectant couple may have about sexual activity. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

23) What self-care measures would a nurse recommend for a client in her first trimester to reduce the discomfort of nausea and vomiting? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Avoid odors or causative factors. B) Have small but frequent meals. C) Drink carbonated beverages. D) Drink milk before arising in the morning. E) Eat highly seasoned food. Answer: A, B, C Explanation: A) The nurse would recommend for a client in her first trimester to avoid odors and causative factors to reduce the discomfort of nausea and vomiting. B) The nurse would recommend for a client in her first trimester to have small but frequent meals to reduce the discomfort of nausea and vomiting. C) The nurse would recommend for a client in her first trimester to drink carbonated beverages to reduce the discomfort of nausea and vomiting. D) The nurse would recommend for a client in her first trimester to eat dry crackers or toast before arising in the morning to reduce the discomfort of nausea and vomiting. E) The nurse would recommend for a client in her first trimester to avoid greasy or highly seasoned foods to reduce the discomfort of nausea and vomiting. Page Ref: 275 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

24) The nurse is preparing material to present to a group of patients in the second trimester of their pregnancies. Which topics should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Clothing 2. Infant feeding 3. Fetal movement 4. Exercise and rest 5. Skin and breast care Answer: 1, 2, 3, 5 Explanation: Topics appropriate to teach patients in the second trimester of pregnancy include clothing, infant feeding, fetal movement, and skin and breast care. Exercise and rest are topics to be reviewed during the first and third trimesters. Page Ref: 259 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Explain the basic goals of childbirth education in providing care to expectant couples and their families. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

25) A pregnant patient in the early stages of labor asks for assistance to sit in the whirlpool tub. What are the advantages of using this intervention for the laboring patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increases relaxation 2. Increases pain threshold 3. Reduces postural hypotension 4. Promotes maternal-infant bonding 5. Reduces the need for pain medication Answer: 1, 2, 5 Explanation: The benefits of using a whirlpool tub during labor include increased relaxation, increased pain threshold, and reduced need for pain medication. The whirlpool tub will not reduce postural hypotension. Breastfeeding promotes maternal-infant bonding. Page Ref: 265 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

26) During a routine health visit the nurse notes that a patient who is 10 weeks pregnant is wearing the following items. On what should the nurse focus when assessing the patient?

A) Heartburn B) Constipation C) Hemorrhoids D) Nausea and vomiting Answer: D Explanation: D) Acupressure wristbands are sometimes used to help relieve nausea during early pregnancy. These wristbands have no impact on heartburn, constipation, or hemorrhoids. Page Ref: 270 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment; Nursing Process. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

27) A patient in the first trimester of pregnancy is experiencing ptyalism. What should the nurse suggest to help this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use chewing gum 2. Suck on hard candy 3. Snack on soda crackers 4. Use an astringent mouthwash 5. Brush the teeth with baking soda Answer: 1, 2, 4 Explanation: Ptyalism is a rare discomfort of pregnancy in which excessive, often bitter, saliva is produced. Its cause has not been established. Effective treatments are limited, however using astringent mouthwashes, chewing gum, or sucking on hard candy may minimize the problem. Many women also choose to carry tissues or a small towel to spit into when necessary. Soda crackers and brushing the teeth with baking soda are not identified as helpful with ptyalism. Page Ref: 271 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

28) The nurse learns that a patient who is 8 weeks pregnant continues to smoke 10 cigarettes a day. In which order should the nurse provide a 5 to 15 minute intervention about smoking with this patient? 1. Ask about tobacco use 2. Advise to quit smoking 3. Assist in attempt to quit 4. Arrange for follow-up care 5. Assess willingness to quit Answer: 1, 2, 5, 3, 4 Explanation: ACOG suggests that a 5- to 15-minute intervention with women who smoke fewer than 20 cigarettes a day is most effective. This program and other programs encourage healthcare providers to use the five As: ask about tobacco use; advise to quit smoking; assess willingness to quit; assist in attempt to quit; and arrange for follow-up care. Page Ref: 284 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the expectant family.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 14 Maternal Nutrition 1) A pregnant teenage client is diagnosed with iron-deficiency anemia. Which nutrient should the nurse encourage her to take to increase iron absorption? A) Vitamin A B) Vitamin C C) Vitamin D D) Vitamin E Answer: B Explanation: A) While vitamin A is good for the body, it does not promote the absorption of iron. B) Vitamin C is known to enhance the absorption of iron from meat and nonmeat sources. C) While vitamin D is good for the body, it does not promote the absorption of iron. D) While vitamin E is good for the body, it does not promote the absorption of iron. Page Ref: 294 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

2) The pregnant client cannot tolerate milk or meat. What would the nurse recommend to the client to assist in meeting protein needs? A) Wheat bread and pasta B) Ice cream and peanut butter C) Eggs and tofu D) Beans and potatoes Answer: C Explanation: A) Wheat bread and pasta are not sources of complete protein. B) Ice cream is a milk by-product, and would not be tolerated by this client. C) The best food choices that are nondairy and complete proteins alone are eggs and tofu. D) Beans and potatoes would not provide the client with adequate protein. Page Ref: 290 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

3) The pregnant client states she does not want "to take all these supplements." What recommendations could the nurse make for the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Folic acid has been found to be essential for minimizing the risk of neural tube defects." B) "You do not have to take these supplements if you think you are healthy enough." C) "Most women do not have adequate intake of iron pre-pregnancy, and iron needs increase with pregnancy." D) "These medications do the same thing. I will call your physician to cancel one of your medications." E) "You should take the folic acid, but the vitamins are not that important." Answer: A, C Explanation: A) An inadequate intake of folic acid has been associated with neural tube defects (NTDs) (e.g., spina bifida, anencephaly). B) This answer is incorrect because prenatal vitamins with iron and folic acid are necessary. C) Iron is essential because many pregnant women do not have adequate intake of iron before pregnancy. D) It is not the nurse's role to tell the physician to cancel any prescribed medication. E) Both folic acid and other vitamins and minerals are necessary for a successful pregnancy and a healthy baby. Page Ref: 295 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

4) The nurse is planning an early-pregnancy class session on nutrition. Which information should the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Protein is important for fetal development. B) Iron helps both mother and baby maintain the oxygen-carrying capacity of the blood. C) Calcium prevents constipation at the end of pregnancy. D) Zinc facilitates synthesis of RNA and DNA. E) Vitamin A promotes development of the baby's eyes. Answer: A, B, D, E Explanation: A) During pregnancy, the woman needs increased amounts of protein to provide amino acids for fetal development. B) Iron deficiency anemia is associated with an increased incidence of preterm birth, low-birthweight infants, and maternal and infant mortality. C) Calcium is not related to constipation. Calcium is involved in the mineralization of fetal bones and teeth, energy and cell production, and acid-base buffering. D) Zinc is involved in RNA and DNA synthesis, and milk production during lactation. E) Vitamin A promotes healthy formation and development of the fetal eyes. Page Ref: 295 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

5) The nurse is presenting a preconception counseling class. The nurse instructs the participants that niacin intake should increase during pregnancy to promote metabolic coenzyme activity. The nurse will know that teaching has been effective if a client suggests which food as a source of niacin? A) Fish B) Apples C) Broccoli D) Milk Answer: A Explanation: A) Dietary sources of niacin include meats, fish, and whole grains. B) Apples are a source of other vitamins; however, they do not contain significant niacin. C) Broccoli is a source of other vitamins; however, it does not contain significant niacin. D) Milk is a source of other vitamins; however, it does not contain significant niacin. Page Ref: 295 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

6) The nurse evaluates the diet of a pregnant client and finds that it is low in zinc. The nurse knows that zinc intake should increase during pregnancy to promote protein metabolism. Which food should the nurse suggest in order to increase intake of zinc? A) Shellfish B) Bananas C) Yogurt D) Cabbage Answer: A Explanation: A) Zinc is found in greatest concentration in meats, shellfish, and poultry. Other good sources include whole grains and legumes. B) Bananas are high in other nutrients, but do not have significant levels of zinc. C) Yogurt is high in other nutrients, but does not have significant levels of zinc. D) Cabbage is high in other nutrients, but does not have significant levels of zinc. Page Ref: 293 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preference, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

7) In early-pregnancy class, the nurse emphasizes the importance of 8-10 glasses of fluid per day. How many of these should be water? A) 1 to 2 B) 2 to 4 C) 4 to 6 D) 3 to 5 Answer: C Explanation: A) One to two glasses of water is not an adequate intake. B) Two to four glasses of water is not an adequate intake. C) A pregnant woman should consume at least 8 to 12 (8 oz) glasses of fluid each day, of which 4 to 6 glasses should be water. D) Three to five glasses of water is not an adequate intake. Page Ref: 296 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

8) What would the nurse do to accurately assess a pregnant client's food intake? A) Assess her most recent laboratory values. B) Ask her to complete a nutritional questionnaire. C) Observe for signs of hunger. D) Ask about her cooking facilities. Answer: B Explanation: A) Laboratory values may provide information on the nutritional status of the client, but do not indicate what foods she has eaten. B) Diet may be evaluated using a food frequency questionnaire, which lists common categories of foods and asks the woman how frequently in a day (or week) she consumes foods from the list. C) Hunger alone is not an adequate indicator of nutritional status. D) Cooking facilities are not related to food intake. Page Ref: 302 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

9) Postpartum nutritional status is determined primarily by assessing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Dietary history B) Menstrual history C) Mother's weight D) Hemoglobin levels E) Mother's height Answer: A, C, D Explanation: A) Postpartum nutritional status is determined by assessing the new mother's dietary history. B) Postpartum nutritional status is not determined by assessing the new mother's menstrual history. C) Postpartum nutritional status is determined by assessing the new mother's weight. D) Postpartum nutritional status is determined by assessing the new mother's hemoglobin levels. E) Postpartum nutritional status is not determined by assessing the new mother's height. Page Ref: 301 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Compare nutritional needs during pregnancy, the postpartum period, and lactation with nonpregnant requirements. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

10) The breastfeeding mother is concerned that her milk production has decreased. The nurse knows that further client teaching is needed based on which statement? A) "I am drinking a minimum of 8 to 10 glasses of liquid a day." B) "I have started cutting back on my protein intake." C) "At least three times a day, I drink a glass of milk." D) "My calorie intake is higher than during the pregnancy." Answer: B Explanation: A) The breastfeeding mother must consume a minimum of 8 to 10 glasses of liquid per day. B) An adequate protein intake is essential while breastfeeding because protein is an important component of breast milk. C) The breastfeeding mother must increase her protein and calcium intake. D) An inadequate caloric intake can reduce milk volume. Breastfeeding mothers should increase their caloric intake by 200 kcal over the pregnancy requirements. Page Ref: 301—302 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

11) The nurse is preparing for a postpartum home visit. The client has been home for a week, is breastfeeding, and experienced a third-degree perineal tear after vaginal delivery. The nurse should assess the client for which of the following? A) Dietary intake of fiber and fluids B) Dietary intake of folic acid and prenatal vitamins C) Return of hemoglobin and hematocrit levels to baseline D) Return of protein and albumin to predelivery levels Answer: A Explanation: A) This mother needs to avoid the risk of constipation. She might be hesitant to have a bowel movement due to anticipated pain from the perineal tear, and constipation will decrease the healing of the laceration. B) Dietary intake of prenatal vitamins is important while breastfeeding, but folic acid is more important prior to conception and in the first weeks of pregnancy to prevent neural tube defects. C) It will take several months for the laboratory levels to return to normal. D) It will take several months for the laboratory levels to return to normal. Page Ref: 292 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Compare nutritional needs during pregnancy, the postpartum period, and lactation with nonpregnant requirements. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

12) Which of the following is important for the development of the central nervous system of the fetus? A) Calcium and phosphorus B) Essential fatty acids C) Iron D) Vitamin D Answer: B Explanation: A) Calcium and phosphorus are involved in the mineralization of fetal bones and teeth, energy and cell production, and acid-base buffering. B) Essential fatty acids are important for the development of the central nervous system of the fetus. Of particular interest are the omega-3 fatty acids and their derivatives. C) Iron requirements increase during pregnancy because of the growth of the fetus and placenta and the expansion of maternal blood volume. D) Vitamin D is known for its role in the absorption and utilization of calcium and phosphorus in skeletal development. Page Ref: 292 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

13) A pregnant client who was of normal pre-pregnancy weight is now 30 weeks pregnant. She asks the nurse what appropriate weight gain for her should be. What is the nurse's best response? A) "25-35 pounds" B) "30-40 pounds" C) "17-18 pounds" D) "Less than 15 pounds" Answer: A Explanation: A) An appropriate weight gain for a woman of normal weight before pregnancy would be 25-35 pounds. B) This is not the correct range for woman of normal weight before pregnancy. C) This is not the correct range for woman of normal weight before pregnancy. D) A woman of normal weight before pregnancy should gain more than 15 pounds by 30 weeks. Page Ref: 288 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe the recommended levels of weight gain during pregnancy. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

14) A client presents to the antepartum clinic with a history of a 20-pound weight loss. Her pregnancy test is positive. She is concerned about gaining the weight back, and asks the nurse if she can remain on her diet. What is the nurse's best response? A) "As long as you supplement your diet with the prenatal vitamin, the amount of weight you gain in pregnancy is not significant." B) "I understand that gaining weight after such an accomplishment might not appeal to you but weight gain during pregnancy is important for proper fetal growth." C) "Dieting during pregnancy is considered child neglect." D) "Excessive weight gain in pregnancy is due to water retention, so weight loss following birth will not be an issue." Answer: B Explanation: A) Supplementation with vitamins is important, but so is maintaining weight gain within the expected parameters. B) Maternal weight gain is an important factor in fetal growth and in infant birth weight. An adequate weight gain over time indicates an adequate caloric intake. C) Child neglect can apply only after the child has been born. D) Weight gain during pregnancy typically is not water-related. Excess weight gain can be difficult to lose. Page Ref: 288 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe the recommended levels of weight gain during pregnancy. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

15) The prenatal clinic nurse is caring for a 15-year-old client who is at 8 weeks' gestation. The client asks the nurse why she is supposed to gain so much weight. What is the best response by the nurse? A) "Gaining 25-35 pounds is recommended for healthy fetal growth." B) "It's what your certified nurse-midwife recommended for you." C) "Inadequate weight gain delays lactation after delivery." D) "Weight gain is important to ensure that you get enough vitamins." Answer: A Explanation: A) For an appropriate-weight woman, 25-35 pounds of weight gain is recommended for optimal fetal growth and development. B) Although this statement might be true, the client has asked a "why" question that should be directly answered. C) Inadequate weight gain can lead to decreased fetal growth and development. D) Vitamin intake is related to the types of food consumed, not to caloric intake. Because this client is 15, her diet may not be optimal from a nutritional standpoint. Page Ref: 288 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patient or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

16) The nurse is planning an educational session for pregnant vegans. What information should the nurse include? A) Eating beans and rice provides complete protein needs. B) Soy is not a good source of protein for vegans. C) Rice contains a high level of vitamin B12. D) Vegan diets are excessively high in iron. Answer: A Explanation: A) Adequate dietary protein can be obtained by consuming a varied diet with adequate caloric intake and plant-based proteins. Consuming an assortment of plant proteins throughout the day such as beans and rice, peanut butter on whole-grain bread, and whole-grain cereal with soy milk ensures that the expectant mother obtains all essential amino acids. B) Good sources of plant proteins include beans, soy products, lentils, nuts, and nut butters. C) Vitamin B12 is the cobalt-containing vitamin found only in animal sources. D) Supplementation may be recommended for vegans who have difficulty meeting the recommended amounts of iron through food sources. Page Ref: 296 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

17) A pregnant client who is a lacto-vegetarian asks the nurse for assistance with her diet. What instruction should the nurse give? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Protein is important; therefore, the addition of one serving of meat a day is necessary." B) "A daily supplement of vitamin B12 is important." C) "The high fiber in a vegetarian diet is dangerous for pregnant women." D) "Eggs are important to add to your diet. Eat six eggs per week." E) "Milk products contain protein, but they are very low in iron." Answer: B, E Explanation: A) Lacto-vegetarians do not eat meat, meat by-products, or eggs, and the nurse should not force this issue. Most vegetables must be combined with another food to form complete proteins. B) Supplementation may be recommended for vegans who have difficulty meeting the recommended amounts of vitamin B12 through food sources. C) The high fiber found in vegetarian diets actually is good for the pregnant woman who may be suffering from constipation. D) Lacto-vegetarians do not eat meat, meat by-products, or eggs, and the nurse should not force this issue. Most vegetables must be combined with another food to form complete proteins. E) Milk products will provide needed protein, but are not significant sources of iron. Page Ref: 296 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

18) A pregnant client confides to the nurse that she is eating laundry starch daily. The nurse should assess the client for which of the following? A) Alopecia B) Weight loss C) Iron deficiency anemia D) Fecal impaction Answer: C Explanation: A) Alopecia, a condition that causes hair loss, is not associated with eating laundry starch. B) Weight gain is related to the client's eating laundry starch. C) Iron deficiency anemia is the most common concern with pica. The ingestion of laundry starch or certain types of clay may contribute to iron deficiency by replacing iron-containing foods from the diet or by interfering with iron absorption. D) Fecal impaction is associated with the eating of clay, not laundry starch. Page Ref: 299 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing care management of pregnant women. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

19) The kosher diet followed by many Jewish people forbids the eating of what foods? A) Pig products and shellfish B) Dairy products C) All animal products D) Dairy products and eggs Answer: A Explanation: A) The kosher diet followed by many Jewish people forbids the eating of pig products and shellfish. Certain cuts of meat from sheep and cattle are allowed, as are fish with fins and scales. In addition, many Jews believe that meat and dairy products should not be mixed or eaten at the same meal. B) Lacto-vegetarian diets include dairy products but no eggs. C) Vegans are strict vegetarians who will not eat any food from animal sources. D) Lacto-ovo-vegetarians include milk, dairy products, and eggs in their diet, but no meat. Page Ref: 298 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing care management of pregnant women. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

20) The nurse is working with a pregnant 14-year-old. Which statement indicates that additional education is required? A) "Because I am still growing, I need more calories than a pregnant adult." B) "I need to eat fruit and vegetables every day to get enough vitamins." C) "My favorite food is pizza, and I eat it once a week." D) "Because I don't eat breakfast, I'll have to eat more at supper." Answer: D Explanation: A) Caloric needs of pregnant adolescents vary widely. Figures as high as 50 kcal/kg have been suggested for young, growing teens who are very active physically. B) Eating a variety of fruits and vegetables helps ensure adequate intake of vitamins and some minerals. C) Pizza is not contraindicated during pregnancy. Eating a food once per week will not lead to nutritional imbalance. D) Pregnant young adolescents should eat breakfast to ensure that adequate calorie and protein intake is achieved. In assessing the diet of the pregnant adolescent, the nurse should consider the eating pattern over time, not simply a single day's intake. Page Ref: 300 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

21) When preparing nutritional instruction, which pregnant client would the nurse consider the highest priority? A) 40-year-old gravida 2 B) 22-year-old primigravida C) 35-year-old gravida 4 D) 15-year-old nulligravida Answer: D Explanation: A) The 40-year-old woman has completed her growth cycle, and her body can focus on diverting nutrition to the fetus. B) The 22-year-old woman has completed her growth cycle, and her body can focus on diverting nutrition to the fetus. C) The 35-year-old woman has completed her growth cycle, and her body can focus on diverting nutrition to the fetus. D) An expectant adolescent must meet the nutritional needs for her own growth in addition to the nutritional needs of pregnancy. Page Ref: 300 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

22) Which statement is best to include when teaching a pregnant adolescent about her nutritional needs in pregnancy? A) "It is important to eat iron-rich foods like meat every day." B) "Calcium and milk aren't needed until the third trimester." C) "Folic acid intake is the key to having a healthy baby." D) "You just need to pay attention to what you eat now." Answer: A Explanation: A) An inadequate iron intake is a major concern with the adolescent diet. Iron needs are high for the pregnant teen because of the requirement for iron by the enlarging maternal muscle mass and blood volume. Giving specific examples is helpful when giving nutritional information. B) Calcium is needed throughout pregnancy, and should be consumed daily. C) Although folic acid is important during pregnancy to prevent neural tube defects, and for lactation, there is no single nutritional element responsible for having a healthy baby. D) This response is too vague to be helpful. Adolescents will need specific information to improve nutrition during pregnancy. Page Ref: 300 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

23) The school nurse is planning a class about nutrition for pregnant teens, several of whom have been diagnosed with iron-deficiency anemia. In order to increase iron absorption, the nurse would encourage the teens to consume more of what beverage? A) Gatorade B) Orange juice C) Milk D) Green tea Answer: B Explanation: A) Gatorade does not contain vitamin C, which increases iron absorption. B) Vitamin C is found in citrus fruits and juices, and is known to enhance the absorption of iron from meat and non-meat sources. C) Milk does not contain vitamin C, which increases iron absorption. D) Green tea does not contain vitamin C, which increases iron absorption. Page Ref: 293—294 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

24) The pregnant teen who was prescribed prenatal vitamins at her initial prenatal visit states that she does not like to take them. How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Folic acid has been found to be essential for minimizing the risk of neural tube defects." B) "You do not have to take these supplements if you think you are healthy enough." C) "These medications do the same thing. I will call your doctor to cancel one of your medications." D) "You can trust your doctor to know what you need." E) "You need the supplements because your dietary intake may not be adequate for fetal development." Answer: A, E Explanation: A) The CDC estimates that most neural tube defects could be prevented if women followed folic acid supplementation recommendations before they became pregnant. B) One role of the nurse is educator, and this client needs additional information on why she needs the supplements. C) One role of the nurse is educator, and this client needs additional information on why she needs the supplements. D) Therapeutic communication requires addressing the client's concern. One role of the nurse is educator, and this client needs additional information on why she needs the supplements. E) One role of the nurse is educator, and this client needs additional information on why she needs the supplements. This response answers the client's concerns. Page Ref: 300 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

25) The nurse is preparing a prenatal class about infant feeding methods. The maternal nutritional requirements for breastfeeding and formula-feeding will be discussed. What statement should the nurse include? A) "Breastfeeding requires a continued high intake of protein and calcium." B) "Formula-feeding mothers should protect their health with a lot of calcium." C) "Producing breast milk requires calories, but any source of food is fine." D) "Formula-feeding mothers need a high protein intake to avoid fatigue." Answer: A Explanation: A) Lactation requires calories, along with increased protein and calcium intake. B) Formula-feeding mothers do not need additional nutrients. C) Although any food source would provide the additional calories, an adequate protein intake is essential while breastfeeding because protein is an important component of breast milk and calcium is an important nutrient in milk production, and increases over non-pregnancy needs are expected. D) Formula-feeding moms do not need additional nutrients. Page Ref: 301—302 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

26) Women with eating disorders who become pregnant are at risk for a variety of complications including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Premature birth B) Too many nutrients available for the fetus C) Miscarriage D) High birth weight E) Perinatal mortality Answer: A, C, E Explanation: A) Risks to the mother and baby include premature birth. B) Risks to the mother and baby include lack of nutrients available for the fetus. C) Risks to the mother and baby include miscarriage. D) Risks to the mother and baby include low birth weight. E) Risks to the mother and baby include perinatal mortality. Page Ref: 299 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing care management of pregnant women. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

27) Carbohydrates provide the body's primary source of energy as well as fiber necessary for proper bowel functioning. If the carbohydrate intake is not adequate, the body will use which of the following for energy? A) Iron B) Protein C) Vitamin C D) Vitamin D Answer: B Explanation: A) The body would not use iron as a source of energy. B) If the carbohydrate intake is not adequate, the body uses protein for energy. Protein then becomes unavailable for growth needs. C) A major function of vitamin C is to aid the formation and development of connective tissue and the vascular system. D) Vitamin D is best known for its role in the absorption and utilization of calcium and phosphorus in skeletal development. Page Ref: 292 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

28) Before becoming pregnant, a patient had a BMI of 28.5 and weighed 150 lbs. What should be the minimum weight of this patient upon delivery? Answer: 165 lbs. Explanation: For a patient who is overweight, the total weight gain during pregnancy should be between 15 and 25 lbs. The minimum weight of this patient upon delivery should be 165 lbs. Page Ref: 288 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 1 Describe the recommended levels of weight gain during pregnancy. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy. 29) A patient who is 12 weeks pregnant is counseled to increase her protein intake by an additional 40 grams per day. If each gram of protein is 4 calories, how many additional calories per day should this patient ingest to reach the recommended 300 calories more per day during the pregnancy? Answer: 140 calories Explanation: The additional protein provides 160 calories (40 grams x 4 = 160). If the total increase in daily calories is to be 300 calories, then subtract 160 calories for the extra protein from 300 or 300 — 160 = 140 calories. Page Ref: 292 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 1 Describe the recommended levels of weight gain during pregnancy. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

30) The nurse is instructing a pregnant patient on the importance of increasing her dietary intake of vitamin E. Which foods should the nurse recommend to meet this dietary need? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Milk 2. Eggs 3. Liver 4. Green salads 5. Whole grain bread Answer: 2, 4, 5 Explanation: Vitamin E is widely distributed in foodstuffs, especially vegetable fats and oils, whole grains, greens, and eggs. Milk and liver are good sources of vitamin A. Page Ref: 294 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

31) A patient asks if seafood is permitted during pregnancy. Which foods should the nurse encourage the patient to consume during this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Shrimp 2. Catfish 3. Salmon 4. Swordfish 5. Canned light tuna Answer: 1, 2, 3, 5 Explanation: Women who are pregnant or who may become pregnant, breastfeeding mothers, and young children should not eat swordfish, shark, tilefish, or king mackerel because these fish contain high levels of methyl mercury. Commonly eaten fish that are low in mercury include canned light tuna, shrimp, salmon, catfish, and pollack. Albacore (white) tuna has more mercury than canned light tuna; therefore, only 6 oz. / week of albacore tuna is recommended. Page Ref: 293 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

32) A breastfeeding mother is instructed to increase her daily caloric intake an additional 500 calories each day. If her daily intake of protein is 65 grams at 4 calories per gram, how many calories will this patient need to ingest to reach the recommended daily intake? Answer: 240 calories Explanation: The amount of calories ingested with the protein is 65 grams x 4 calories or 260 calories. To reach the recommended daily caloric increase of 500 calories, subtract 260 from 500 or 500 — 260 = 240 calories. Page Ref: 301 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning; Teaching/Learning. Learning Outcome: 8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers. MNL LO: Demonstrate understanding of maternal nutrition during pregnancy.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 15 Pregnancy in Selected Populations 1) The pregnant 16-year-old is seeing the nurse during a prenatal visit. Based on the client's developmental level, which statement would the nurse expect the client to make? A) "My friends and I all wear totally different styles of clothing." B) "Having a baby will change my college plans." C) "I drink alcohol at parties most weekends." D) "My mom is my best friend." Answer: C Explanation: A) Early and middle adolescents conform to group standards by wearing the same types of clothing that their friends wear. B) Late adolescence (18-19) is when the ability to think about the future develops, including understanding the impact that a baby will have on acquiring education. C) Middle adolescence (15-17) is a time of experimentation, including drinking alcohol, using other drugs, and sex. D) From early adolescence on, friends have an increasingly important role in the search for independence, which includes friends' replacing parents as the primary source of support. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 9. Assess level of patient's decisional conflict and provide access to resources. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

2) The school nurse is planning a presentation on pregnancy for 13- and 14-year-olds who are currently pregnant. When planning the content of this presentation, what should the nurse keep in mind about these teens? A) They are working on independence and autonomy. B) They are no longer developing a sense of achievement. C) They are confident in their own identity. D) They are in control of their impulses. Answer: A Explanation: A) The developmental tasks of adolescence include developing an identity, gaining autonomy and independence, developing intimacy in a relationship, developing comfort with one's own sexuality, and developing a sense of achievement. Teens in early adolescence will not have achieved all of these tasks yet. B) One developmental task of adolescence is developing a sense of achievement. C) One developmental task of adolescence is developing an identity. D) Teens in early adolescence may lack impulse control, which can result in risk-taking behaviors. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Describe the scope of the problem and the impact of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

3) The nurse working in an adolescent prenatal clinic knows which of the following about the clients who are 15-17 years old? A) They are more at ease with their individuality. B) They see authority as resting with parents. C) They are able to solve problems and make decisions. D) They seek independence and identify with their peer group. Answer: D Explanation: A) Teens in late adolescence are more at ease with their individuality. B) Teens in early adolescence see authority as resting with parents. C) Teens in late adolescence are able to solve problems and make decisions. D) Teens who are in middle adolescence (15-17 years old) seek independence and identify with their peer group. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

4) The nurse is working at a clinic for pregnant teens. What issues related to development will the nurse expect to encounter in most of the pregnant clients? A) Peer pressure to stop using alcohol once pregnancy is diagnosed B) Contraception failure that resulted in this pregnancy C) The baby's father being emotionally supportive to the client D) Feelings of not living up to parents' expectations Answer: D Explanation: A) Pregnant teens face risk factors based on the developmental tasks of adolescence. One of these is peer pressure to engage in substance use. B) Pregnant teens face risk factors based on the developmental tasks of adolescence. These include sexual activity without contraception due to lack of a future orientation. C) Pregnant teens face risk factors based on the developmental tasks of adolescence. One of these is sexual activity as experimentation without emotional intimacy. D) Pregnant teens face risk factors based on the developmental tasks of adolescence. One of these is developing an identity. If the adolescent feels she has not lived up to parental expectations by becoming pregnant, she could adopt a negative identity. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: V. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe atmosphere that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

5) The nurse is preparing an in-service presentation for a group of middle-school nurses. Which statements by the nurse would indicate that the middle-school nurse understood the role of culture in adolescent pregnancy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Studies show that 85% of teen mothers are middle class, and give birth to gain adult status." B) "Teenage pregnancy is the leading reason why adolescent women drop out of school." C) "Teens of color are more likely to become pregnant." D) "Intelligence and academic ability are positively associated with delayed sexual activity, greater use of contraception, and lower rates of pregnancy." E) "Over 50% of adolescents who have had an abortion or recent birth become pregnant again within two years." Answer: B, C, D Explanation: A) Poverty is a major risk factor for adolescent pregnancy. Studies show that 85% of births to unmarried teens occur to those from poor or low-income families. Adolescents who do not have access to middle-class opportunities tend to maintain their pregnancies, because they see pregnancy as their only option for adult status. B) An estimated 30% to 40% of female teenage dropouts are mothers. C) In the United States, the adolescent birth rate is higher among African American and Hispanic teens than among white teens. To some degree, the higher teenage pregnancy rate in these groups reflects the impact of poverty because a disproportionately higher number of African American and Hispanic youths live in poverty. D) Teens with future goals (i.e., college or job) tend to use birth control more consistently compared with other teens; if they become pregnant, they are also more likely to have abortions. E) Just over one-third (35%) of adolescents who have had an abortion or recent birth become pregnant again within two years. Page Ref: 307—308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

6) The nurse who is counseling a group of middle-school girls on pregnancy avoidance should include which statement? A) "Although sexuality is common in the media, peer pressure to have sex is not an important factor." B) "It has become far less acceptable to give birth during your teenage years than it used to be." C) "Although condom use is growing, there is still an increasing rate of STIs among teens." D) "You have learned enough from your friends and families to understand how pregnancy occurs." Answer: C Explanation: A) Sexual innuendo permeates every aspect of the popular media. Peer pressure to have sex is also common, and is a strong influence on when a teen becomes sexually active. B) Premarital sexual activity is commonplace, and teenage pregnancy is more socially acceptable today than it was in the past. C) Condom use is increasing, but the rate of STI infections, including HIV, is also rising. D) Comprehensive approaches to sex education do not increase initiation of sexual activity at an earlier age. In fact, it helps teens withstand the pressure to have sex too soon. Page Ref: 308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

7) The nurse has given a community presentation on adolescent pregnancy. Which statements indicate that further teaching is necessary? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Low educational achievement is major risk factor for adolescent pregnancy." B) "Teens who are on a low economic trajectory are more likely to become pregnant." C) "When a teen plans to attend college, abortion is less likely." D) "In the United States, the adolescent birth rate is higher among white teens." E) "Teens from low-income households are less likely to become pregnant." Answer: C, D, E Explanation: A) Teenage pregnancy is the leading reason why adolescent women drop out of school. An estimated 30% to 40% of female teenage dropouts are mothers. B) Teens who are on a low economic trajectory are more likely to become pregnant because of the lack of economic opportunity and the social marginalization that comes with poverty. C) Teens with future goals (i.e., college or job) tend to use birth control more consistently compared with other teens; if they become pregnant, they are also more likely to have abortions. D) In the United States, the adolescent birth rate is higher among African American and Hispanic teens than among white teens. E) Poverty is a major risk factor for adolescent pregnancy. As many as 85% of births to unmarried teens occur to those from low-income families. Page Ref: 307—308 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Describe the scope of the problem and the impact of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

8) During the initial prenatal visit, the pregnant teenager states that she does not know how she got pregnant. The nurse can help to educate her regarding anatomy by doing what? A) Allowing her to witness a pelvic exam on another teenager B) Encouraging her to ask her mother about the physiology of pregnancy C) Including anatomic models and drawings in the teaching session D) Discussing the process of fetal development with the client Answer: C Explanation: A) One client is not allowed to be present during another client's visit or exam. B) The client's mother might not have accurate information, or might be uncomfortable discussing these issues with her teen daughter. C) To teach the client about anatomy and physiology, use simple explanations and lots of audiovisuals. D) While fetal development is important to understand, discussing it now does not address the client's stated concern. Page Ref: 312 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Describe successful community approaches to prevention of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

9) Which statements might a pregnant teenager be likely to make at her initial prenatal examination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "I didn't know I could get pregnant the first time I had sex." B) "Several of my friends go to clinics to get contraception." C) "It's no big deal; two of my best friends have babies, too." D) "I was 13 years old when I had sex the first time." E) "My family and my boyfriend are really happy and supportive." Answer: A, C, D Explanation: A) Many factors contribute to the high teenage pregnancy rate, and one of them is lack of knowledge about conception. B) A teen whose friends go to clinics for contraception would be more likely to use contraception herself. C) Many factors contribute to the high teenage pregnancy rate, and one of them is a decreased social stigma of being a young and single mother. D) Many factors contribute to the high teenage pregnancy rate, and one of them is a younger age at onset of sexual activity. E) Lack of support from the partner and parents is the norm, especially when the pregnancy is first diagnosed and disclosed. Page Ref: 307—308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

10) Several adolescent female students are waiting to be seen by the school sexual health clinic nurse. Which student should the nurse see first? A) 14-year-old whose 17-year-old sister is pregnant B) 15-year-old who reports using condoms regularly C) 16-year-old who had chlamydia treated 2 weeks ago D) 17-year-old with a history of child abuse Answer: C Explanation: A) It is not known whether this client is sexually active. This student is not the top priority. B) Condom use will decrease the risk of becoming pregnant. This client is a low priority. C) This client is the top priority. Teenagers 15 to 19 years old have a high incidence of STIs. The incidence of chlamydial infection is increased in this age group. The presence of such infections during a pregnancy greatly increases the risk to the fetus. D) Although adolescents with a history of abuse are more likely to become pregnant than are their peers who have not experienced abuse, too little information is given about this client to determine risk for pregnancy. This client is not the top priority. Page Ref: 308 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

11) In planning a conference for adolescents, the nurse researches the most common socioeconomic and cultural factors that contribute to adolescent pregnancy. Which true statements should be included in this conference? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Economic status has a relatively low impact on an adolescent's sexual activity. B) Nearly three quarters of all teens ages 15-19 have had sex at least once. C) Poor self-esteem contributes to adolescent pregnancy. D) 38% percent of sexually active students use a condom. E) Sexual abuse is not an issue with teen mothers. Answer: B, C Explanation: A) Poverty is a major risk factor for adolescent pregnancy. B) By 19 years of age, 70% of all teens have had intercourse. C) This is a true statement. Poor self-esteem is a major contributing factor in adolescent pregnancy. D) 68% of females aged 15 to 19 and 80% of males use condoms during their first sexual intercourse. E) More teens who become pregnant, compared with teens who have not been pregnant, have been physically, emotionally, or sexually abused. Page Ref: 306, 308 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Describe the scope of the problem and the impact of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

12) A 16-year-old is making her first prenatal visit to the clinic in her fourth month of pregnancy. What is the nurse's first responsibility? A) Contact the social worker. B) Develop a trusting relationship. C) Schedule the client for prenatal classes. D) Teach the client about proper nutrition. Answer: B Explanation: A) A social worker might be able to provide assistance, but contacting one is not the first priority. B) Developing a trusting relationship with the pregnant adolescent is essential. Honesty and respect for the individual and a caring attitude promote the client's self-esteem. C) Childbirth education is important, however, scheduling classes is not the first goal when dealing with a pregnant teen. D) Although nutrition is an important physiologic need, it is not the first priority in dealing with the pregnant adolescent. Page Ref: 315 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

13) Which statement made by the pregnant adolescent would indicate to the nurse that she understood her increased risk of physiologic complications during pregnancy? A) "It's no big deal that I started prenatal care in my seventh month." B) "My anemia and eating mostly fast food are not important." C) "I need to take good care of myself so my baby doesn't come early." D) "Smoking and using crack cocaine won't harm my baby." Answer: C Explanation: A) There is an increased incidence of maternal complications, premature birth, and low-birth-weight babies among adolescent mothers. This statement indicates a lack of understanding of the client's increased risk of physiologic complications during pregnancy. B) There is an increased incidence of maternal complications, premature birth, and low-birthweight babies among adolescent mothers. This statement indicates a lack of understanding of the client's increased risk of physiologic complications during pregnancy. C) In the adolescent age group, prenatal care is the critical factor that most influences pregnancy outcome. D) Adolescents are at high risk for experimentation with drugs and alcohol. This statement indicates a lack of understanding of the client's increased risk of physiologic complications during pregnancy. Page Ref: 310 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

14) The 19-year-old pregnant woman begins a job to "save money for the baby." What is the most significant developmental task the nurse understands this statement to demonstrate? A) Striving for gaining autonomy and independence B) Completed development of a sense of identity C) Attainment of a sense of achievement D) Having developed an intimate relationship Answer: A Explanation: A) Having a job is how most teens develop financial independence and autonomy. B) Having a job can give teens a sense of identity, but it is not an indication that the development of a sense of identity is completed. C) Having a job does give teens a sense of achievement, but this is not the most significant developmental task. D) Having a job does not indicate that the teen has developed an intimate relationship. Page Ref: 306 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Knowledge and Science: Systematically reflect on practice as a basis for the generations of new knowledge and innovation. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

15) Which of the following is the most prevalent medical complication of pregnant adolescents? A) Constipation B) Preeclampsia-eclampsia C) Heartburn D) Rapid enlargement and sensitivity of breasts Answer: B Explanation: A) Constipation is a discomfort of pregnancy, but not a medical complication. B) Preeclampsia-eclampsia is the most prevalent medical complication of pregnant adolescents and is typically characterized by high blood pressure, proteinuria, and edema. C) Heartburn is a discomfort of pregnancy, but not a medical complication. D) Rapid enlargement and sensitivity of breasts are discomforts of pregnancy, but not medical complications. Page Ref: 308 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

16) The nurse is working with a group of pregnant teens. Which statement indicates that teaching has been successful? A) "Pregnant teens are more likely to quit school prior to graduation." B) "Because I am young, I have a low risk for preeclampsia." C) "My baby could come late because I am a teenager." D) "I am more likely to use birth control after I have this baby." Answer: A Explanation: A) Many teenage mothers drop out of school during their pregnancy and then are less likely to complete their schooling. B) Preeclampsia-eclampsia is the most prevalent medical complication of pregnant adolescents. C) A physical risk of adolescent pregnancies includes preterm births. D) Many factors contribute to the high teenage pregnancy rate, including lack of knowledge about conception and lack of easy access to contraception. Page Ref: 308 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

17) The nurse is teaching a pregnant 14-year-old client who is at 10 weeks' gestation about the expected body changes that will occur during pregnancy. Which client statement indicates that additional information is needed? A) "My breasts are going to get even bigger than they've gotten over the past couple of years." B) "My belly will gradually get more round, especially from the middle of pregnancy on." C) "I will feel my baby move in about 16 weeks." D) "My diet can stay the same even though I'm pregnant." Answer: D Explanation: A) The breasts will enlarge. B) The abdomen will enlarge. C) Fetal movement begins in the second trimester. D) Because the adolescent is at risk for anemia, she will need education regarding the importance of iron in her diet. Page Ref: 313 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

18) The nurse seeks to involve the adolescent father in the prenatal care of his girlfriend. What is the rationale for this nursing strategy? A) Having the father more involved with the birth B) Avoiding conflict between the adolescent father and pregnant teenager C) Including his name on the birth certificate D) Avoiding legal action by the adolescent father's family Answer: A Explanation: A) Many young fathers genuinely want to be involved with their children and would have more contact and input if they could. B) Issues such as conflicts with the teen mother or maternal grandparents and a lack of financial resources may act as additional barriers for the young father, but is not the reason for involving the father in prenatal care for his girlfriend. C) Fathers are being included on birth certificates far more frequently today than in the past. This helps ensure the father's rights and encourages him to meet his responsibilities to his child, but this is not the reason for involving the father in prenatal care for his girlfriend. D) Avoiding legal action by the adolescent father's family is not the reason for involving the father in the prenatal care of his girlfriend. Page Ref: 309—310 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships to promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Delineate the characteristics of the fathers of children of adolescent mothers. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

19) The nurse is working with male teens whose partners are pregnant. What statement by the father-to-be requires that the nurse intervene? A) He will be the only other person who will be present for the birth, although his girlfriend wants her mother to be with her. B) He was very sexually active at an earlier age and he has had more sexual partners than his girlfriend. C) The pregnancy does not seem real to him, and he is not sure what he should do to plan for the future. D) He does not want to be married. Answer: A Explanation: A) Even if the adolescent father has been included in the healthcare of the client throughout the pregnancy, it is not unusual for her to want her mother as her primary support person during labor and birth. Overriding his girlfriend's expressed desire could be an indication that their relationship is abusive. B) This may be true, but is not a reason for the nurse to intervene. C) The adolescent who attempts to assume his responsibility as a father faces many of the same psychologic and sociologic risks as the adolescent mother. It is normal for a teen to be unsure about the future. D) Although not married, many adolescent couples are involved in meaningful relationships. This is not a reason for the nurse to intervene. Page Ref: 309—310 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Systematically reflect on practice as a basis for the generation of new knowledge and innovations. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Delineate the characteristics of the fathers of children of adolescent mothers. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

20) A 14-year-old girl is brought to the clinic by her mother. The nurse determines that the teen is about 28 weeks pregnant. The mother states, "We knew she was gaining weight, but we can't tell anyone she is pregnant." The nurse understands that the client's mother's behavior exemplifies which of the following? A) Low self-esteem B) Anger C) Shame D) Ignorance Answer: C Explanation: A) Nothing in the scenario indicates that the client's mother has low self-esteem. B) Anger will often manifest as loud or negative speech. Nothing in the scenario indicates that this is true. C) In families who foster educational and career goals for their children, adolescent pregnancy is often a shock. Anger, shame, and sorrow are common reactions. D) The parents might be ignorant of their child's sexual activity, but when faced with weight gain, they acknowledged the pregnancy. Page Ref: 311 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I. C. 14. Appreciate shared decision-making with empowered patients and families, even when conflicts occur. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Discuss the possible reactions of the adolescent's family and social network to her pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

21) The nurse is talking with the parents of a pregnant 15-year-old. Which statement by one of the parents is expected? A) "We're very happy for her. It will be easier to focus on education with a new baby." B) "I'm not going to get involved. She understands how her health insurance works." C) "Her father told her to stop dating that boy. Now look at the trouble she's gotten into." D) "An abortion is the best choice for her. She can deal with our Catholic priest later." Answer: C Explanation: A) Most parents accept the pregnancy but are not excited when their 15-year-old daughter is pregnant. Education is harder when childcare is involved. Teens who give birth are less likely to complete their education. B) The parent of a pregnant teen is usually the support person, and helps the teen understand how to access prenatal care. It is unlikely that a 15-year-old would understand health insurance. C) This statement indicates anger, which is to be expected when a parent finds out about a teen daughter's pregnancy. D) This is not necessarily expected from a parent. It indicates that the parent might be forcing the teen into abortion despite their being a part of a religious tradition that disapproves of abortion. Page Ref: 311 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Discuss the possible reactions of the adolescent's family and social network to her pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

22) After telling a mother that her 13-year-old daughter is pregnant, the nurse would expect the mother to respond with which statement? A) "We had such high hopes for you." B) "But you have always been a happy child." C) "I've always liked that boy." D) "This is just one of those things that happen." Answer: A Explanation: A) When an adolescent pregnancy is first revealed to the teen's mother, the result is often anger, shame, or sorrow. The degree of negative response will be determined by the age of the teen, the family expectations for the teen, and the presence or absence of other teen pregnancies in the family or support network. B) This response is not necessarily typical of parental responses to their young teen daughter's pregnancy. C) When an adolescent pregnancy is first revealed to the teen's mother, the result is often anger and shame and not expressions of fondness for the father. D) This attitude of indifference is not typical of the response of most parents of teen daughters who are pregnant. Page Ref: 311 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Developmental Stages and Transitions Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress to patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Discuss the possible reactions of the adolescent's family and social network to her pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

23) The nurse's goals for prenatal classes may include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increasing self-esteem B) Preparing the participants for childrearing C) Offering information on the risks of breastfeeding D) Providing anticipatory guidance about pregnancy E) Helping participants develop more adaptive coping skills Answer: A, D, E Explanation: A) Goals for prenatal classes would include increasing self-esteem. B) The nurse would be preparing the participants for labor and birth, not childrearing. C) Goals for prenatal classes would include information on the benefits of breastfeeding. D) Goals for prenatal class would include providing anticipatory guidance about pregnancy. E) Goals for prenatal class would include helping participants develop more adaptive coping skills. Page Ref: 317 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

24) Recommendations for parents to help their teens avoid pregnancy include which of the following? A) Parents need to encourage frequent and steady dating. B) Parents need to let their children set their own goals for the future. C) Parents need to have their children taught about sex by school programs and community resources. D) Parents should be clear about their own sexual attitudes and values. Answer: D Explanation: A) Parents need to clearly discourage early dating as well as frequent and steady dating. B) Parents need to help children set goals for their future and have options that are more attractive than early pregnancy and childrearing. C) Parents need to talk with their children about sex early and often and be specific in the discussions. D) This is true. Parents should be clear about their own sexual attitudes and values in order to communicate clearly with children. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: V. C. 4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: RelationshipCentered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Describe successful community approaches to prevention of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

25) The nurse developing a care plan for a pregnant teen knows that what plan is best suited to pregnant teens? A) Assess menstrual history and the presence of any food allergies. B) Inquire about family relationships and location of the home. C) Ask what her body image is, then correct her misconceptions. D) Determine whether there are substance abuse issues. Answer: D Explanation: A) Menstrual history is important for determining gestational age, and food allergies can impact nutritional intake. However, assessment of these factors is not necessarily better suited to pregnant teens than to pregnant women of other ages. B) Family relationships are important to understand, specifically to find out what support systems are available to the teen. However, the location of the home is not important. C) Body image must be addressed more indirectly, not by asking a client what she thinks about her body. A client's body image is her belief, and cannot be corrected by the nurse. D) Substance abuse issues are important to assess during pregnancy of teens. Page Ref: 307 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of a clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

26) The nurse is working in a teen pregnancy clinic. In order to give the pregnant adolescent a role in her prenatal care, the nurse should allow the teen to do which of the following? A) Choose the type of prenatal vitamin she takes B) Measure and record her weight at each visit C) Choose the schedule of her prenatal visits D) Decide whether she wants her labor to be induced Answer: B Explanation: A) Prenatal vitamins are prescribed by healthcare professionals. The client would not be given a choice. B) Having the client weigh herself and record her weight provides her the opportunity to participate in her own care plan. C) Prenatal visit schedules are set to detect developing complications of pregnancy. D) Induction of labor is a medical decision, and not one to be made at the client's discretion. Page Ref: 311 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

27) The nurse discussing different pregnancy programs explains that which of the following is critical to the success of an adolescent pregnancy-prevention program? A) Including role models from the same cultural and racial backgrounds as the participants B) Focusing on the adolescent female C) Having short-term, informal programs available twice per year D) Focusing on the expectations of the adolescents' parents Answer: A Explanation: A) The National Campaign to Prevent Teen and Unplanned Pregnancy's task forces found that the programs most effective at preventing teen pregnancy include models from the same cultural and racial backgrounds as the participants. B) The National Campaign to Prevent Teen and Unplanned Pregnancy's task forces found that the programs most effective at preventing teen pregnancy include focusing on the adolescent male. C) The National Campaign to Prevent Teen and Unplanned Pregnancy's task forces found that the programs most effective at preventing teen pregnancy are both long-term and intensive. D) The National Campaign to Prevent Teen and Unplanned Pregnancy's task forces found that the programs most effective at preventing teen pregnancy focus on adolescent males. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: III. B. 6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Describe successful community approaches to prevention of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

28) The nurse has been asked by a community organization to give a presentation on prevention of teen pregnancy. Which statement indicates appropriate steps toward reduction of the local teen pregnancy rate? A) Abstinence-only education will be offered in the school and clinics. B) Classes on how to parent will be mandatory in high school. C) A low-cost reproductive health clinic will be planned. D) Parents will be encouraged to avoid discussing sexual activity. Answer: C Explanation: A) Abstinence with information on contraception is most effective in reducing teen pregnancy rates. B) Parenting classes for teens who are neither pregnant nor parents do not reduce teen pregnancy. C) Key strategies for prevention of unintended teen pregnancy and sexual health promotion include the provision of services that ensure accessible and high-quality reproductive healthcare; sex education programs that provide developmentally appropriate, evidence-based curricula; and youth development strategies to enhance life skills. A low-cost reproductive health clinic would be able to provide these services. D) Parents are a big influence on teens' decisions to begin or avoid sexual activity. Parents need to talk with their children about sex early and often and be specific in the discussions. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: III. B. 6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Describe successful community approaches to prevention of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

29) The nurse is preparing an educational session for parents of adolescents. In which order should the nurse explain the psychosocial development for this population? 1. Thinks abstractly 2. Lack impulse control 3. Formal operational thought 4. Egocentric and a concrete thinker 5. Experiments with drugs and alcohol Answer: 2, 4, 5, 1, 3 Explanation: The early adolescent (age 14 and under) lacks impulse control, is very egocentric, and is a concrete thinker. The middle adolescent (15 to 17 years) experiments with drugs, alcohol, and sex. The late adolescent (18 to 19 years) thinks abstractly and is capable of formal operational thought. Page Ref: 306—307 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Describe the scope of the problem and the impact of adolescent pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

30) The community nurse is preparing to visit the home of an adolescent who is 18 weeks pregnant. Which health problems should the nurse focus on when assessing this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Preeclampsia 2. Preterm birth 3. Low-birth-weight 4. Gestational diabetes 5. Iron deficiency anemia Answer: 1, 2, 3, 5 Explanation: Risks for pregnant adolescents include preterm births, low-birth-weight (LBW) infants, preeclampsia-eclampsia and its sequelae, iron deficiency anemia, and cephalopelvic disproportion (CPD). Gestational diabetes is not identified as a health risk for pregnant adolescents. Page Ref: 308—309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

31) An adolescent in the third trimester of pregnancy comes into the clinic for a routine examination. What should the nurse assess to determine if the patient is working through this trimester's developmental tasks? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Amount of weight gained 2. Adequacy of nutritional intake 3. Supplies purchased for the baby 4. Presence of heartburn or constipation 5. Place in the home identified for the baby Answer: 3, 4, 5 Explanation: During the third trimester, the nurse should assess whether the adolescent is preparing for the baby by buying supplies and preparing a place in the home. Assess for discomforts of pregnancy, such as heartburn and constipation. Adolescent may be uncomfortable mentioning these and other problems. Weight gain and nutritional intake are developmental tasks associated with the second trimester of pregnancy. Page Ref: 308—309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

32) The nurse is preparing an educational program for pregnant adolescents in the community. What goals should the nurse identify as appropriate for this teaching? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Managing finances 2. Increasing self-esteem 3. Preparing for labor and birth 4. Developing adaptive coping skills 5. Providing information about resources Answer: 2, 3, 4, 5 Explanation: Goals for prenatal classes include preparing the participants for labor and birth, increasing self-esteem, developing adaptive coping skills, and providing information about available community resources. Managing finances is not an identified goal for adolescent prenatal classes. Page Ref: 308—310 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

33) A pregnant adolescent is scheduled for her first prenatal visit. For which sexually transmitted infections (STIs) should the nurse anticipate testing will occur? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. HPV 2. Candida 3. Gonorrhea 4. Chlamydia 5. Trichomonas Answer: 2, 3, 4, 5 Explanation: Adolescents have an increased incidence of STIs. The initial prenatal examination should include gonococcal and chlamydial cultures and wet prep for Candida, Trichomonas, and Gardnerella. HPV is not identified as a sexually transmitted infection to be tested during the initial prenatal examination. Page Ref: 308 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

34) The nurse is presenting a class to women who are currently pregnant or are planning pregnancy in the near future. Which client statement indicates that additional teaching is required? A) "The older a woman is when she conceives, the safer the pregnancy is." B) "Pregnant teens can have additional nutritional needs." C) "A woman whose sisters all had hypertension will be watched carefully." D) "Pregnancy may be more difficult to achieve in my 40s." Answer: A Explanation: A) The health risks associated with pregnancy vary by age. The risk for maternal death is significantly higher for women over age 35 and even higher for women age 40 and older. The incidence of low-birth-weight infants, preterm births, miscarriage, stillbirth, and perinatal morbidity and mortality is higher among women age 35 or older. B) The health risks associated with pregnancy vary by age. Young teens who are still growing need additional calories and protein. C) The health risks associated with pregnancy vary by age. The risk of pregnancy complications is higher in women over age 35 who have a chronic condition such as hypertension or diabetes, or who are in poor general health. D) The decreased fertility of women over age 35 may make conception more difficult. Page Ref: 317 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Summarize the nursing care needs of an expectant woman over age 35. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

35) The nurse is preparing a brochure for couples considering pregnancy after the age of 35. Which statements should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) There is a decreased risk of Down syndrome. B) Preexisting medical conditions can complicate pregnancy. C) Preterm births are more common. D) Amniocentesis can be performed to detect genetic anomalies. E) The increased fertility of women over age 35 makes conception easier. Answer: B, C, D Explanation: A) The incidence of Down syndrome increases somewhat in women over age 35 and increases significantly in those over age 40. B) Preexisting medical conditions, such as hypertension or diabetes, probably play a more significant role than age in maternal well-being and the outcome of pregnancy. C) The incidence of low-birth-weight infants, preterm births, miscarriage, stillbirth, and perinatal morbidity and mortality is higher among women age 35 or older. D) Amniocentesis is offered to all women over age 35 to permit the early detection of several chromosomal abnormalities, including Down syndrome; noninvasive analysis of fetal nucleic acid is now commonly recommended to women of advanced maternal age. E) The decreased fertility of women over age 35 may make conception more difficult. Page Ref: 317 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Summarize the nursing care needs of an expectant woman over age 35. MNL LO: Demonstrate use of the nursing process in the care of the pregnant adolescent and woman over 35, and women with special needs.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 16 Assessment of Fetal Well-Being 1) A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Confirm fetal heart activity. B) Evaluate the cervix. C) Determine fetal presentation. D) Assess amniotic fluid volume. E) Determine fetal number. Answer: C, D, E Explanation: A) A limited ultrasound may be used to address a specific question or determine specific information including confirming fetal heart activity. B) A limited ultrasound may be used to address a specific question or determine specific information including evaluating the cervix. C) A standard ultrasound examination is performed during the second or third trimester and includes an evaluation to determine fetal presentation. D) A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of amniotic fluid volume. E) A standard ultrasound examination is performed during the second or third trimester and includes an evaluation of fetal number. Page Ref: 325 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Delineate the use of ultrasound in the second trimester to assess fetal life, number, presentation, anatomy, age, and growth. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

2) When assisting with a transabdominal ultrasound sampling, which of the following would the nurse do? A) Obtain preliminary urinary samples. B) Have the woman empty her bladder before the test begins. C) Assist the woman into a supine position on the examining table. D) Instruct the woman to eat a fat-free meal 2 hours before the scheduled test time. Answer: C Explanation: A) Preliminary blood work may be obtained, not urinary samples. B) The morning of the procedure, the woman is asked to drink fluids to fill her bladder because displacement of an anteverted uterus by a full bladder may aid in positioning the uterus for catheter insertion. C) Clients are placed in a supine position on the table. D) Dietary intake is not relevant to this procedure. Page Ref: 328 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify indications and interpret findings for ultrasound examinations performed in the first trimester. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

3) The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching has been effective? A) "If the ultrasound is normal, it means my baby has no abnormalities." B) "The nuchal translucency measurement will diagnose Down syndrome." C) "I might be able to see who the baby looks like with the ultrasound." D) "Measuring the length of my cervix will determine whether I will deliver early." Answer: C Explanation: A) Not all fetal anomalies are detectable by ultrasound. B) Nuchal translucency measurements are for detection, not diagnosis, of trisomies 13, 18, and 21. C) Three-dimensional ultrasound uses algorithms to vary opacity, transparency, and depth to project an image. This allows curved structures such as the fetal face to be viewed. D) Transvaginal ultrasound can most accurately identify shortened cervical length indicating cervical insufficiency or risk of preterm labor. However, a cervix of normal length does not preclude preterm birth. Page Ref: 326 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Delineate the use of ultrasound in the second trimester to assess fetal life, number, presentation, anatomy, age, and growth. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

4) A woman at 28 weeks' gestation is asked to keep a fetal activity record and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for more than 30 minutes. Which of the following would be the nurse's most appropriate initial comment? A) "You need to come to the clinic right away for further evaluation." B) "Have you been smoking?" C) "When did you eat last?" D) "Your baby might be asleep." Answer: D Explanation: A) The mother would need to come to the clinic only if there had been no fetal activity for several hours. B) Certain substances such as tobacco, drugs, alcohol, and caffeine have been shown to affect fetal movements and can increase fetal movement. C) After meals, an infant typically has increased movement. D) Lack of fetal activity for 30 minutes typically is insignificant. Movement varies considerably, but most women feel fetal movement at least 10 times in 3 hours. Page Ref: 335 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 5 Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

5) Which of the following tests provides information about the fetal number? A) Amniocentesis B) Standard second-trimester sonogram C) Beta hCG D) Maternal serum alpha-fetoprotein Answer: B Explanation: A) Amniocentesis can make chromosomal and biochemical determinations and can validate abnormalities detected by ultrasound. B) A standard (comprehensive) second trimester sonogram provides information about the fetus, placenta, and uterine conditions, including fetal number. C) Serial quantitative beta hCG testing can be used to distinguish a normally developing fetus from an ectopic pregnancy. D) Maternal serum alpha-fetoprotein (MSAFP) is a component of the screening test, the "quadruple check" that utilizes the multiple markers, including AFP, hCG, diameric inhibin-A, and estriol, to screen pregnancies for NTD, trisomy 21 (Down syndrome), and trisomy 18. Page Ref: 326 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Knowledge and Science: Systematically reflect on practice as a basis for the generation of new knowledge and innovation. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Delineate the use of ultrasound in the second trimester to assess fetal life, number, presentation, anatomy, age, and growth. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

6) The client at 24 weeks' gestation is experiencing painless vaginal bleeding after intercourse. The physician has ordered a transvaginal ultrasound examination. Which statements by the client indicate an understanding of why this exam has been requested? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "This ultrasound will show the baby's gender." B) "This ultrasound might cause the miscarriage of my baby." C) "This ultrasound carries a risk of creating a uterine infection." D) "This ultrasound can determine the location of my placenta." E) "This ultrasound might detect whether the placenta is detaching prematurely." Answer: D, E Explanation: A) Although gender can sometimes be detected with second-trimester ultrasound, that is never the primary reason for the procedure. B) Ultrasound is non-invasive, and does not increase the risk for either fetal loss or uterine infection. C) Ultrasound is non-invasive, and does not increase the risk for either fetal loss or uterine infection. D) Painless bleeding in the second and third trimesters can be a symptom of placenta previa. Transvaginal ultrasound will determine the placental location. E) Painless bleeding in the second and third trimesters can be a symptom of placenta previa. Transvaginal ultrasound will determine the placental location. Page Ref: 326—327 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Delineate the use of ultrasound in the second trimester to assess fetal life, number, presentation, anatomy, age, and growth. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

7) The nurse is returning phone calls from clients. Which client does the nurse anticipate would not require a serum beta hCG? A) A client with a risk of ectopic pregnancy B) A client with spotting during pregnancy C) A client with previous pelvic inflammatory disease D) A client with a previous history of twins Answer: D Explanation: A) Serial quantitative beta hCG testing can be used to distinguish a normally developing fetus from an ectopic pregnancy. B) Serologic evaluation in the first trimester is indicated for women with vaginal bleeding. C) Serial quantitative beta hCG testing can be used to distinguish a normally developing fetus from a risk of ectopic pregnancy (intrauterine device in place, previous pelvic inflammatory disease, or reversal of a tubal sterilization). D) A previous history of twins is not a risk factor for ectopic pregnancy. Beta hCG testing is not indicated for this client. Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify indications and interpret findings for ultrasound examinations performed in the first trimester. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

8) Which of the following tests has become a widely accepted method of evaluating fetal status? A) Contraction stress test (CST) B) MSAFP test C) Nonstress test (NST) D) Nuchal translucency test Answer: C Explanation: A) The contraction stress test (CST) is a means of evaluating the respiratory function (oxygen and carbon dioxide exchange) of the placenta. B) The maternal serum alpha-fetoprotein (MSAFP) test is a component of the screening test, the "quadruple check" that utilizes multiple markers to screen pregnancies for NTD, trisomy 21 (Down syndrome), and trisomy 18. C) The nonstress test (NST) has become a widely accepted method of evaluating fetal status. This test involves using an external electronic fetal monitor to obtain a tracing of the fetal heart rate (FHR) and observation of acceleration of the FHR with fetal movement. D) The nuchal translucency test is a blood test and sonogram combined that screens for trisomy 18 and 21. Page Ref: 336 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Integration of knowledge from nursing and other disciplines. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the indications for ordering a nonstress test for compromised or at-risk fetuses or maternal at-risk pregnancies. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

9) The prenatal clinic nurse is explaining test results to a client who has had an assessment for fetal well-being. Which statement indicates that the client understands the test results? A) "The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby." B) "The reactive nonstress test means that my baby is not growing because of a lack of oxygen." C) "Because my contraction stress test was positive, we know that my baby will tolerate labor well." D) "My biophysical profile score of 6 points to everything being normal and healthy for my baby." Answer: A Explanation: A) A decrease in fetal cardiac output or an increase in resistance of placental vessels will reduce umbilical artery blood flow. Doppler velocimetry is best used when intrauterine growth restriction is diagnosed; a normal result indicates that the baby is getting an adequate blood supply. B) The nonstress test involves using an external electronic fetal monitor to obtain a tracing of the fetal heart rate (FHR) and observation of acceleration of the FHR with fetal movement. C) A contraction stress test (CST) provides a method for observing the response of the FHR to the stress of uterine contractions. The desired result is a negative test. D) A score of 6 is abnormal, and indicates that further assessment is needed. Page Ref: 342 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify the indications for ordering a nonstress test for compromised or at-risk fetuses or maternal at-risk pregnancies. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

10) At 32 weeks' gestation, a woman is scheduled for a second nonstress test (following one she had at 28 weeks' gestation). Which statement by the client would indicate an adequate understanding of this procedure? A) "I can't get up and walk around during the test." B) "I'll have an IV started before the test." C) "I can still smoke before the test." D) "I need to have a full bladder for this test." Answer: A Explanation: A) The purpose of the nonstress test is to determine the results of movement on fetal heart rate. The NST is typically performed with the woman in the semi-Fowler's position with a small pillow or blanket under the right hip to displace the uterus to the left. B) No IV is needed to administer medications. C) Cigarette smoking can adversely affect the test results, so the woman should be counseled to avoid smoking prior to testing. D) Clients usually are asked to have their bladders full only for ultrasounds. Page Ref: 336 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify the indications for ordering a nonstress test for compromised or at-risk fetuses or maternal at-risk pregnancies. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

11) During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as which of the following? A) A negative test B) A reactive test C) A nonreactive test D) An equivocal test Answer: C Explanation: A) Nonstress tests are scored as either reactive or nonreactive. B) A reactive NST has two or more fetal heart accelerations within a 20-minute period. C) The FHR acceleration must be at least 15 beats per minute above baseline for at least 15 seconds from baseline to baseline. A nonreactive NST is one that lacks sufficient FHR accelerations over a 40-minute period. D) Nonstress tests are scored as either reactive or nonreactive. Page Ref: 337—338 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 6 Identify the indications for ordering a nonstress test for compromised or at-risk fetuses or maternal at-risk pregnancies. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

12) The nurse is responding to phone calls. Whose call should the nurse return first? A) A client at 37 weeks' gestation reports no fetal movement for 24 hours. B) A client at 29 weeks' gestation reports increased fetal movement. C) A client at 32 weeks' gestation reports decreased fetal movement X 2 days. D) A client at 35 weeks' gestation reports decreased fetal movement X 4 hours. Answer: A Explanation: A) Lack of fetal movement can be an indication of nonreassuring fetal status or even fetal death. This client is the highest priority. B) Increased fetal movement is not indicative of a problem. C) Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, this client is not the highest priority. D) Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, 4 hours is a very short period of time to assess decreased fetal movement. Page Ref: 340 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the indications for ordering a nonstress test for compromised or at-risk fetuses or maternal at-risk pregnancies. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

13) The nurse is working in an outpatient clinic. Which client's indications most warrant fetal monitoring in the third trimester? A) Gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks B) Gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior appendectomy C) Gravida 3, para 2, with a history of gestational diabetes controlled by diet D) Gravida 2, para 1, 36 weeks, with a history of preterm labor or cervical insufficiency Answer: D Explanation: A) The client with the spontaneous abortion would have needed to be monitored in the first trimester. B) The client with endometriosis and appendectomy would have been a concern with conception. C) The client with a history of gestational diabetes controlled by diet would need maternal monitoring and fetal monitoring if she developed gestational diabetes again. D) The client with a history of preterm labor or cervical insufficiency needs close monitoring for preterm labor onset. Page Ref: 335 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Identify the indications for ordering a nonstress test for compromised or at-risk fetuses or maternal at-risk pregnancies. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

14) A client at 37 weeks' gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates three contractions in 10 minutes, no decelerations, and accelerations four times in 1 hour. What would this test be considered? A) Positive nonstress test B) Negative contraction stress test C) Positive contraction stress test D) Negative nonstress test Answer: B Explanation: A) The fact that contractions are present rules out the nonstress test. B) A negative CST shows three contractions of good quality lasting 40 or more seconds in 10 minutes without evidence of late decelerations. This is the desired result. C) A positive CST shows repetitive persistent late decelerations with more than 50% of the contractions. This is not a desired result. D) The fact that contractions are present rules out the nonstress test. Page Ref: 339 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Compare the indications and procedures used when conducting a nonstress test, a contraction stress test, the biophysical profile, and the collection of an amniotic fluid index. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

15) Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician to clarify the order for which client? A) A gravida with intrauterine growth restriction B) A gravida with mild hypotension of pregnancy C) A gravida who is postterm D) A gravida who complains of decreased fetal movement for 2 days Answer: B Explanation: A) The infant who has intrauterine growth problems might be compromised due to placental insufficiency. B) The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypotension will need to be monitored more closely throughout the pregnancy, but is not a candidate at present for a biophysical profile. C) The infant who is postterm might be compromised due to placental insufficiency. D) The gravida who is experiencing decreased fetal movement for 2 days needs assessment of the placenta and the fetus. Page Ref: 340 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Compare the indications and procedures used when conducting a nonstress test, a contraction stress test, the biophysical profile, and the collection of an amniotic fluid index. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

16) The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance? A) "After the ultrasound, my partner and I will decide how to decorate the nursery." B) "During the ultrasound we will see which of us the baby looks like most." C) "The ultrasound will show whether there are abnormalities with the baby's spine." D) "The blood test wasn't run correctly, and now we need to have the sonogram." Answer: C Explanation: A) Parents often try to identify the baby's sex and which parent the fetus resembles more during an ultrasound. B) Parents often try to identify the baby's sex and which parent the fetus resembles more during an ultrasound. C) Ultrasound is used to detect neural tube defects. An abnormal serum quadruple screen is not the result of a lab error, and can indicate either an open neural tube defect or trisomy 18 or 21. D) Ultrasound is used to detect neural tube defects. Page Ref: 325 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patient or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Explain the purposes of the sequential screen, quad screen, and cell-free DNA testing and the implications of abnormal values. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

17) A 27-year-old married woman is 16 weeks pregnant and has an abnormally low maternal serum alpha-fetoprotein test. Which statement indicates that the couple understands the implications of this test result? A) "We have decided to have an abortion if this baby has Down syndrome." B) "If we hadn't had this test, we wouldn't have to worry about this baby." C) "I'll eat plenty of dark green leafy vegetables until I have the ultrasound." D) "The ultrasound should be normal because I'm under the age of 35." Answer: A Explanation: A) A low maternal serum alpha-fetoprotein test can indicate trisomy 18 or trisomy 21 (Down syndrome). Many couples abort a fetus that has a genetic abnormality that significantly affects quality of life or has multiple medical problems. Down syndrome is more likely to occur in the fetuses of women over the age of 35 at delivery, but is not limited to this age group. B) A low maternal serum alpha-fetoprotein test can indicate trisomy 18 or trisomy 21 (Down syndrome). C) The condition begins in very early fetal life. Dark green leafy vegetables contain folic acid. Low folic acid levels in the first trimester can lead to neural tube defects, which would cause a high maternal serum alpha-fetoprotein screen. D) Down syndrome is more likely to occur in women over the age of 35 at delivery, but is not limited to this age group. Page Ref: 344 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Explain the purposes of the sequential screen, quad screen, and cell-free DNA testing and the implications of abnormal values. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

18) The nurse is preparing a client for amniocentesis. Which statement would indicate that the client clearly understands the risks of amniocentesis? A) "I might go into labor early." B) "It could produce a congenital defect in my baby." C) "Actually, there are no real risks to this procedure." D) "The test could stunt my baby's growth." Answer: A Explanation: A) Amniocentesis has the potential to cause spontaneous abortion. B) Congenital defects are the result of heredity or medications. C) Amniocentesis has potential complications such as infection, bleeding and spontaneous abortion. D) Growth retardation most commonly is associated with heredity or poor nutrition. Page Ref: 345—346 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 12. Facilitate informed patient consent for care. | AACN Essentials Competencies: Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Contrast the use of amniocentesis and chorionic villus sampling in detecting a fetus with a chromosomal disorder. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

19) The nurse is reviewing amniocentesis results. Which of the following would indicate that client care was appropriate? A) The client who is Rh-positive received Rh immune globulin after the amniocentesis. B) The client was monitored for 30 minutes after completion of the test. C) The client began vaginal spotting before leaving for home after the test. D) The client identified that she takes insulin before each meal and at bedtime. Answer: B Explanation: A) Only Rh-negative clients receive Rh immune globulin after amniocentesis. The Rh-positive client should not ever receive RhoGAM. B) 20 to 30 minutes of fetal monitoring is performed after the amniocentesis. C) Vaginal spotting after the amniocentesis is not an expected finding. Instruct the woman to report any changes or symptoms to her primary caregiver regarding vaginal discharge–either clear drainage or bleeding. D) Whether a client takes insulin has nothing to do with amniocentesis. Page Ref: 346 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Contrast the use of amniocentesis and chorionic villus sampling in detecting a fetus with a chromosomal disorder. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

20) Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client? A) 28-year-old with history of rheumatic heart disease B) 18-year-old with exposure to HIV C) 20-year-old with a history of preterm labor D) 35-year-old with a child with spina bifida Answer: D Explanation: A) The client with rheumatic heart disease would need to be monitored for pregnancy-related physiological stress. B) The client with HIV exposure needs HIV testing and protection education. C) The client with a history of preterm labor needs education on prevention and on signs and symptoms of preterm labor. D) Alpha-fetoprotein (AFP) is a fetal protein that is excreted from the fetal yolk sac during the first 6 weeks of pregnancy. AFP levels can be high or low, with each having different implications for the fetus. If the fetus has a neural tube defect (NTD), the AFP levels will be elevated. NTDs can range from anencephaly to spina bifida. With a past history of a child with spina bifida, this client would be strongly encouraged to have the AFP screening. Page Ref: 344 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Explain the purposes of the sequential screen, quad screen, and cell-free DNA testing and the implications of abnormal values. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

21) The pregnant client and her partner are both 40 years old. The nurse is explaining the options of chorionic villus sampling (CVS) and amniocentesis for genetic testing. The nurse should correct the client if she makes which statement? A) "Amniocentesis results are available sooner than CVS results are." B) "CVS carries a higher risk of limb abnormalities." C) "Amniocentesis cannot detect a neural tube defect." D) "CVS is performed through my belly or my cervix." Answer: A Explanation: A) Amniocentesis results take longer to process than do CVS results. B) Limb anomalies are associated with CVS, but not with amniocentesis. C) Neural tube defects are not genetic in nature; therefore, they are not detected by either amniocentesis or CVS. D) CVS can be performed through either a transabdominal or transvaginal approach. Page Ref: 348 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Contrast the use of amniocentesis and chorionic villus sampling in detecting a fetus with a chromosomal disorder. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

22) The client and her partner are carriers of sickle cell disease. They are considering prenatal diagnosis with either amniocentesis or chorionic villus sampling (CVS). Which statements indicate that further teaching is needed on these two diagnostic procedures? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Chorionic villus sampling carries a lower risk of miscarriage." B) "Amniocentesis can be done earlier in my pregnancy than CVS." C) "Neither test will conclusively diagnose sickle cell disease in our baby." D) "The diagnosis comes sooner if we have CVS, not amniocentesis." E) "Amniocentesis is more accurate in diagnosis than the CVS." Answer: A, B, E Explanation: A) CVS has a risk of spontaneous abortion of 0.3% in cases. This rate is higher than second trimester amniocentesis. B) CVS is performed in some medical centers for first trimester diagnosis after 9 completed weeks. Amniocentesis is performed between 15 and 20 weeks' gestation. C) This is a true statement. D) CVS is performed in some medical centers for first trimester diagnosis after 9 completed weeks. Amniocentesis is performed between 15 and 20 weeks' gestation. E) Much like amniocentesis, chorionic villus sampling (CVS) is a procedure that is used to detect genetic, metabolic, and DNA abnormalities. CVS permits earlier diagnosis than can be obtained by amniocentesis. Page Ref: 348 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Contrast the use of amniocentesis and chorionic villus sampling in detecting a fetus with a chromosomal disorder. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

23) The nurse anticipates that the physician will most likely order a cervicovaginal fetal fibronectin test for which client? A) The client at 34 weeks' gestation with gestational diabetes B) The client at 32 weeks' gestation with regular uterine contractions C) The client at 37 weeks' multi-fetal gestation D) The client at 20 weeks' gestation with ruptured amniotic membranes Answer: B Explanation: A) Gestational diabetes does not predispose a client to preterm labor. B) The absence of cervicovaginal fFN between 20 and 34 weeks' gestation has been shown to be a strong predictor of a woman not experiencing preterm birth due to spontaneous preterm labor or premature rupture of membranes. Positive findings indicate a 99% probability of birth within the next 2 weeks. C) Multi-fetal pregnancies often experience preterm delivery, but the client at 37 weeks is at term. D) A pregnancy at 20 weeks has not reached the point of viability, and is treated as an impending spontaneous abortion, not preterm labor. Page Ref: 349 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Discuss fetal fibronectin and transvaginal ultrasound measurement of cervical length as predictors of preterm labor. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

24) The client at 14 weeks' gestation has undergone a transvaginal ultrasound to assess cervical length. The ultrasound revealed cervical funneling. How should the nurse explain these findings to the client? A) "Your cervix has become cone-shaped and more open at the end near the baby." B) "Your cervix is lengthened, and you will deliver your baby prematurely." C) "Your cervix is short, and has become wider at the end that extends into the vagina." D) "Your cervix was beginning to open but now is starting to close up again." Answer: A Explanation: A) Transvaginal ultrasound can most accurately identify shortened cervical length and cervical funneling, which is a cone-shaped indentation in the cervical os indicating cervical insufficiency or risk of preterm labor. B) Transvaginal ultrasound can most accurately identify shortened cervical length and cervical funneling, not lengthening of the cervix. C) Transvaginal ultrasound can most accurately identify shortened cervical length and cervical funneling, which is a cone-shaped indentation in the cervical os indicating cervical insufficiency or risk of preterm labor. D) Cervical change in pregnancy is progressive, and the cervix does not spontaneously constrict or close again until after delivery. Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Discuss fetal fibronectin and transvaginal ultrasound measurement of cervical length as predictors of preterm labor. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

25) The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 in amniotic fluid means which of the following? A) Fetal lungs are still immature. B) The fetus has a congenital anomaly. C) Fetal lungs are mature. D) The fetus is small for gestational age. Answer: C Explanation: A) Early in pregnancy the lecithin concentration in amniotic fluid is less than that of sphingomyelin (0.5:1 at 20 weeks), resulting in a low lecithin/sphingomyelin (L/S) ratio, which is not the case in this instance. B) The L/S ratio isn't a measurement for congenital anomalies or size of the fetus. C) The concentration of lecithin begins to exceed that of sphingomyelin, and at 35 weeks the L/S ratio is 2:1. When at least two times as much lecithin as sphingomyelin is found in the amniotic fluid, RDS is very unlikely. D) The L/S ratio isn't a measurement for congenital anomalies or size of the fetus. Page Ref: 349 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Discuss how the lecithin/sphingomyelin ratio of the amniotic fluid and phosphatidylglycerol (PG) can be used to assess fetal lung maturity. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

26) A 28-year-old woman has been an insulin-dependent diabetic for 10 years. At 36 weeks' gestation, she has an amniocentesis. A lecithin/sphingomyelin (L/S) ratio test is performed on the sample of her amniotic fluid. Because she is a diabetic, what would an obtained 2:1 ratio indicate for the fetus? A) The fetus may or may not have immature lungs. B) The amniotic fluid is contaminated. C) The fetus has a neural tube defect. D) There is blood in the amniotic fluid. Answer: A Explanation: A) Infants of diabetic mothers (IDMs) have a high incidence of false-positive results (i.e., the L/S ratio is thought to indicate lung maturity, but after birth the baby develops RDS). B) Meconium contaminates the amniotic fluid and does not indicate fetal lung maturity. C) Neural tube defects are screened with the maternal serum alpha-fetoprotein test, and diagnosed with ultrasound. D) LBCs testing, not a lecithin/sphingomyelin (L/S) ratio test, tests diabetic women and can be performed when there is blood in the amniotic fluid. Page Ref: 349 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 11 Discuss how the lecithin/sphingomyelin ratio of the amniotic fluid and phosphatidylglycerol (PG) can be used to assess fetal lung maturity. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

27) The nurse provides the following diagram to a patient who is 10 weeks pregnant and scheduled for a sonogram. Why is this test being used?

A) Estimate fetal weight B) Determine gestational age C) Evaluate placenta integrity D) Calculate pelvis dimensions Answer: B Explanation: B) An early transvaginal or abdominal sonogram is indicated when there is a need to establish an accurate gestational age. When dating a pregnancy using ultrasound the crownrump length is considered most accurate for 6- to 12-week gestational periods (plus or minus 3 to 5 days). Dotted line shows the measurement from the top of the fetal crown (head) to the bottom of the rump (buttocks). This test is not used to estimate fetal weight, evaluate placental integrity, or calculate pelvis dimensions. Page Ref: 329 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 2 Identify indications and interpret findings for ultrasound examinations performed in the first trimester. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

28) A pregnant patient's healthcare provider is using the Hadlock method to determine gestational age and growth of the fetus. Which measurements will be used to make this fetal determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Femur length 2. Biparietal diameter .3. Head circumference 4. Abdominal circumference 5. Crown to rump measurement Answer: 1, 2, 3, 4 Explanation: The Hadlock method uses an average of measures of the biparietal diameter, head circumference, abdominal circumference, and femur length to estimate gestational age. The crown to rump measurement is used to determine gestational age of an embryo between 6 and12 weeks. Page Ref: 331 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment; Nursing Process. Learning Outcome: 4 Delineate the use of ultrasound in the second trimester to assess fetal life, number, presentation, anatomy, age, and growth. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

29) The nurse is preparing to conduct a nonstress test with a pregnant patient. In which order should the nurse complete the steps of the procedure? 1. Obtain baseline measurement for 20 minutes 2. Place the patient in the semi-Fowler's position 3. Place the pressure transducer over the uterine fundus 4. Give the patient a handheld marker to indicate when fetal movement is felt 5. Place the ultrasound transducer from the external fetal monitor over the FHR Answer: 2, 5, 3, 1, 4 Explanation: When conducting a nonstress test the nurse should first place the patient in the semi-Fowler's position. Then the ultrasound transducer form the external fetal monitor should be placed over the fetal heart rate. The pressure transducer is then placed over the uterine fundus. Baseline measurement should be obtained for 20 minutes. Finally, the nurse should provide the patient with a marker to indicate when fetal movement is felt. Page Ref: 336 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Compare the indications and procedures used when conducting a nonstress test, a contraction stress test, the biophysical profile, and the collection of an amniotic fluid index. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

30) A pregnant patient is completing an ultrasound to grade the integrity of the placenta. Which diagram should the nurse provide to the patient if the findings are grade 0? A)

Answer: A Explanation: A) Choice 1 shows the ultrasonic appearance of a grade 0 placenta. Choice 2 shows the ultrasonic appearance of a grade I placenta. Choice 3 shows the ultrasonic appearance of a grade II placenta. Choice 4 shows the ultrasonic appearance of a grade III placenta. Page Ref: 343 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Compare the indications and procedures used when conducting a nonstress test, a contraction stress test, the biophysical profile, and the collection of an amniotic fluid index. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

31) The nurse provides the following diagram to a patient in the 3rd trimester of pregnancy. For which diagnostic test is the nurse preparing this patient?

A) Ultrasound B) Amniocentesis C) Biophysical profile D) Contraction stress test Answer: B Explanation: B) For an amniocentesis the patient is usually scanned by ultrasound to determine the placental site and to locate a pocket of fluid. As the needle is inserted, three levels of resistance are felt when the needle penetrates the skin, fascia, and uterine wall. When the needle is placed within the amniotic cavity, amniotic fluid is withdrawn. A needle is not injected into the amniotic sac for an ultrasound, biophysical profile, or contraction stress test. Page Ref: 346 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Compare the indications and procedures used when conducting a nonstress test, a contraction stress test, the biophysical profile, and the collection of an amniotic fluid index. MNL LO: Demonstrate ability to perform assessment and interpret data for a fetal during antenatal period.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 17 Pregnancy at Risk: Pregestational Problems 1) The nurse is caring for a pregnant woman who admits to using cocaine and ecstasy on a regular basis. The client states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal about ecstasy?" What is the nurse's best response? A) "Ecstasy can cause a high fever in you and therefore cause the baby harm." B) "Ecstasy leads to deficiencies of thiamine and folic acid, which help the baby develop." C) "Ecstasy produces babies with small heads and short bodies with brain function alterations." D) "Ecstasy produces intrauterine growth restriction and meconium aspiration." Answer: A Explanation: A) Hyperthermia (elevated temperature) is a side effect of MDMA (ecstasy). B) Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid. Folic acid helps prevent neural tube defects. C) Cocaine, not ecstasy, causes these fetal effects (small heads and short bodies with brain function alterations). D) Heroin, not ecstasy, causes these fetal effects (intrauterine growth restriction and meconium aspiration). Page Ref: 368 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

2) The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which statement made by the client indicates to the nurse that the client has understood the teaching? A) "I can continue to drink alcohol until I am diagnosed as pregnant." B) "I need to stop drinking alcohol completely when I start trying to get pregnant." C) "A beer once a week will not damage the fetus." D) "I can drink alcohol while breastfeeding because it doesn't pass into breast milk." Answer: B Explanation: A) The expectant woman should avoid alcohol completely. B) Women should discontinue drinking alcohol when they start to attempt to become pregnant due to possible effects of alcohol on the fetus. C) The effects of alcohol on the fetus may include a group of signs referred to as fetal alcohol spectrum disorders (FASD). D) Alcohol is excreted in breast milk; therefore, it should be avoided. Page Ref: 368 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

3) A woman's history and appearance suggest drug abuse. What is the nurse's best approach? A) Ask the woman directly, "Do you use any street drugs?" B) Ask the woman whether she would like to talk to a counselor. C) Ask some questions about over-the-counter medications and avoid mention of illicit drugs. D) Explain how harmful drugs can be for her baby. Answer: A Explanation: A) If drug abuse is suspected, the nurse should ask direct questions and be matterof-fact and nonjudgmental to elicit honest responses. B) Advising the client to seek counseling would not occur until the nurse verifies that the woman uses street drugs. C) If abuse is suspected, the nurse should ask direct questions, beginning with less threatening questions about the use of tobacco, caffeine, and over-the-counter medications, but not avoid the mention of illicit drugs. D) When talking to clients in a therapeutic manner, it is important not to be threatening or judgmental; an example of judgmental behavior would be stating that the drugs will harm the baby. Page Ref: 370 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I. C. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

4) A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for which condition? A) Erythroblastosis fetalis B) Diabetes mellitus C) Abruptio placentae D) Pregnancy-induced hypertension Answer: D Explanation: A) Erythroblastosis fetalis is secondary to physiological blood disorders such as Rh incompatibility. B) Diabetes is an endocrine disorder that is unrelated to drug use and abuse. C) Abruptio placentae is seen more commonly with cocaine or crack use. D) Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or preeclampsia-eclampsia). Page Ref: 369 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

5) The client has just been diagnosed as diabetic. The nurse knows teaching was effective when the client makes which statement? A) "Ketones in my urine mean that my body is using the glucose appropriately." B) "I should be urinating frequently and in large amounts to get rid of the extra sugar." C) "My pancreas is making enough insulin, but my body isn't using it correctly." D) "I might be hungry frequently because the sugar isn't getting into the tissues the way it should." Answer: D Explanation: A) Ketones are produced when fat is being utilized for glucose, and this is not a desirable response. B) Frequent urination is an indication of glucose above the renal threshold, and is not a good indicator of diabetic stability. C) Diabetes is a result of lack of insulin production. If the insulin is being produced, the body will utilize it. D) The client who understands the disease process is aware that if the body is not getting the glucose it needs, the message of hunger will be sent to the brain. Page Ref: 354—356 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

6) The maternal health nurse is caring for a pregnant client with obsessive-compulsive disorder (OCD). Which action will the nurse take when teaching the client, based on the client's psychological disorder? A) Allow the client opportunity for repetitive rituals. B) Ask the client to follow along with written material. C) Repeat instructions as needed. D) Provide multiple handouts with various photographs Answer: C Explanation: A) Although those with OCD may have repetitive rituals, this does not promote learning and is not the best action for the nurse. B) While written material may be helpful as a supplement to learning, it may be difficult for the client with OCD to follow along. C) The best action for the nurse is to repeat any instructions or teachings as needed. This allows the client more opportunity to learn. D) While multiple learning techniques and opportunities are helpful for most individuals, those with OCD have a difficult time following along with teaching material. Page Ref: 371 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Explain the possible implications of maternal psychologic factors and disorders in caring for the childbearing family. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

7) A newly diagnosed insulin-dependent type 1 diabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. What would the best explanation include? A) "Your baby could be smaller than average at birth." B) "Your baby will probably be larger than average at birth." C) "As long as you control your blood sugar, your baby will not be affected at all." D) "Your baby might have high blood sugar for several days." Answer: B Explanation: A) Characteristically, infants of mothers with diabetes are large for gestational age (LGA). B) Characteristically, infants of mothers with diabetes are large for gestational age (LGA), as a result of high levels of fetal insulin production stimulated by the high levels of glucose crossing the placenta from the mother. Sustained fetal hyperinsulinism and hyperglycemia ultimately lead to excessive growth, called macrosomia, and deposition of fat. C) The demands of pregnancy will make it difficult for the best of clients to control blood sugar on a regular basis. D) After birth, the umbilical cord is severed, and, thus, the generous maternal blood glucose supply is eliminated. Page Ref: 355 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

8) A 26-year-old client is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client? A) "Exercise either just before meals or wait until 2 hours after a meal." B) "Carry hard candy (or other simple sugar) when exercising." C) "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." D) "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk." Answer: B Explanation: A) It is best to exercise just after the meal, in order to utilize the glucose. B) The nurse should advise her to carry a simple sugar such as hard candy, because of the possibility of exercise-induced hypoglycemia. C) A finger stick result of 120 mg/dL is considered to be normal. D) Such clients need no additional carbohydrate or protein intake. Page Ref: 362 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

9) A 26-year-old client is 26 weeks pregnant. Her previous births include two large-forgestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? A) A 50g, 1-hour glucose screening test B) A single fasting glucose level C) A 100g, 1-hour glucose tolerance test D) A 100g, 3-hour glucose tolerance test Answer: D Explanation: A) All women get the initial 50 g of glucose and a 1-hour screening. B) A single fasting glucose level is not an adequate indicator of the glucose level in relation to food. C) The 100g, 1-hour tolerance test is not an adequate indicator of the glucose level in relation to food. D) Gestational diabetes is diagnosed if two or more of the following values are met or exceeded after taking the 100 g, 3-hour OGTT: Fasting: 95 mg/dL; 1 hour: 180 mg/dL; 2 hours: 155 mg/dL; 3 hours: 140 mg/dL. Page Ref: 356 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

10) A woman asks her nurse what she can do before she begins trying to get pregnant to help her baby, as she is prone to anemia. What would the nurse correctly advise her to do? A) Get pregnant, then start iron supplementation. B) Add more carbohydrates to her diet. C) Begin taking folic acid supplements daily. D) Have a hemoglobin baseline done now so her progress can be followed. Answer: C Explanation: A) Waiting until one is pregnant to add iron or evaluate a diet is not being proactive. B) Adding carbohydrates to her diet will not help prevent anemia. C) The common anemias of pregnancy are due to insufficient hemoglobin production related to nutritional deficiency in either iron or folic acid during pregnancy. Folic acid deficiency during pregnancy is prevented by a daily supplement of 0.4 mg (400 micrograms) of folate. D) Having a hemoglobin baseline done will not help the patient prevent anemia in pregnancy. Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

11) Which of the following may be the main presenting symptom of iron deficiency anemia? A) Frequent urination B) Fatigue C) Nausea D) Headaches Answer: B Explanation: A) The main presenting symptom of iron deficiency anemia would not be frequent urination. B) The main presenting symptom of iron deficiency anemia may be fatigue. C) The main presenting symptom of iron deficiency anemia would not be nausea. D) The main presenting symptom of iron deficiency anemia would not be headaches. Page Ref: 363—364 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

12) The client with thalassemia intermedia has a hemoglobin level of 9.0. The nurse is preparing an education session for the client. Which statement should the nurse include? A) "You need to increase your intake of meat and other iron-rich foods." B) "Your low hemoglobin could put you into preterm labor." C) "Increasing your vitamin C intake will help your hemoglobin level." D) "You should not take iron supplements." Answer: D Explanation: A) Iron-rich foods and supplementation should be avoided. B) Because the client's iron levels are normal, increasing dietary iron will not affect the hemoglobin. C) Vitamin C increases iron absorption, but a client with thalassemia does not need additional iron. D) Folic acid supplements are indicated for women with thalassemia, but iron supplements are not. Page Ref: 366 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

13) The client at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The client's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the client? A) "Your low iron intake has caused anemia, which leads to the neural tube defect." B) "You should increase your vitamin C intake to improve your anemia." C) "You are too picky about food. Your poor diet caused your baby's defect." D) "You haven't had enough folic acid in your diet. You should take a supplement." Answer: D Explanation: A) Low hemoglobin does not cause neural tube defects. B) Vitamin C will increase iron absorption, but this client is deficient in folic acid. C) Therapeutic communication requires that the nurse avoid making judgmental statements. D) An inadequate intake of folic acid has been associated with neural tube defects (NTDs) (e.g., spina bifida, anencephaly, meningomyelocele) in the fetus or newborn. Page Ref: 364 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 10. Value active partnerships with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nursepatient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

14) The client at 9 weeks' gestation has been told that her HIV test was positive. The client is very upset, and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the client makes which statement? A) "I cannot take the medications that control HIV during my pregnancy, because they will harm the baby." B) "My baby can get HIV during the pregnancy and through my breast milk." C) "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." D) "The HIV won't affect my baby, and I will have a low-risk pregnancy without additional testing." Answer: B Explanation: A) Antiretroviral therapy is recommended to all infected pregnant women, regardless of whether or not they are symptomatic, to reduce the rate of perinatal transmission. B) HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth. C) There is no evidence to indicate that pregnancy increases the progression of HIV/AIDS. D) A pregnancy complicated by HIV infection, even if asymptomatic, is considered high risk, and the fetus is monitored closely. Weekly non-stress testing (NST) is begun at 32 weeks' gestation. Page Ref: 372—373 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations. | NLN Competencies: Relationship-Centered Care. Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

15) During the history, the client admits to being HIV-positive and says she knows that she is about 16 weeks pregnant. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "During labor and delivery, I can expect the zidovudine (ZDV) to be given in my IV." B) "After delivery, the dose of zidovudine (ZDV) will be doubled to prevent further infection." C) "My baby will be started on zidovudine (ZDV) for six weeks following the birth." D) "My baby's zidovudine (ZDV) will be given in a cream form." E) "My baby will not need zidovudine (ZDV) if I take it during my pregnancy." Answer: A, C Explanation: A) ART therapy generally includes oral Zidovudine (ZDV) daily, IV ZDV during labor and until birth, and ZDV therapy for the infant for 6 weeks following birth. B) The mother will continue with her oral dosage of zidovudine (ZDV) after delivery just as prior to delivery. C) ART therapy generally includes oral Zidovudine (ZDV) daily, IV ZDV during labor and until birth, and ZDV therapy for the infant for 6 weeks following birth. D) The initial treatment is zidovudine (ZDV) orally every day. E) The infant will be started on oral zidovudine (ZDV) after birth for 6 weeks. Page Ref: 372—373 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: IX. 4. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

16) A woman is 32 weeks pregnant. She is HIV-positive but asymptomatic. The nurse knows that what would be important in managing her pregnancy and delivery? A) An amniocentesis at 30 and 36 weeks B) Weekly non-stress testing beginning at 32 weeks' gestation C) Application of a fetal scalp electrode as soon as her membranes rupture in labor D) Administration of intravenous antibiotics during labor and delivery Answer: B Explanation: A) Invasive procedures such as amniocentesis are avoided when possible to prevent the contamination of a noninfected infant. B) Weekly non-stress testing (NST) is begun at 32 weeks' gestation and serial ultrasounds are done to detect IUGR. C) Invasive procedures are avoided when possible to prevent the contamination of a noninfected infant. D) Antibiotics would be ineffective for either the mother or the infant who was HIV-positive. Page Ref: 372—373 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

17) A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the client needs to be retested for HIV? A) Hemoglobin of 11 g/dL and a rapid weight gain B) Elevated blood pressure and ankle edema C) Shortness of breath and frequent urination D) Persistent candidiasis Answer: D Explanation: A) Hemoglobin of 11 g/dL and a rapid weight gain do not indicate a need to be retested for HIV. B) Elevated blood pressure and ankle edema do not indicate a need to be retested for HIV. C) Shortness of breath and frequent urination do not indicate a need to retest for HIV. D) Signs and symptoms of infections include fever, weight loss, fatigue, persistent candidiasis, diarrhea, cough, and skin lesions (Kaposi's sarcoma and hairy leukoplakia in the mouth). Page Ref: 373 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

18) Women with HIV should be evaluated and treated for other sexually transmitted infections and for what condition occurring more commonly in women with HIV? A) Syphilis B) Toxoplasmosis C) Gonorrhea D) Herpes Answer: B Explanation: A) Women with HIV should be evaluated and treated for other sexually transmitted infections and for conditions occurring more commonly in women with HIV, such as tuberculosis, cytomegalovirus, toxoplasmosis, and cervical dysplasia. Syphilis occurs more often in men. B) Women with HIV should be evaluated and treated for other sexually transmitted infections and for conditions occurring more commonly in women with HIV, such as tuberculosis, cytomegalovirus, toxoplasmosis, and cervical dysplasia. C) Women with HIV should be evaluated and treated for other sexually transmitted infections and for conditions occurring more commonly in women with HIV, such as tuberculosis, cytomegalovirus, toxoplasmosis, and cervical dysplasia. Gonorrhea affects both men and women. D) Women with HIV should be evaluated and treated for other sexually transmitted infections and for conditions occurring more commonly in women with HIV, such as tuberculosis, cytomegalovirus, toxoplasmosis, and cervical dysplasia. Herpes affects both men and women. Page Ref: 373 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Quality and Safety: Contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

19) A 21-year-old at 12 weeks' gestation with her first baby has known cardiac disease, class III, as a result of childhood rheumatic fever. During a prenatal visit, the nurse reviews the signs of cardiac decompensation with her. The nurse will know that the client understands these signs and symptoms if she states that she would notify her doctor if she had which symptom? A) "A pulse rate increase of 10 beats per minute" B) "Breast tenderness" C) "Mild ankle edema" D) "A frequent cough" Answer: D Explanation: A) In most pregnant clients, the heart rate will increase. B) Most pregnant clients will develop breast tenderness. C) The client with rheumatic heart disease who develops congestive heart failure would have severe ankle edema. D) The heart's signal of its decreased ability to meet the demands of pregnancy includes frequent cough (with or without hemoptysis). Page Ref: 378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the effects of various heart disorders on pregnancy, including their implications for nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

20) A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. What should the nurse's response be? A) "Heparin is used when coagulation problems are resolved." B) "Heparin is safer because it does not cross the placenta." C) "They are the same drug, but heparin is less expensive." D) "Coumadin interferes with iron absorption in the intestines." Answer: B Explanation: A) Heparin is used when coagulation problems develop. B) Heparin is safest for the client to take because it does not cross the placental barrier. C) Heparin does not cost less than Coumadin. D) Coumadin does not interfere with iron absorption in the intestines. Page Ref: 378 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the effects of various heart disorders on pregnancy, including their implications for nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

21) A 21-year-old woman is at 12 weeks' gestation with her first baby. She has cardiac disease, class III, as a result of having had childhood rheumatic fever. Which planned activity would indicate to the nurse that the client needs further teaching? A) "I will be sure to take a rest period every afternoon." B) "I would like to take childbirth education classes in my last trimester." C) "I will have to cancel our trip to Disney World." D) "I am going to start my classes in water aerobics next week." Answer: D Explanation: A) Because the heart disease is class III, this client is encouraged to get adequate rest. B) Childbirth classes would be helpful for the client as long as she were careful not to overexert herself. C) Travel during the pregnancy would be based upon the tolerance of the client. However, a trip to Disney World would involve a large amount of activity, which would stress the pregnancy. D) With the slightest exertion, the client's heart rate will rise, and she will become symptomatic. Therefore, she should not establish a new exercise program. Page Ref: 378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the effects of various heart disorders on pregnancy, including their implications for nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

22) Which of the following symptoms, if progressive, are indicative of CHF, the heart's signal of its decreased ability to meet the demands of pregnancy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Palpitations B) Heart murmurs C) Dyspnea D) Frequent urination E) Rales Answer: A, B, C, E Explanation: A) Palpitations are indicative of CHF. B) Heart murmurs are indicative of CHF. C) Dyspnea is indicative of CHF. D) Frequent urination is not indicative of CHF. E) Rales are indicative of CHF. Page Ref: 378—379 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally, and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the effects of various heart disorders on pregnancy, including their implications for nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

23) The prenatal clinic nurse has received four phone calls. Which client should the nurse call back first? A) Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing and shortness of breath B) Pregnant woman at 6 weeks with a seizure disorder who is inquiring which foods are good folic acid sources for her C) Pregnant woman at 35 weeks with a positive HBsAG who is wondering what treatment her baby will receive after birth D) Pregnant woman at 11 weeks with untreated hyperthyroidism who is describing the onset of vaginal bleeding Answer: A Explanation: A) The goal of therapy is to prevent maternal exacerbations, because even a mild exacerbation can cause severe hypoxia-related complications in the fetus. B) Women with seizure disorders should be started on folic acid supplements prior to pregnancy, and should continue throughout pregnancy. However, this client is not the highest priority. C) A client with a positive HBsAG is contagious for hepatitis B. Within 12 hours of birth, infants born to women with HBV infection should receive hepatitis B immune globulin and the first dose of the HBV vaccine series. However, this client is not the highest priority. D) Pregnant women with untreated hyperthyroidism have increased rates of abortion, intrauterine death, and stillbirth. Vaginal bleeding at 11 weeks could indicate that spontaneous abortion is taking place. However, this client is not the highest priority. Page Ref: 381 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Compare the effects of selected gestational medical conditions on pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

24) A patient in the second trimester of pregnancy with gestational diabetes is counseled to ingest 35 calories/kg of ideal body weight. The patient's ideal weight is 154 lbs. How many calories should the patient ingest every day? Answer: 2450 calories Explanation: First determine the patient's ideal body weight in kg by dividing 154 lbs. by 2.2 kg or 154/2.2 = 70 kg. Then multiply the weight in kg by the number of calories per kg to consume or 70 kg x 35 calories = 2450. The patient's daily caloric intake should be 2450 calories. Page Ref: 357 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem. 25) A patient in the 10th week of pregnancy is diagnosed with gestational diabetes. The dietician determines that the patient's daily caloric intake should be 2200 calories and instructs the patient to ingest 40% of calories from carbohydrates, 20% of calories from protein, and 40% of calories from fats. How many calories should the patient ingest of protein each day? Answer: 440 calories Explanation: To determine the number of calories of protein that should be ingested each day the daily caloric total is multiplied by 20% or 2200 x 20% = 440 calories. Page Ref: 357 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

26) A patient with gestational diabetes (GDM) is instructed to measure capillary blood glucose levels 4 times a day. If the patient eats meals at 8 a.m., 1 p.m., and 7 p.m., at which times should the nurse reinforce glucose testing to occur? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. 10 a.m. 2. 12 noon 3. 4 p.m. 4. 3 p.m. 5. 9 p.m. Answer: 1, 4, 5 Explanation: Women with GDM typically measure their blood glucose four times a day - fasting and 1 to 2 hours after meals. Page Ref: 362 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

27) During a routine prenatal visit, the nurse suspects that the patient is experiencing undiagnosed depression. What findings did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Insomnia 2. Headaches 3. Fear of labor 4. Ritualistic behavior 5. Lack of interest in the pregnancy Answer: 1, 2, 5 Explanation: Manifestations of depression in the pregnant patient include withdrawn behavior, physical fatigue due to insomnia, crying spells, sadness, hopelessness, feelings of guilt, lack of interest in the baby, thoughts of suicide, and headaches. Fear of labor is associated with a panic disorder. Ritualistic behavior is associated with obsessive-compulsive disorder (OCD). Page Ref: 367 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 4 Explain the possible implications of maternal psychologic factors and disorders in caring for the childbearing family. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

28) The nurse is preparing teaching material for a patient with multiple sclerosis who is in the third trimester of pregnancy. What information should the nurse emphasize with this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Plan for frequent rest periods 2. Breastfeeding should be avoided 3. Plan to experience heightened pain during labor 4. Determine the need for childcare help after delivery 5. Relapses may increase during the first 3 months after delivery Answer: 1, 4, 5 Explanation: For the pregnant patient with multiple sclerosis, the nurse should emphasize that the relapse rate is reduced during the second and third trimester but increased during the 3 months following birth. Exclusive breastfeeding for the first 2 months postpartum may be independently associated with decreased post-pregnancy relapse rate. Rest is important; help with childcare should be planned. Uterine contraction strength is not diminished, but because sensation is frequently lessened, labor may be almost painless. Page Ref: 383 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Compare the effects of selected gestational medical conditions on pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

29) The nurse is providing care to a pregnant client who is diagnosed with iron deficiency anemia. Which teaching statement from the nurse to the client is appropriate? A) "You will need to begin iron supplements at 30 mg/day." B) "You will need to increase your intake of bananas." C) "You will need to increase your intake of green leafy vegetables." D) "You will need to begin iron supplements at 150 mg/day." Answer: C Explanation: A) Pregnant clients are prescribed 30 mg of iron daily to prevent anemia. Once anemia is diagnosed, the prescribed dosage is increased. This teaching statement is not appropriate. B) Pregnant clients diagnosed with anemia should increase their consumption of foods that are rich in iron. Bananas are not rich in iron. This teaching statement is not appropriate. C) Pregnant clients diagnosed with anemia should increase their consumption of foods that are rich in iron. Green, leafy vegetables are rich in iron. This teaching statement is appropriate. D) Pregnant clients diagnosed with iron deficiency anemia will require an increased dose of supplemental iron, typically 60 mg to 120 mg/day. Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

30) The nurse is providing care to a client who would like to become pregnant within the next year. The client has a history of folic acid deficiency anemia and asks, "What can I do to decrease the risk of neural tube defects?" Which response by the nurse is most appropriate? A) "You will need to have genetic testing done to identify your risk." B) "Do you have a family history of these disorders?" C) "Daily consumption of orange juice decreases your risk." D) "You will be prescribed an iron supplement, which decreases your risk." Answer: C Explanation: A) Genetic testing does not identify the risk for neural tube defects. This response is not appropriate by the nurse. B) Asking the client if there is a family history of neural tube defects will not decrease the client's risk. This response is not appropriate by the nurse. C) Daily consumption of foods rich in folic acid, such as orange juice, provides the client with the necessary amount of folic acid to decrease the risk of neural tube defects. This response is appropriate by the nurse. D) Folic acid supplements, not iron supplements, are prescribed to decrease the risk for neural tube defects. This response is not appropriate by the nurse. Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

31) The nurse is providing care to a laboring pregnant client who is diagnosed with sickle cell disease. What will the nurse prepare for upon delivery of the client's newborn, based on this diagnosis? A) Hemorrhage B) Intrauterine growth restriction C) Neonatal resuscitation D) Cesarean birth Answer: B Explanation: A) A pregnant client diagnosed with sickle cell anemia is not at an increased risk for hemorrhage. B) When providing care for a pregnant client diagnosed with sickle cell anemia, the nurse will prepare for a neonate experiencing intrauterine growth restriction, as this is a known consequence during pregnancy. C) The newborn of a client diagnosed with sickle cell anemia is not at an increased risk for requiring neonatal resuscitation. D) A pregnant client diagnosed with sickle cell anemia is not at an increased for cesarean birth. Page Ref: 363 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

32) The nurse is caring for a postpartum client who is experiencing a sickle cell crisis. Which is the priority assessment by the nurse? A) Blood pressure B) Lochia C) Temperature D) Fundal height Answer: C Explanation: A) The postpartum client experiencing a sickle cell crisis is at risk for infection. While monitoring blood pressure is important, this is not the priority assessment. B) The postpartum client experiencing a sickle cell crisis is at risk for infection. While monitoring lochia is important, this is not the priority assessment. C) The postpartum client experiencing a sickle cell crisis is at risk for infection. The priority assessment for this client is to closely monitor temperature. D) The postpartum client experiencing a sickle cell crisis is at risk for infection. While monitoring fundal height is important, this is not the priority assessment. Page Ref: 363 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Discriminate among the four major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

33) The nurse is providing care to a client in labor who admits to using heroin throughout the pregnancy. Which will the neonate be at risk for following birth? A) Seizure activity B) Congenital anomalies C) Large for gestational age D) Cardiac anomalies Answer: A Explanation: A) The neonate who has been exposed to heroin in utero is at an increased risk for seizure activity following birth. B) The neonate who has been exposed to heroin in utero is not at an increased risk for congenital anomalies. This is expected if the neonate was exposed to lithium carbonate while in utero. C) The neonate who has been exposed to heroin in utero is not an increased risk for being large for gestational age. This is expected for the neonate who is born to a mother who is diagnosed with gestational diabetes mellitus. D) The neonate who has been exposed to heroin in utero is not at an increased risk for cardiac anomalies. This is expected for the neonate who is exposed to cocaine in utero. Page Ref: 367 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

34) The nurse is conducting an admission assessment for a pregnant client who is in labor. Which finding would cause the nurse to expect that the client has been abusing an illegal substance? A) The client is asking for an epidural and rates pain as an 8 on a 0 to 10 numeric scale. B) The client is diaphoretic during the transition stage of labor. C) The client has constricted pupils and inflamed nasal mucosa. D) The client has a history of precipitous labor. Answer: C Explanation: A) The nurse would not suspect that this client has been abusing an illegal substance based on asking for an epidural and rating pain as an 8 on a 0 to 10 numeric scale. B) The nurse would not suspect that this client has been abusing an illegal substance based on experiencing diaphoresis during the transition stage of labor. This is an expected finding. C) A client who has constricted pupils and inflamed nasal mucosa would be suspected of abusing illegal substances. D) A client who has a history of precipitous labor would not cause the nurse to expect substance abuse. Page Ref: 367 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; apply health promotion/disease prevention strategies; apply health policy. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a pregestational problem.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 18 Pregnancy at Risk: Gestational Onset 1) A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what? A) Sodium B) Carbohydrates C) Protein D) Fruits Answer: C Explanation: A) It is important that the client limit her intake of sodium. B) While it is important that the client have an adequate intake of carbohydrates, another food group is more important. C) The client who experiences preeclampsia is losing protein. D) It is important that the client have adequate intake of fruits, but another food group is more important. Page Ref: 402 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

2) The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician? A) Excretion of less than 300 mg of protein in a 24-hour period B) Platelet count of less than 150,000/mm3 C) Urine output of 50 mL per hour D) 12 respirations Answer: B Explanation: A) Excretion of more than 300 mg of protein in a 24-hour period is considered abnormal. B) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 150,000/mm3). C) Urine output of a least 30mL/hour is considered normal. D) Respirations of 12 are normal. Page Ref: 400 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

3) A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, what should the nurse also say? A) "Your baby will be fine. We'll start IV, and get this stopped in no time at all." B) "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." C) "You are going to miscarry. But you should be relieved because most miscarriages are the result of abnormalities in the fetus." D) "I really can't say. However, when your physician comes, I'll ask her to talk to you about it." Answer: B Explanation: A) This is a serious situation. The client should not be offered false hope of everything being fine. B) If bleeding persists and abortion is imminent or incomplete, the woman may be hospitalized, IV therapy or blood transfusions may be started to replace fluid, and dilation and curettage (D&C) or suction evacuation is performed to remove the remainder of the products of conception. C) The nurse should avoid giving a justification of the miscarriage. D) The nurse should not defer the conversation to someone else (e.g., the physician). Page Ref: 388 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person with his or her own life story and ideas of the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

4) The nurse is supervising care in the emergency department. Which situation most requires an intervention? A) Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour B) Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour C) Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 D) Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports an absence of fetal movement Answer: C Explanation: A) Bleeding in the third trimester is usually due to placenta previa or placental abruption. The primary intervention for placenta previa or placental abruption is intravenous (IV) therapy, which the patient already has in place. B) Bleeding in the first trimester can be indicative of spontaneous abortion beginning, or of an ectopic pregnancy. Transvaginal ultrasound is used for diagnosis. C) Bleeding in the third trimester is usually due to placenta previa or placental abruption. Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness. Monitor vital signs, particularly blood pressure and pulse, for evidence of developing shock. D) Bleeding in the third trimester can indicate placental abruption. Normal vital signs indicate a normal vascular volume. Decrease in fetal movement or cessation of movement may indicate fetal compromise. The fetus is at greatest risk in this situation; the mother is stable. Page Ref: 387 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors or actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

5) A client who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain. Laboratory tests reveal a beta-hCG at a lower-than-expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The client is crying and asks what is happening. The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include? A) "You're feeling dizzy because the pregnancy is compressing your vena cava." B) "The pain is due to the baby putting pressure on nerves internally." C) "The baby is in the fallopian tube; the tube has ruptured and is causing bleeding." D) "This is a minor problem. The doctor will be right back to explain it to you." Answer: C Explanation: A) Dizziness from vena cava compression occurs in the third trimester when women are supine. B) The fetus is too small to be putting pressure on the nerves. C) The woman who experiences one-sided lower abdominal pain or diffused lower abdominal pain, vasomotor disturbances such as fainting or dizziness, and referred right shoulder pain from blood irritating the subdiaphragmatic phrenic nerve is experiencing an ectopic pregnancy. D) Therapeutic communication requires giving the client an answer rather than referring the client to someone else. Page Ref: 392 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

6) A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority? A) Fluid Volume: Deficient B) Cardiac Output, Decreased C) Injury, Risk for D) Nutrition, Imbalanced: Less than Body Requirements Answer: A Explanation: A) The newly admitted client with hyperemesis gravidarum has been experiencing excessive vomiting, and is in a fluid volume-deficit state. B) Because no preexisting cardiac condition is present, the body has compensated for this fluid loss. C) The risk for injury is present due to the symptoms of fluid volume deficit; however, it is not the priority. D) The nutrition status of the client is compromised until the emesis and the fluid volume status are corrected. But it is not the first priority. Page Ref: 395 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management, across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 3 Discuss the medical therapy and nursing care of a woman with hyperemesis gravidarum. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

7) The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? A) Weigh the client. B) Give 1 liter of lactated Ringer's solution IV. C) Administer 30 mL Maalox (magnesium hydroxide) orally. D) Encourage clear liquids orally. Answer: B Explanation: A) Weighing the client provides information on weight gain or loss, but is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. B) The vital signs indicate hypovolemia from dehydration, which leads to hypotension and increased pulse rate. Giving this client a liter of lactated Ringer's solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down. C) The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. D) Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia. Page Ref: 395 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce harm to self or others. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team, and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the medical therapy and nursing care of a woman with hyperemesis gravidarum. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

8) A primary herpes simplex infection in the first trimester can increase the risk of which of the following? A) Spontaneous abortion B) Preterm labor C) Intrauterine growth restriction D) Neonatal infection Answer: A Explanation: A) A primary herpes simplex infection can increase the risk of spontaneous abortion when infection occurs in the first trimester. B) Preterm labor (PTL) is a greater risk if the primary infection occurs late in the second trimester or early in the third trimester. C) Intrauterine growth restriction is a greater risk if the primary infection occurs late in the second trimester or early in the third trimester. D) Neonatal infection is a greater risk if the primary infection occurs late in the second trimester or early in the third trimester. Page Ref: 411 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team, and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Contrast the effects of various infections on the pregnant woman and her unborn child. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

9) The nurse is performing a preoperative assessment on a client who is in the second trimester of pregnancy. For which finding(s) should the nurse monitor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Respiratory infection B) Fever C) Urinary tract infection D) Anemia E) ABO incompatibility Answer: A, B, C, D Explanation: A) Assessing for respiratory infections is an important part of the preoperative assessment for the client who is pregnant. B) Assessing for fever is an important part of the preoperative assessment for the client who is pregnant. C) Assessing for urinary tract infection is an important part of the preoperative assessment for the client who is pregnant. D) Assessing for anemia is an important part of the preoperative assessment for the client who is pregnant. E) ABO incompatibility is not routinely assessed as part of the preoperative assessment for the client who is pregnant, as it rarely has serious life-threatening consequences and is almost exclusively seen after the birth of the newborn. Page Ref: 417 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Summarize the risks and implications of surgical procedures performed during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

10) The community health nurse is teaching a class about causes of traumatic injury leading to pregnancy complications. What statement should the nurse include in the teaching? A) "Although falls are an uncommon cause of trauma, it is important to know what to do in the case of these incidents." B) "In early pregnancy, the woman is at a greater risk for injury due to decreased balance and coordination." C) "The pregnant woman should be given the same care as any person suffering from trauma." D) "Violence, including domestic violence, is the most common cause of injury for pregnant women, after motor vehicle accidents." Answer: D Explanation: A) Falls are a common cause of trauma in the client who is pregnant. B) Late pregnancy, not early pregnancy, causes a decrease in balance in the client who is pregnant. C) The physiologic changes that occur with pregnancy have clinical implications for victims of trauma; the client who is pregnant does not receive the same care. D) Violence, including domestic violence, is the next most common cause of injury for clients who are pregnant after motor vehicle accidents. This is the statement the nurse should include in the teaching. Page Ref: 417 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Context and environment: Read and interpret data; apply health promotion/disease prevention strategies. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Discuss the needs and care of the pregnant woman who suffers from intimate partner violence. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

11) When blood pressure and other signs indicate that preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Fetal heart rate B) Blood pressure C) Temperature D) Urine color E) Pulse and respirations Answer: A, B, C, E Explanation: A) Determine the fetal heart rate along with blood pressure, or monitor continuously with the electronic fetal monitor if the situation indicates. B) Determine blood pressure every 1 to 4 hours, or more frequently if indicated by medication or other changes in the woman's status. C) Determine temperature every 4 hours, or every 2 hours if elevated or if premature rupture of the membranes (PROM) has occurred. D) Urine color is not monitored. However, urine output, urine protein, and urine specific gravity are monitored. E) Determine pulse rate and respirations along with blood pressure. Page Ref: 400 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

12) The community nurse is working with a client at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the client would indicate that additional information is needed? A) "I should call the doctor if I develop a headache or blurred vision." B) "Lying on my left side as much as possible is good for the baby." C) "My urine could become darker and smaller in amount each day." D) "Pain in the top of my abdomen is a sign my condition is worsening." Answer: C Explanation: A) Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the physician. B) The left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia. C) Oliguria is a complication of preeclampsia. Specific gravity of urine readings over 1.040 correlate with oliguria and proteinuria and should be reported to the physician. D) Liver distention causes epigastric pain and may ultimately result in rupture. It is a symptom of worsening preeclampsia, and should be reported to the physician. Page Ref: 400 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

13) Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of which condition? A) Intrauterine growth restriction B) Oliguria C) Proteinuria D) Hypertension Answer: A Explanation: A) Infants of women with preeclampsia during pregnancy tend to be small for gestational age (SGA) because of intrauterine growth restriction. The cause is related specifically to maternal vasospasm and hypovolemia, which result in fetal hypoxia and malnutrition. B) Oliguria is a sign of preeclampsia, but does not cause infants to be small for gestational age (SGA). C) Proteinuria is a sign of preeclampsia, but does not cause infants to be small for gestational age (SGA). D) Hypertension is a sign of preeclampsia, but does not cause infants to be small for gestational age (SGA). Page Ref: 400 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Personal and Professional Development: Identify problems. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

14) A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response? A) "This medication will halt the labor process until the baby is more mature." B) "This medication will relax the smooth muscles in the infant's lungs so the baby can breathe." C) "This medication is effective in stimulating lung development in the preterm infant." D) "This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor." Answer: C Explanation: A) This medication has no effect on the labor process or on the smooth muscles in the lungs. B) This medication has no effect on the labor process or on the smooth muscles in the lungs. C) Betamethasone or dexamethasone is often administered to the woman whose fetus has an immature lung profile to promote fetal lung maturation. D) This medication is not an antibiotic, and therefore will not help resolve a urinary tract infection. Page Ref: 402 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

15) A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rhnegative pregnant client. When should the first dose of RhoGAM be administered? A) After the birth of the infant B) 1 month postpartum C) During labor D) At 28 weeks' gestation Answer: D Explanation: A) After birth would be too late for the first dose of RhoGAM if transplacental hemorrhage, which is possible during pregnancy, has occurred. B) One month postpartum would be too late for the first dose of RhoGAM if transplacental hemorrhage, which is possible during pregnancy, has occurred. C) During labor would be too late for the first dose of RhoGAM if transplacental hemorrhage, which is possible during pregnancy, has occurred. D) When the woman is Rh negative and not sensitized and the father is Rh positive or unknown, Rh immune globulin is given prophylactically at 28 weeks' gestation. Page Ref: 421 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team, and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the fetus and newborn (HDFN) secondary to Rh incompatibility. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

16) Whether sensitization is the result of a blood transfusion or maternal-fetal hemorrhage for any reason, what test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation, and to calculate the amount of Rh immune globulin needed? A) Indirect Coombs' test B) Non-stress test C) Kleihauer-Betke or rosette test D) Direct Coombs' test Answer: C Explanation: A) An indirect Coombs' test is done on the mother's blood to measure the number of Rh-positive antibodies. B) A non-stress test is performed to assess the fetal heart rate in response to fetal movement. C) A Kleihauer-Betke or rosette test can be performed to determine the amount of Rh(D) positive blood present in the maternal circulation and to calculate the amount of Rh immune globulin needed. D) A direct Coombs' test is done on the infant's blood to detect antibody-coated Rh-positive RBCs. Page Ref: 422 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the fetus and newborn (HDFN) secondary to Rh incompatibility. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

17) The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective? A) "I need to get RhoGAM so I don't have problems with my next pregnancy." B) "Because my baby is Rh-positive, I don't need RhoGAM." C) "If my baby had the same blood type I do, it might cause complications." D) "Before my next pregnancy, I will need to have a RhoGAM shot." Answer: A Explanation: A) Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization. B) If the baby is Rh-negative, the mother does not need RhoGAM. C) It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization. D) The injection must be given within 72 hours after delivery to prevent alloimmunization. Page Ref: 420 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the fetus and newborn (HDFN) secondary to Rh incompatibility. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

18) Which maternal-child client should the nurse see first? A) Blood type O, Rh-negative B) Indirect Coombs' test negative C) Direct Coombs' test positive D) Blood type B, Rh-positive Answer: C Explanation: A) This client is Rh-negative, but there is no indication that the alloimmunization has occurred. B) If the mother's indirect Coombs' test is negative and the infant's direct Coombs' test is negative (confirming that sensitization has not occurred), the mother is given Rh immune globulin within 72 hours of birth. C) A direct Coombs' test is done on the infant's blood to detect antibody-coated Rh-positive RBCs. If the mother's indirect Coombs' test is positive and her Rh-positive infant has a positive direct Coombs' test, Rh immune globulin is not given; in this case, the infant is carefully monitored for hemolytic disease. D) This client's blood type creates no problems. Page Ref: 421 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team, and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the cause and prevention of hemolytic disease of the fetus and newborn (HDFN) secondary to Rh incompatibility. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

19) A client is concerned because she has been told that her blood type and her baby's are incompatible. What is the nurse's best response? A) "This is called ABO incompatibility. It is somewhat common but rarely causes significant hemolysis, a breakdown of red blood cells." B) "This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy." C) "This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby." D) "This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring." Answer: A Explanation: A) When blood types, not Rh, are incompatible, it is called ABO incompatibility. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal RBCs. B) Although this can be serious, additional blood studies are not typically done. There is no medication that can be given to the mother to prevent this from occurring. C) The incompatibility is not between the mother's and the father's blood, but between the mother's and the infant's blood. D) ABO incompatibility is common, but there is no medication to give the baby that will prevent jaundice. Page Ref: 425 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, treatment, and implications for the fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

20) If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent what? A) The potential for hemorrhage B) Hyperhomocysteinemia C) Antibody formation D) Tubal pregnancy Answer: C Explanation: A) If the woman is Rh negative and not sensitized, she is not given Rh immune globulin to prevent the potential for hemorrhage. B) Hyperhomocysteinemia (HHcy) is a risk factor for vascular disease. C) If the woman is Rh negative and not sensitized, she is given Rh immune globulin to prevent antibody formation. D) If the woman is Rh negative and not sensitized, she is not given Rh immune globulin to prevent a tubal pregnancy. Page Ref: 420 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and (a) quality and safe patient care, (b) excellence in nursing, and (c) advancement of the profession. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, treatment, and implications for the fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

21) The client presents to the clinic for an initial prenatal examination. She asks the nurse whether there might be a problem for her baby because she has type B Rh-positive blood and her husband has type O Rh-negative blood, or because her sister's baby had ABO incompatibility. What is the nurse's best answer? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Your baby would be at risk for Rh problems if your husband were Rh-negative." B) "Rh problems only occur when the mother is Rh-negative and the father is not." C) "ABO incompatibility occurs only after the baby is born." D) "We don't know for sure, but we can test for ABO incompatibility." E) "Your husband's being type B puts you at risk for ABO incompatibility." Answer: B, C Explanation: A) Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive. B) Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rhpositive. C) ABO incompatibility is limited to type O mothers with a type A or B fetus and occurs after the baby is born. D) ABO incompatibility is limited to type O mothers with a type A or B fetus and occurs after the baby is born. E) The husband's blood type is not an issue for ABO incompatibility. Page Ref: 425 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, treatment, and implications for the fetus/newborn. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

22) A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the client understands that what is essential? A) That she not become pregnant until after the follow-up program is completed B) That she receive RhoGAM with her next pregnancy and birth C) That she has her blood pressure checked weekly for the next 30 days D) That she seek genetic counseling with her partner before the next pregnancy Answer: A Explanation: A) Because of the risk of choriocarcinoma, the woman treated for hydatidiform mole should receive extensive follow-up therapy. Follow-up care includes a baseline chest X-ray to detect lung metastasis and a physical examination including a pelvic examination. The woman should avoid pregnancy during this time because the elevated hCG levels associated with pregnancy would cause confusion as to whether cancer had developed. B) There is no indication for the administration of RhoGAM. C) There is no indication of blood pressure problems or preeclampsia. D) This is not a genetic defect that genetic counseling could/would resolve. Page Ref: 393 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Delineate the bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

23) A client at 10 weeks' gestation has developed cholecystitis. If surgery is required, what is the safest time during pregnancy? A) Immediately, before the fetus gets any bigger B) Early in the second trimester C) As close to term as possible D) The risks are too high to do it anytime in pregnancy Answer: B Explanation: A) The risk of miscarriage is greater in the first trimester. B) The early second trimester is the best time to operate because there is less risk of spontaneous abortion or early labor, and the uterus is not so large as to impinge on the abdominal field. C) A fetus close to term is so large that it might interfere with the abdominal field. D) There is always a risk, but it is greater in the first and third trimesters. Page Ref: 417 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. Demonstrate effective strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Summarize the risks and implications of surgical procedures performed during pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

24) The nurse is presenting a class to newly pregnant families. What form of trauma will the nurse describe as the leading cause of fetal and maternal death? A) Falls B) Domestic violence C) Gun accidents D) Motor vehicle accidents Answer: D Explanation: A) Falls are not the leading cause of fetal and maternal death. B) Domestic violence is not the leading cause of fetal and maternal death. C) Gun accidents are not common in pregnancy. D) Trauma from motor vehicle accidents is the leading cause of fetal and maternal death. Page Ref: 417 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Relate the impact of major trauma during pregnancy to the nursing care of the woman and her fetus. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

25) During a prenatal exam, a client describes several psychosomatic symptoms and has several vague complaints. What could these behaviors indicate? A) Abuse B) Mental illness C) Depression D) Nothing, they are normal Answer: A Explanation: A) Chronic psychosomatic symptoms and vague complaints can be indicators of abuse. B) Chronic psychosomatic symptoms and vague complaints are not indicators of mental illness. C) Chronic psychosomatic symptoms and vague complaints are not indicators of depression. D) Chronic psychosomatic symptoms and vague complaints should not be discounted as normal. Page Ref: 419 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Abuse/Neglect Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the needs and care of the pregnant woman who suffers from intimate partner violence. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

26) The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern? A) "Blood pressure 110/68, pulse 90." B) "Entrance wound present below the umbilicus." C) "Client is positioned in a left lateral tilt." D) "Clear fluid is leaking from the vagina." Answer: B Explanation: A) These are normal vital signs, indicating a hemodynamically stable client. B) Penetrating trauma includes gunshot wounds and stab wounds. The mother generally fares better than the fetus if the penetrating trauma involves the abdomen, as the enlarged uterus is likely to protect the mother's bowel from injury. C) Positioning the client in a lateral tilt position prevents vena cava syndrome. D) Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term, and would likely survive birth at this time. Page Ref: 418 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Relate the impact of major trauma during pregnancy to the nursing care of the woman and her fetus. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

27) The client at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the client understands the treatment being administered? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "The baby needs to be monitored to check the heart rate." B) "My bowel has probably been lacerated by the knife." C) "I might need an ultrasound to look at the baby." D) "The catheter in my bladder will prevent urinary complications." E) "The IV in my arm will replace the amniotic fluid if it is leaking." Answer: A, C Explanation: A) Ongoing assessments of trauma include evaluation of uterine tone, contractions and tenderness, fundal height, fetal heart rate, intake and output and other indicators of shock, normal postoperative evaluation in those women requiring surgery, determination of neurologic status, and assessment of mental outlook and anxiety level. B) The pregnancy usually sustains the majority of the damage, sparing the bowel from injury. C) In cases of noncatastrophic trauma, where the mother's life is not directly threatened, fetal monitoring for 4 hours should be sufficient if there is no vaginal bleeding, uterine tenderness, contractions, or leaking amniotic fluid. D) The Foley catheter is placed to assess for hematuria. E) The IV will replace intravascular volume, not amniotic fluid. Page Ref: 418 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Relate the impact of major trauma during pregnancy to the nursing care of the woman and her fetus. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

28) The nurse prepares teaching material for a patient who is experiencing a spontaneous abortion. Based upon the material selected, which type of abortion is the patient experiencing?

A) Threatened B) Imminent C) Incomplete D) Complete Answer: B Explanation: B) For an imminent abortion the placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased. For a threatened abortion the cervix is not dilated, and the placenta is still attached to the uterine wall, but some bleeding occurs. For an incomplete abortion the embryo/fetus has passed out of the uterus; however, the placenta remains. In a complete abortion all contents of the pregnancy have been expelled from the uterus. Page Ref: 389 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk. 28 Copyright © 2020 Pearson Education, Inc.

29) The maternity nurse is preparing material for a staff development seminar on ectopic pregnancy. When using the diagram below, which area should the nurse identify as being the most common location for the implantation of an ectopic pregnancy?

A) A B) B C) C D) D Answer: B Explanation: B) The most common location for implantation of an ectopic pregnancy is the ampulla of the tube. Fimbrial, intramural, and ovarian are not the most common locations for the implantation of an ectopic pregnancy. Page Ref: 391 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: II. B. 9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and collaborative skills to deliver evidencebased, patient-centered care. | NLN Competencies: Teamwork: Practice; choose communication styles that diminish risks associated with authority gradients among team members to accomplish care, assert one's own views, and minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

30) A female patient seeks medical attention for vaginal discharge that at times is bright red but is mostly dark brown in color. When preparing materials to share with this patient, why should the nurse include this diagram?

A) It shows the size of the uterus. B) It explains the location of the cervix. C) It portrays the vessels within the uterus. D) It demonstrates the location of the uterus. Answer: C Explanation: C) A common sign of a hydatidiform mole is vaginal bleeding, often brownish (the characteristic "prune juice" appearance), but sometimes bright red. In this figure, some of the hydropic vessels are being passed. This occurrence is diagnostic for hydatidiform mole. This diagram is not being used because it shows the size of the uterus, the location of the cervix, or the location of the uterus. Page Ref: 393 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 2 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

31) A pregnant patient weighing 165 lb is diagnosed with preeclampsia and is prescribed to ingest 1.5 g/kg/day of protein. How many grams of protein should the nurse instruct the patient to ingest? Answer: 112.5 grams Explanation: First convert the patient's weight in lb to kg by dividing the weight by 2.2 or 165/2.2 = 75 kg. Next multiply the weight in kg by 1.5 grams of protein or 75 x 1.5 = 112.5 grams. The nurse should instruct the patient to ingest 112.5 grams of protein each day. Page Ref: 405 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Describe the maternal and fetal-neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

32) A patient in the first trimester of pregnancy recently emigrated from a foreign country and is diagnosed with rubella. What can occur to the developing fetus because of this infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Congenital cataracts 2. Sensorineural deafness 3. Ophthalmia neonatorum 4. Congenital heart defects 5. Intrauterine growth restriction Answer: 1, 2, 4 Explanation: The most common clinical signs of rubella syndrome are congenital cataracts, sensorineural deafness, and congenital heart defects. Ophthalmia neonatorum is associated with maternal gonorrhea at the time of birth. Intrauterine growth restriction is not associated with rubella. Page Ref: 410 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 5 Contrast the effects of various infections on the pregnant woman and her unborn child. MNL LO: Demonstrate use of the nursing process in the care of a pregnant woman with a gestational risk.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 19 Processes and Stages of Labor and Birth 1) How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? A) Breech, transverse B) Breech, longitudinal C) Breech, frank D) Vertex, transverse Answer: A Explanation: A) A shoulder presentation is one type of breech presentation, and is also called a transverse lie. B) A shoulder presentation is not a longitudinal lie. C) In a frank breech, the buttocks are the presenting part. D) A shoulder presentation is not vertex. Page Ref: 435 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

2) A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Android B) Anthropoid C) Gynecoid D) Platypelloid E) Lambdoidal suture Answer: A, D Explanation: A) In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. B) The anthropoid pelvis type is considered favorable for vaginal childbirth. C) The gynecoid pelvis type is considered favorable for vaginal childbirth. D) In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. E) This is not a pelvis type. Page Ref: 431 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

3) The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Woman at 7 cm, fetus in general flexion B) Woman at 3 cm, fetus in longitudinal lie C) Woman at 4 cm, fetus with transverse lie D) Woman at 6 cm, fetus at -2 station, mild contractions E) Woman at 5 cm, fetal presenting part is right shoulder Answer: C, D, E Explanation: A) Fetal attitude refers to the relation of the fetal body parts to one another and describes the posture the fetus assumes as it conforms to the shape of the uterine cavity. The normal attitude of the fetus is termed general flexion, where the head is flexed so that the chin is on the chest with the arms crossed over the chest, and the legs are flexed at the knees with the thighs on the abdomen. B) Fetal lie refers to the relationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, or cephalocaudal, axis of the mother. The fetus may assume either a longitudinal (vertical) or a transverse (horizontal) lie; a longitudinal lie is normal. C) A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. D) Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. E) When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part. Page Ref: 432 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

4) The charge nurse has received the shift change report. Which client requires immediate intervention? A) Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes B) Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation C) Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge D) Woman at 3 cm screaming in fear because her mother died during childbirth Answer: D Explanation: A) Strong contractions every 3 minutes constitute an adequate labor pattern during induction of labor. This client is experiencing no complications. B) Longitudinal lie with cephalic presentation is a head-down position. This is expected. C) 10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected. D) This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority. Page Ref: 443 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. C. 6. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that reflects high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe the physiologic and psychosocial changes that are indicative of the maternal progress during each of the stages of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

5) Premonitory signs of labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Braxton Hicks contractions B) Cervical softening and effacement C) Weight gain D) Rupture of membranes E) Sudden loss of energy Answer: A, B, D Explanation: A) A premonitory sign of labor includes Braxton Hicks contractions. B) A premonitory sign of labor includes cervical softening and effacement. C) A premonitory sign of labor includes weight loss, not weight gain. D) A premonitory sign of labor includes rupture of membranes. E) A premonitory sign of labor includes a sudden burst of energy, not a loss of energy. Page Ref: 440 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

6) A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? A) Second phase B) Latent phase C) Active phase D) Transition phase Answer: B Explanation: A) There is no phase of labor that is identified as the second phase. B) In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions. C) When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. During this phase the cervix dilates from about 4 to 7 cm. D) When the woman enters the transition phase, she may demonstrate significant anxiety. She becomes acutely aware of the increasing force and intensity of the contractions. She may become restless, frequently changing position. Page Ref: 443 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

7) The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client? A) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." B) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "The hormones that cause labor to begin are just getting to be at levels that will change your cervix." Answer: A Explanation: A) With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls. B) As the fetal head descends to the pelvic floor, the pressure of the presenting part causes the perineal structure, which was once 5 cm in thickness, to change to a structure less than 1 cm thick. The perineal body's thinning primarily occurs during later stages of labor; it is not expected now. C) This reply is not therapeutic. The nurse must always be therapeutic in all communication. D) The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Quality and Safety: Encourage patients and families to communicate their observations and concerns regarding safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

8) To identify the duration of a contraction, the nurse would do which of the following? A) Start timing from the beginning of one contraction to the completion of the same contraction. B) Time between the beginning of one contraction and the beginning of the next contraction. C) Palpate for the strength of the contraction at its peak. D) Time from the beginning of the contraction to the peak of the same contraction. Answer: A Explanation: A) The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction. B) Duration is not measured this way. C) Duration is not measured this way. D) Duration is not measured this way. Page Ref: 437 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the physiology of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

9) The client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? A) "Unless you have pain with urination, we don't need to worry about it." B) "These symptoms usually mean the baby's head has descended further." C) "Come in for an appointment today and we'll check everything out." D) "This might indicate that the baby is no longer in a head-down position." Answer: B Explanation: A) Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection. B) This is the best response because it most directly addresses what the client has reported. C) There is no need for an additional appointment. D) The fetus's changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

10) The client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? A) "You shouldn't work so much at this point in pregnancy." B) "What you are describing is not commonly experienced in the last weeks." C) "Your body may be telling you it is going into labor soon." D) "If the bladder pressure continues, come in to the clinic tomorrow." Answer: C Explanation: A) There is no indication that the client should decrease her work schedule. B) Lightening is a common and expected finding. C) One of the premonitory signs of labor is lightening: The fetus begins to settle into the pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing. D) Lightening does not indicate pathology, and therefore there is no need for the client to come to the clinic if the symptoms continue. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

11) A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? A) Engagement B) Lightening C) Molding D) Braxton Hicks contractions Answer: B Explanation: A) Engagement of the presenting part occurs when the largest diameter of the fetal presenting part reaches or passes through the pelvic inlet. B) Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet. C) The fetal cranial bones overlap under pressure of the powers of labor and the demands of the unyielding pelvis. This overlapping is called molding. D) Braxton Hicks contractions occur before the onset of labor. Page Ref: 440 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

12) A client who is having false labor most likely would have which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) Contractions that lessen with rest and warm tub baths Answer: A, D, E Explanation: A) True labor contractions intensify while walking. B) The contractions of true labor produce progressive dilation and effacement of the cervix. They occur regularly and increase in frequency, duration, and intensity. C) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. D) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. E) In true labor, contractions do not lessen with rest and warm tub baths. Page Ref: 440 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Differentiate between false and true labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

13) The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? A) True labor contractions begin in the back and sweep toward the front. B) False labor often feels like abdominal tightening, or "balling up." C) True labor can be diagnosed only if cervical change occurs. D) False labor contractions do not increase in intensity or duration. Answer: C Explanation: A) Although this is a true statement, it is not the most important indication of true labor. B) Although this is a true statement, it is not the most important fact about false and true labor. C) Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilation. D) Although this is a true statement, it is not the most important fact about true and false labor. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Differentiate between false and true labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

14) The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor will most likely include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) Contractions are at regular intervals Answer: A, D Explanation: A) True labor contractions intensify while walking. B) True labor results in increased intensity and frequency of contractions. C) True labor results in progressive dilation. D) The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen. E) With false labor, contractions are irregular. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Differentiate between false and true labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

15) A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor? A) Active B) Latent C) Transition D) Fourth Answer: C Explanation: A) In the active phase, the woman dilates from 4 to 7 centimeters. B) The latent phase is the beginning of labor contractions and the cervix may be dilated 0 to 3 centimeters. C) The transition phase begins with 8 cm to 10 cm of dilation, and contractions become more frequent, are longer in duration, and increase in intensity. D) There is no fourth phase. The fourth stage occurs after delivery of the placenta. Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

16) A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? A) Active B) Transition C) Latent D) Second Answer: B Explanation: A) During the active phase, the cervix dilates from about 4 to 7 cm. When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. B) During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety. C) The latent phase is characterized by mild contractions lasting 20 to 40 seconds with a frequency of 3 to 30 minutes. In the latent stage, the woman may be relieved that labor has finally started. D) The second stage is the pushing stage, and the woman might feel relieved that the birth is near and she can push. There is no second phase of labor. Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

17) The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? A) "In normal labor, as the uterine contractions become stronger, they usually also become less frequent." B) "In normal labor, as the uterine contractions become stronger, they usually also become less painful." C) "In normal labor, as the uterine contractions become stronger, they usually also become longer in duration." D) "In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration." Answer: C Explanation: A) The uterine contractions of labor become more frequent as labor progresses. B) The uterine contractions of labor become more painful over time. C) During the active and transition phases, contractions become more frequent, are longer in duration, and increase in intensity. D) The uterine contractions of labor do not become shorter in duration as labor progresses. Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly or cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

18) Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? A) Place the client in McRoberts position. B) Watch for the emergence of the placenta. C) Prepare for the delivery of an undiagnosed twin. D) Place the client in a supine position. Answer: B Explanation: A) Exercises aimed at adducting the legs into an extended McRoberts position, which is performed by flexing the mother's thighs toward her shoulders while she is lying on her back, help enable the woman to stretch her hamstring muscles, a task usually required during the second stage of labor. B) Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina. C) The first placenta usually does not deliver before the birth of the second twin. D) Blood pressure may drop precipitously when the pregnant woman lies in a supine position and experiences aortocaval compression. Page Ref: 445 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

19) A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? A) Cervical dilation 6 cm B) Mild contraction intensity C) Contraction frequency every 5 minutes D) Contraction duration 30-40 seconds Answer: A Explanation: A) Cervical dilation of 6 cm indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 cm and contractions and pain intensify. B) Mild contractions are consistent with most of the scenario. C) This contraction frequency is consistent with most of the scenario. D) This contraction duration is consistent with most of the scenario. Page Ref: 444 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

20) The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal exhaustion B) Cervical edema C) Tearing and bruising of the cervix D) Enhanced perineal thinning E) Having to perform an episiotomy Answer: A, B, C Explanation: A) If the cervix is not completely dilated, maternal exhaustion can occur. B) If the cervix is not completely dilated, cervical edema can occur. C) If the cervix is not completely dilated, tearing and bruising of the cervix can occur. D) Cervical dilation has nothing to do with perineal thinning. E) Not bearing down until the cervix is completely dilated has nothing to do with needing an episiotomy. Page Ref: 437 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe the physiologic and psychosocial changes that are indicative of the maternal progress during each of the stages of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

21) The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? A) Leave the client alone so she can rest. B) Ask the family to take a coffee-and-snack break. C) Encourage the client to have an epidural for pain. D) Reassure the client that she will not be left alone. Answer: D Explanation: A) The client is in the transitional phase of the first stage of labor, and will not want to be alone. B) The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone. C) The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief. D) Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time. Page Ref: 444 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

22) During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? A) Turn the client onto her left side. B) Place the bed in Trendelenburg position. C) Massage the fundus. D) Continue to monitor. Answer: D Explanation: A) A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. B) The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. C) The uterus should be midline and firm; massage is not necessary. D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia. Page Ref: 449 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

23) The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? A) Weak B) Mild C) Moderate D) Strong Answer: D Explanation: A) Weak contractions are not identified. B) If the uterine wall can be indented easily, the contraction is considered mild. C) Moderate intensity falls between these two ranges. When intensity is measured with an intrauterine catheter, the normal resting tonus (between contractions) is about 10 to 12 mmHg of pressure. During acme the intensity ranges from 25 to 40 mmHg in early labor, 50 to 70 mmHg in active labor, 80 to 100 mmHg during transition, and greater than 100 mmHg while the woman is pushing in the second stage. D) Strong intensity exists when the uterine wall cannot be indented. Page Ref: 437 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Describe the physiology of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

24) The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? A) Client at 5 cm requesting labor epidural analgesia B) Client whose cervix remains at 6 cm for 4 hours C) Client who has developed nausea and vomiting D) Client requesting her partner to stay with her Answer: B Explanation: A) Contacting the supervisor is required when an abnormal situation is present. Requests for medication are not abnormal. B) Average cervical change in the active phase of the first stage of labor is 1.2 cm/hour; thus, this client's lack of cervical change is unexpected, and should be reported to the supervisor. C) Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation is present. D) Clients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present. Page Ref: 444 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II. B. 9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

25) Which client requires immediate intervention by the labor and delivery nurse? A) Client at 8 cm, systolic blood pressure has increased 35 mmHg B) Client who delivered 1 hour ago with WBC of 50,000/mm3 C) Client at 5 cm with a respiratory rate of 22 between contractions D) Client in active labor with polyuria Answer: B Explanation: A) In the first stage, systolic pressure may increase by 35 mmHg, and there may be further increases in the second stage during pushing efforts. B) The white blood cell (WBC) count increases to between 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification. C) Oxygen demand and consumption increase at the onset of labor because of the presence of uterine contractions. This client requires no further intervention. D) Polyuria is common during labor. This results from the increase in cardiac output, which causes an increase in the glomerular filtration rate and renal plasma flow, and requires no further intervention. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Summarize maternal systemic responses to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

26) The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? A) Increased pulse B) Elevated blood pressure C) Muscle tension D) Increased respirations Answer: C Explanation: A) Increased pulse is a manifestation of pain, but does not impede labor. B) Elevated blood pressure is a manifestation of pain, but does not impede labor. C) It is important for the woman to relax each part of her body. Be alert for signs of muscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process. D) Increased respiration is a manifestation of pain, but does not impede labor. Page Ref: 428 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Summarize maternal systemic responses to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

27) While caring for a client in labor, the nurse notices during a vaginal exam that the fetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be? A) Flexion, extension, restitution, external rotation, and expulsion B) Expulsion, external rotation, and restitution C) Restitution, flexion, external rotation, and expulsion D) Extension, restitution, external rotation, and expulsion Answer: D Explanation: A) The next set of cardinal movements would not begin with flexion. B) This is not the correct order of fetal position changes. C) This is not the correct order of fetal position changes. D) The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. Page Ref: 445 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

28) When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are what? A) Both are approximately the same size. B) Both close within 12 months of birth. C) Both are used in labor to identify station. D) Both allow for assessing the status of the newborn after birth. Answer: D Explanation: A) The anterior fontanelle measures approximately 2-3 cm. The posterior fontanelle is much smaller. B) The anterior fontanelle closes around the 18th month. The posterior fontanelle closes between 8 and 12 weeks after birth. C) In labor, the presenting part, not the fontanelles, is used to identify station. D) The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth. Page Ref: 432 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

29) The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? A) Right-acromion-dorsal-anterior B) Right-sacrum-transverse C) Occiput anterior D) Posterior position Answer: D Explanation: A) Right-acromion-dorsal-anterior denotes a fetal position in a shoulder presentation, which would be a difficult delivery. B) Right-sacrum-transverse indicates a breech delivery, which would be a difficult delivery. C) The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally. D) The fetal head presents a larger diameter in a posterior position than in an anterior position. A posterior position increases the pressure on the maternal sacral nerves, causing the laboring woman to experience backache and pelvic pressure. Page Ref: 436 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

30) The midwife performs a vaginal exam and determines that the fetal head is at a -2 station. What does this indicate to the nurse about the birth? A) The birth is imminent. B) The birth is likely to occur in 1-2 hours. C) The birth will occur later in the shift. D) The birth is difficult to predict. Answer: D Explanation: A) Birth is not imminent at this time. B) Birth will not likely occur in 1-2 hours. C) Birth cannot really be predicted at this time. D) A -2 station means that the fetus is 2 cm above the ischial spines. The ischial spines as a landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. With the fetus's head that high in the pelvis, it is difficult to predict when birth will occur. Page Ref: 436 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

31) Childbirth preparation offers several advantages including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) It helps a pregnant woman and her support person understand the choices in the birth setting. B) It promotes awareness of available options. C) It provides tools for a pregnant woman and her support person to use during labor and birth. D) Women who receive continuous support during labor require more analgesia, and have more cesarean and instrument births. E) Each method has been shown to shorten labor. Answer: A, B, C, E Explanation: A) Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. B) Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. C) Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. D) This is not true. Women who receive continuous support during labor require less analgesia, and have fewer cesarean and instrument births. E) Childbirth preparation offers several advantages. Each method has been shown to shorten labor. Page Ref: 428 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Compare methods of childbirth preparation. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

32) The nurse is reviewing educational material on newborn care with a patient in the 3rd trimester of pregnancy. Which area on the following diagram should the nurse point out as being the anterior fontanelle?

A) A B) B C) C D) D Answer: C Explanation: C) The greater, or anterior, fontanelle (bregma) is diamond shaped, measures 2 to 3 cm, and is situated at the junction of the sagittal, coronal, and frontal sutures. It permits growth of the brain by remaining unossified for as long as 18 months. Choice 1 is the posterior fontanelle. Choice 2 is the sagittal suture. Choice 4 is the frontal suture. Page Ref: 432 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Compare methods of childbirth preparation. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

33) The fetus of a patient in labor is determined to be in the brow presentation. Which diagram should the nurse provide to the patient to explain this position? A)

Answer: C Explanation: C) In the brow presentation, the fetal head is in partial (halfway) extension. The occipitomental diameter, which is the largest diameter of the fetal head, presents to the pelvis. Choice 1 is the vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis. Choice 2 is the Sinciput (median vertex) presentation (also called military presentation) with no flexion or extension. The occipitofrontal diameter presents to the pelvis. Choice 4 is the face presentation. The fetal head is in complete extension, and the submentobregmatic diameter presents to the pelvis. Page Ref: 435 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

34) A pregnant patient's fetus is in the left-occiput-transverse position. Which diagram should the nurse use to explain this position to the patient? A)

Answer: A Explanation: A) Choice 1 is the LOT or left-occiput-transverse position. Choice 2 is the LOP or left-occiput-posterior position. Choice 3 is the ROT or right-occiput-transverse position. Choice 4 is the LOA or left-occiput-anterior position. Page Ref: 436 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Describe fetal adaptations to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

35) The cervix of a laboring patient is measured as being 50% effaced. Which diagram should the nurse use to explain this finding to the patient? A)

Answer: C Explanation: C) The cervix is about one half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. Choice 1 is the beginning of labor, where there is no cervical effacement or dilation. The fetal head is cushioned by amniotic fluid. Choice 2 is the beginning of cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. Choice 4 is complete effacement and dilation. Page Ref: 441 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Describe fetal adaptations to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

36) The nurse is assisting in the delivery of a pregnant patient's placenta post-delivery. The placenta appears as follows. What term should the nurse use to document this placental delivery?

A) Schultz mechanism of delivery B) Duncan mechanism of delivery C) Complete mechanism of delivery D) Incomplete mechanism of delivery Answer: B Explanation: B) If the placenta separates from the outer margins inward, it will roll up and present sideways with the maternal surface delivering first. This is known as the Duncan mechanism of placental delivery and is commonly called dirty Duncan because the placental surface is rough. If the placenta separates from the inside to the outer margins, it is expelled with the fetal (shiny) side presenting. This is known as the Schultze mechanism of placental delivery or, more commonly, shiny Schultze. This diagram does not demonstrate complete or incomplete mechanisms of placental delivery. Page Ref: 448 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Relationship-Centered Care: Knowledge; effective communication. | Nursing/Integrated Concepts: Implementation: Communication and Documentation. Learning Outcome: 7 Describe the physiologic and psychosocial changes that are indicative of the maternal progress during each of the stages of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 20 Intrapartum Nursing Assessment 1) The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status? A) "How did you decide to have your baby at this hospital?" B) "Who will be your labor support person?" C) "Have you chosen names for your baby yet?" D) "What feeding method will you use for your baby?" Answer: B Explanation: A) The reason the client is delivering at this facility is not an indication of psychosocial status. B) The expectant mother's partner or support person is an important member of the birthing team, and assessments of the couple's coping, interactions, and teamwork are integral to the nurse's knowledge base. The nurse's physical presence with the laboring woman provides the best opportunity for ongoing assessment. C) Naming the infant is influenced by culture, and is not an indicator of psychosocial status. D) The chosen feeding method is not an indicator of psychosocial status. Page Ref: 456 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

2) The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? A) Blood pressure 120/88 B) Father a carrier of sickle-cell trait C) Dark red vaginal bleeding D) History of domestic abuse Answer: C Explanation: A) Although the diastolic reading is slightly elevated, this blood pressure reading is not the top priority. B) The infant also might have sickle-cell trait, but it is not life-threatening at this time. C) Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus. D) This client is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the client. Page Ref: 458 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

3) The nurse is reviewing the FHR monitor for a client in labor. The rhythm strip yields the following result: How should the nurse interpret this pattern? A) Moderate variability B) Minimal variability C) Absent variability D) Marked variability Answer: A Explanation: A) The pattern demonstrates Moderate FHR variability (normal) with an amplitude range of 6 to 25 beats/minute. B) Minimal variability refers to a FHR with an amplitude range detectable but 5 beats/minute or less. C) Absent variability refers to a pattern with no detectable amplitude range. D) Marked variability refers to a pattern with an amplitude range greater than 25 beats/minute. Page Ref: 484 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Discuss fetal heart rates and patterns using National Institute of Child Health and Human Development (NICHD) terminology. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

4) While caring for a client in labor, the nurse notes the following FHR pattern: Which action should the nurse perform? A) Continue to monitor the client B) Fetal scalp stimulation C) Palpate contraction strength D) Discontinue oxytocin Answer: A Explanation: A) This is a benign finding; there is no slowing of fetal heart rate with contractions. B) Fetal scalp stimulation is not indicated based on this finding. C) Contraction strength assessment is not indicated based on this finding. D) Discontinuing oxytocin should not be performed based on this finding. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Discuss fetal heart rates and patterns using National Institute of Child Health and Human Development (NICHD) terminology. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

5) The nurse is caring for a client undergoing fetal heart rate monitoring, and the FHR is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal anxiety B) Fetal asphyxia C) Prematurity D) Fetal anemia E) Maternal hypotension Answer: A, B, C, D Explanation: A) Maternal anxiety may result in fetal tachycardia. B) Fetal asphyxia may result in fetal tachycardia. C) Prematurity may result in fetal tachycardia. D) Fetal anemia may result in fetal tachycardia. E) Maternal hypotension may result in fetal bradycardia, not fetal tachycardia. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Examine the differences between fetal tachycardia and fetal bradycardia. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

6) The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus? A) Infection B) Umbilical cord compression C) Vagus nerve stimulation D) Hypoxemia Answer: A Explanation: A) Infection is one of the most common causes of fetal tachycardia. B) Umbilical cord compression may result in bradycardia, not tachycardia. C) Vagus nerve stimulation may result in bradycardia, not tachycardia. D) Hypoxemia may result in bradycardia, not tachycardia. Page Ref: 482 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Examine the differences between fetal tachycardia and fetal bradycardia. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

7) The nurse is caring for a client who has experienced premature rupture of membranes. For which maternal implication(s) should the nurse monitor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Infection B) Preterm labor C) Dyspnea D) Discomfort E) Uterine distention Answer: A, B Explanation: A) Premature rupture of membranes places the client at an increased risk for infection. B) Premature rupture of membranes places the client at an increased risk for preterm labor. C) Hydramnios, not premature rupture of membranes, increases dyspnea. D) Hydramnios, not premature rupture of membranes, increases discomfort. E) Multiple gestation, not premature rupture of membranes, increases uterine distention. Page Ref: 459 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss the outer limits of normal progress of each of the phases and stages of labor. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

8) The nurse is assessing the baseline fetal heart rate for a client in labor. What action should the nurse take first? A) Measure the fetal heart rate for 10 minutes B) Round the heart rate to increments of 5 beats/minute C) Exclude periods of marked variation D) Calculate the mean (average) heart rate Answer: A Explanation: A) The first action the nurse should take is measuring the fetal heart rate for 10 minutes. B) The nurse should round the fetal heart rate to increments of 5 beats/minute after taking a 10minute measurement of the fetal heart rate. C) The nurse should exclude periods of marked variation after taking a 10-minute measurement of the fetal heart rate. D) The nurse should calculate the mean (average) heart rate after taking a 10-minute measurement of the fetal heart rate. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Explain the steps to be performed in the systematic evaluation of fetal heart rate tracings. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

9) While caring for a client in labor, the nurse notes the following persistent rhythm on the fetal heart rate monitor: Which action should the nurse take first? A) Notify the provider. B) Prepare for expedient delivery. C) Reposition the client. D) Discontinue oxytocin therapy. Answer: A Explanation: A) The fetal heart rate monitor demonstrates a persistent sinusoidal pattern. The provider should be notified immediately. B) Expeditious birth of the baby is a priority after the healthcare provider is notified. C) Repositioning the client is not the immediate action that should be taken to address a persistent sinusoidal pattern. D) Discontinuing oxytocin therapy is not the immediate action that should be taken to address a persistent sinusoidal pattern. Page Ref: 483 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Explain the steps to be performed in the systematic evaluation of fetal heart rate tracings. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

10) The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? A) Woman at 7 cm, fetal heart tones auscultated every 90 minutes B) Woman at 10 cm and pushing, external fetal monitor applied C) Woman with meconium-stained fluid, internal fetal scalp electrode in use D) Woman in preterm labor, external monitor in place Answer: A Explanation: A) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough. B) External monitoring can be done instead of auscultation of the fetal heart tones during labor. C) Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. D) External monitoring during preterm labor will assess both contractions and fetal status. Page Ref: 469 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

11) The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? A) "The monitor is necessary so we can see how your labor is progressing." B) "The monitor will prevent complications from the meconium in your fluid." C) "The monitor helps us to see how the baby is tolerating labor." D) "The monitor can be removed, and oxygen given instead." Answer: C Explanation: A) The fetal monitor does not help visualize labor progress. B) The fetal monitor does not prevent complications such as meconium aspiration syndrome. C) Electronic fetal monitoring (EFM) provides a continuous tracing of the fetal heart rate (FHR), allowing characteristics of the FHR to be observed and evaluated. D) Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Page Ref: 478 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively: listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

12) The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? A) Mild B) Moderate C) Strong D) Weak Answer: C Explanation: A) The consistency of mild contractions is similar to that of the nose. B) The consistency of moderate contractions is similar to that of the chin. C) The consistency of strong contractions is similar to that of the forehead. D) Weak contractions are not identified. Page Ref: 470 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

13) Before performing Leopold maneuvers, what would the nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Have the client empty her bladder. B) Place the client in Trendelenburg position. C) Have the client lie on her back with her feet on the bed and knees bent. D) Turn the client to her left side. E) This is not the optimal position for the client when performing Leopold maneuvers. Answer: A, C Explanation: A) The woman should have recently emptied her bladder before performing Leopold maneuvers. B) Placing the client in Trendelenburg position is not consistent with accurately performing Leopold maneuvers. C) The woman should lie on her back with her abdomen uncovered. To aid in relaxation of the abdominal wall, the shoulders should be raised slightly on a pillow and the knees drawn up a little. D) Placing the client on her left side is not consistent with accurately performing Leopold maneuvers. Page Ref: 473 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

14) The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? A) The client is assisted into supine position, and the position of the fetus is assessed. B) The upper portion of the uterus is palpated, then the middle section. C) After determining where the back is located, the cervix is assessed. D) Following voiding, the client's abdomen is palpated from top to bottom. Answer: C Explanation: A) Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation. B) This is the correct order of the first and second Leopold maneuvers. C) The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers. D) The client is instructed to void prior to beginning Leopold maneuvers to enhance comfort. Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix. Page Ref: 473 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team. | AACN Essentials Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

15) The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? A) Perform Leopold maneuvers to determine fetal position. B) Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (UC). C) Dry the maternal abdomen before using the Doppler. D) The diaphragm should be cooled before using the Doppler. Answer: A Explanation: A) Performing Leopold maneuvers is the first step. B) This is how to auscultate the fetal heart rate, but it is not the first step in assessment. C) Prior to using the Doppler device, a water-based gel is applied to the skin. D) The diaphragm should be warmed before using the Doppler. Page Ref: 474 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

16) After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? A) Breech presentation B) Uteroplacental insufficiency C) Compression of the fetal head D) Umbilical cord compression Answer: D Explanation: A) Breech presentations by themselves do not cause decelerations. B) Uteroplacental insufficiency causes late decelerations. C) Early decelerations occur with fetal head compression. D) Variable decelerations occur when there is umbilical cord compression. Page Ref: 483 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

17) The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? A) Inform the maternal client that the rate is normal. B) Reassess the FHR in 5 minutes because the rate is low. C) Report the FHR to the doctor immediately. D) Turn the maternal client on her side and administer oxygen. Answer: A Explanation: A) A fetal heart rate of 112 beats/min. falls within the normal range of 110-160 beats/min., so there is no need to inform the doctor. B) There is no need to reassess later. C) There is no need to inform the doctor. D) There is no need to reposition the client. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

18) Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Early fetal hypoxia B) Prolonged fetal stimulation C) Fetal anemia D) Fetal sleep cycle E) Infection Answer: A, B, C, E Explanation: A) Early fetal hypoxia can cause fetal tachycardia. B) Prolonged fetal stimulation can cause fetal tachycardia. C) Fetal anemia can cause fetal tachycardia. D) The fetal sleep cycle does not cause fetal tachycardia. E) Infection can cause fetal tachycardia. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

19) Persistent early decelerations are noted. What would the nurse's first action be? A) Turn the mother on her left side and give oxygen. B) Check for prolapsed cord. C) Do nothing. This is a benign pattern. D) Prepare for immediate forceps or cesarean delivery. Answer: C Explanation: A) Early decelerations do not require any intervention. B) Early decelerations do not indicate a prolapsed cord. C) Early decelerations are considered benign, and do not require any intervention. D) Early decelerations do not warrant an immediate delivery. Page Ref: 487 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

20) The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? A) Document the fetal heart rate. B) Apply oxygen via mask at 10 liters. C) Prepare for imminent delivery. D) Assist the client into Fowler's position. Answer: A Explanation: A) The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. B) No oxygen is necessary. C) There is no indication that delivery will be occurring soon. D) There is no need to put the client in Fowler's position. Page Ref: 487 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

21) A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? A) Change the client's position in bed. B) Notify the physician that birth is imminent. C) Administer oxygen at 2 liters per minute. D) Begin continuous fetal heart rate monitoring. Answer: D Explanation: A) Changing the client's position is not indicated. B) Meconium-stained amniotic fluid does not indicate that birth is imminent. C) Oxygen administration is not indicated. D) Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring. Page Ref: 463 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

22) A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? A) "The most important part of fetal heart monitoring is the absence of variable decelerations." B) "The most important part of fetal heart monitoring is the presence of variability." C) "The most important part of fetal heart monitoring is the fetal heart rate baseline." D) "The most important part of fetal heart monitoring is the depth of decelerations." Answer: B Explanation: A) Variable decelerations indicate cord compression. B) Baseline variability is a reliable indicator of fetal cardiac and neurologic function, and overall well-being. The opposing "push-pull" balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the FHR. C) The fetal heart rate baseline does not indicate central nervous system function. D) The depth of decelerations does not indicate central nervous system function. Page Ref: 484 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Differentiate between baseline and periodic changes in the fetal heart rate. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

23) The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? A) Assist the client to change position. B) Apply oxygen to the client at 2 liters per nasal cannula. C) Notify the operating room of the need for a cesarean birth. D) Determine the color of the leaking amniotic fluid. Answer: A Explanation: A) The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava. B) A nasal cannula is rarely used in labor and birth. C) There is no indication that a cesarean delivery is needed. D) There is no indication that the amniotic fluid is meconium-stained or bloody. Page Ref: 488 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Evaluate abnormal findings on a fetal heart rate tracing. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

24) Fetal factors that possibly indicate electronic fetal monitoring include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Meconium passage B) Multiple gestation C) Preeclampsia D) Grand multiparity E) Decreased fetal movement Answer: A, B, E Explanation: A) Meconium passage is an indicator for electronic fetal monitoring. B) Multiple gestation is an indicator for electronic fetal monitoring. C) Preeclampsia is a maternal indicator for electronic fetal monitoring. D) Grand multiparity is a maternal indicator for electronic fetal monitoring. E) Decreased fetal movement is an indicator for electronic fetal monitoring. Page Ref: 480 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

25) The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? A) Early decelerations with each contraction B) Variable decelerations that recover to the baseline C) Late decelerations with minimal variability D) Accelerations Answer: C Explanation: A) Early decelerations are usually benign. B) Variable decelerations indicate cord compression, but those that recover to the baseline indicate that the fetus is tolerating the decelerations. C) Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention. D) Accelerations of the fetal heart rate indicate good oxygen reserve. Page Ref: 488 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Explain the interventions that are indicated when a nonreassuring fetal heart rate pattern is identified. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

26) The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? A) Moderate variability B) Early decelerations C) Late decelerations D) Accelerations Answer: D Explanation: A) Normal FHR variability is in the moderate range. B) Early deceleration is usually considered benign. C) Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign. D) Accelerations are thought to be a sign of fetal well-being. Page Ref: 488 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Explain the interventions that are indicated when a nonreassuring fetal heart rate pattern is identified. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

27) After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? A) Increase the mother's oxygen rate. B) Turn the mother to the left lateral position. C) Prepare the mother for a higher-risk delivery. D) Increase the intravenous infusion rate. Answer: D Explanation: A) Use of oxygen is not a nursing action that would change the status of the depressed fetus. B) Position change to the left side is not a nursing action that would change the status of the depressed fetus. C) Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk. D) Increasing the IV rate is not a nursing action that would change the status of the depressed fetus. Page Ref: 493 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

28) The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? A) Late decelerations B) Early decelerations C) Accelerations D) Fetal dysrhythmia Answer: C Explanation: A) Late decelerations indicate uteroplacental insufficiency. B) Early decelerations are indicative of head compression. C) A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the FHR. D) Fetal dysrhythmia is associated with complete heart block in the fetus. Page Ref: 493 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

29) The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? A) "I stimulated the top of the fetus's head to wake him up a little." B) "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." C) "I stimulated the top of the fetus's head to calm the fetus down before birth." D) "I stimulated the top of the fetus's head to find out whether he is in distress." Answer: B Explanation: A) Waking the fetus is not the goal or outcome of fetal scalp stimulation. B) Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being. C) Calming the fetus is not the goal or outcome of fetal scalp stimulation. D) The nurse wants to assess what the fetus does with stimulation. Page Ref: 493 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Describe the steps used to perform fetal scalp stimulation. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

30) During an intrapartum vaginal examination the nurse palpates the following:

Based upon this information, which diagram best describes the fetal descent and station? A)

Answer: C Explanation: C) When the posterior fontanelle is in the upper right quadrant of the maternal pelvis, the fetus is in the right occiput anterior (ROA) position. Choice 1: When the fetus is in left occiput anterior (LOA) position, the posterior fontanelles are in the upper left quadrant of the maternal pelvis. Choice 2: When the fetus is in the left occiput posterior (LOP) position, the posterior fontanelle is in the lower left quadrant of the maternal pelvis. Choice 4: When the fetus is in the right occiput posterior (ROP) position, the posterior fontanelle is in the lower right quadrant of the maternal pelvis. Page Ref: 472 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 1 Describe the intrapartum physical, psychosocial, and cultural assessments necessary for optimum maternal-fetal outcome. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

31) The fetus of a laboring patient is in the following position:

What should the nurse expect when conducting the intrapartum vaginal examination? A)

Answer: D Explanation: D) The head has completed internal rotation. The cervix is fully dilated. In Choice 1, the fetus is at station 0 with the head engaged at the spine and a significant amount of cervix that has not yet dilated. In Choice 2, the fetus is engaged at station +2 as the cervix is thinner and more of the fetal head can be palpated. In Choice 3. the fetus is engaged at station +4 with the posterior fontanelle towards the maternal left pelvis. Page Ref: 473 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Discuss the outer limits of normal progress of each of the phases and stages of labor. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

32) The nurse is performing Leopold maneuvers with a patient in the 3rd trimester of pregnancy. Which maneuver should the nurse perform first? A)

Answer: B Explanation: B) For the first maneuver, while facing the woman, the nurse palpates the upper abdomen with both hands. Choice 1 is the second maneuver, where the nurse tries to determine the location of the fetal back and notes whether it is on the right or left side of the maternal abdomen. Choice 3 is the third maneuver, where the nurse determines what fetal part is lying above the inlet by gently grasping the lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the right hand. Choice 4 is the fourth maneuver, where the nurse faces the woman's feet and attempts to locate the cephalic prominence or brow. Location of this landmark assists in assessing the descent of the presenting part into the pelvis. The fingers of both hands are moved gently down the sides of the uterus toward the pubis. Page Ref: 475 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 4 Describe the procedure for performing Leopold maneuvers and the information they provide. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

33) The fetus of a pregnant patient is in the right occiput anterior (ROA) position. Where should the nurse auscultate the fetal heart sounds?

A) A B) B C) C D) D Answer: C Explanation: C) The heart tones for the right occiput anterior position would be in the maternal lower right quadrant next to the symphysis pubis. Choice 1 is the location to auscultate sounds if the fetus is in the left occiput posterior position. Choice 2 is the location to auscultate sounds if the fetus is in the left occiput anterior position. Choice 4 is the location to auscultate sounds if the fetus is in the right occiput posterior position. Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Compare the various methods of monitoring fetal heart rate and contractions, giving advantages and disadvantages of each. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period. 37 Copyright © 2020 Pearson Education, Inc.

34) A laboring patient being monitored has the following rhythm strip:

How should the nurse interpret this finding? A) Early decelerations B) Periodic accelerations C) Episodic accelerations D) Variable decelerations with overshoot Answer: C Explanation: C) Episodic accelerations are not associated with contractions and tend to be more peaked and abrupt. They are often associated with fetal movement, stimulation, or an environmental stimulus. Episodic accelerations are reassuring FHR patterns, whether or not they are accompanied by fetal movement. Early decelerations are a visually apparent, usually symmetrical, gradual decrease and return of the FHR associated with a uterine contraction. Periodic accelerations are associated with uterine contractions. When they occur on a repetitive basis, they may be smooth in configuration, multiphasic, and may precede variable decelerations. In variable decelerations with overshoot, the timing of the decelerations is variable, and most have a sharp decline. Rebound accelerations (overshoot) occur after most of the decelerations. Page Ref: 486 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 9 Evaluate abnormal findings on a fetal heart rate tracing. MNL LO: Demonstrate ability to perform assessment and interpret data for a patient during the intrapartum period.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 21 The Family in Childbirth: Needs and Care 1) The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? A) Fear/Anxiety related to discomfort of labor and unknown labor outcome B) Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent C) Coping: Family, Compromised, related to labor process D) Knowledge, Deficient, related to lack of information about normal labor process and comfort measures Answer: B Explanation: A) The client is not exhibiting fear or anxiety, but acute pain; therefore, this diagnosis does not fit. B) The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor. C) There is no evidence regarding the family's coping, only the client's coping with the pain. D) The client used breathing and relaxation techniques earlier in labor, demonstrating knowledge of these techniques. Page Ref: 498 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 1 Identify nursing diagnoses specific to the first, second, third, and fourth stages of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

2) A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? A) Latent phase B) Active phase C) Transition phase D) Fourth stage Answer: C Explanation: A) This is not the latent phase; in the latent phase of labor, contractions are every 10-20 minutes, 15-20 seconds' duration progressing to every 5-7 minutes, and 30-40 seconds' duration. Dilatation is 1-3 cm. B) This is not the active phase; in the active phase of labor, contractions are every 2-3 minutes with a dilatation of 4-7 cm. C) The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense. D) The fourth stage occurs after delivery of the placenta. Page Ref: 504 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

3) The nurse is assessing the comfort of the parents during the third stage of labor. Which finding(s) indicate that the parents feel comfortable during this stage? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Talking to the newborn B) Verbally expressing feelings of pride C) Requesting to dim the lights D) Preferring limited contact with the newborn initially E) Immediately placing phone calls Answer: A, B Explanation: A) Talking to the newborn and verbally expressing feelings of pride are indications that the parents feel comfortable in the environment. B) Talking to the newborn and verbally expressing feelings of pride are indications that the parents feel comfortable in the environment. C) Requesting to dim the lights does not necessarily indicate whether or not the parents feel comfortable in the environment. D) The parents may prefer to limit contact with the newborn initially, and it is important for the nurse to support the wishes of the parent. However, this does not necessarily indicate whether or not the parents feel comfortable in the environment. E) Immediately placing phone calls after the newborn is delivered does not necessarily indicate whether or not the parents feel comfortable in the environment. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the components of care for the woman during the third stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

4) The nurse is caring for a client and her spouse during the third stage of labor. Which action(s) support initial parental-newborn attachment at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Minimizing assessments B) Delaying ophthalmic antibiotics for 2 hours C) Dimming the room lights D) Talking quietly E) Providing privacy Answer: A, C, D, E Explanation: A) Minimizing assessments enhances parental newborn attachment during this time. B) Ophthalmic antibiotics may be delayed during the first hour, but not up to 2 hours. C) Dimming the room lights enhances parental-newborn attachment during this time. D) Talking quietly enhances parental-newborn attachment during this time. E) Providing privacy enhances parental-newborn attachment during this time. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Discuss initial measures to help the woman and family integrate the newborn into family life. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

5) The nurse is assessing the emotional state of a client following the delivery of her newborn. Which response by the client requires further follow up by the nurse? A) Excitability B) Crying C) Quiet D) Withdrawn Answer: D Explanation: A) The emotional response to birth varies, and excitability is considered a normal finding. B) The emotional response to birth varies, and crying is considered a normal finding. C) The emotional response to birth varies, and being quiet is considered a normal finding. D) Being withdrawn is not considered a normal emotional response to delivery of a newborn, and requires further follow up by the nurse. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Discuss initial measures to help the woman and family integrate the newborn into family life. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

6) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Fetal heart rate of 130 with average variability B) Blood pressure of 130/80 C) Maternal pulse of 160 D) Protein of +1 in urine E) Odorless, clear fluid on underwear Answer: A, B, E Explanation: A) Fetal heart rate (FHR) of 110-160 with average variability is a normal indication. B) Maternal vital sign of blood pressure below 140/90 is a normal indication. C) A pulse of 60-100 is a normal indication. D) Proteinuria of +1 or more could be a sign of preeclampsia. E) Fluid clear and without odor if membranes ruptured is a normal indication. Page Ref: 500 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

7) The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching? A) "The fetus's heart rate will vary between 110 and 160." B) "The heart rate is monitored to see whether the fetus is tolerating labor." C) "By listening to the heart, we can tell the gender of the fetus." D) "After listening to the heart rate, you will contact the midwife." Answer: C Explanation: A) A normal fetal heart rate is 110-160. B) The fetal heart rate (FHR) is auscultated every 30 minutes. It should remain between 110 and 160 beats per minute (beats/min) without the presence of decelerations. C) Fetal heart rate is not a predictor of gender. D) Once the admission is complete, the nurse will contact the client's provider with the assessment findings. Page Ref: 500 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

8) The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? A) The sterile vaginal exam B) Welcoming the couple C) Auscultation of the fetal heart rate D) Checking for ruptured membranes Answer: B Explanation: A) The sterile vaginal exam should be performed after maternal vital signs have been assessed. B) It is important to establish rapport and to create an environment in which the family feels free to ask questions. The support and encouragement of the nurse in maintaining a caring environment begins with the initial admission. C) The fetal heart rate should be listened to after the client is made comfortable. D) Assessing for intact or ruptured membranes is a part of the admission assessment after the client is made comfortable. Page Ref: 507 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe factors that are assessed in the laboring woman during the admission process. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

9) An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be which of the following? A) Insist that he leave the room for at least the next hour. B) Tell him he is not being as effective as he was, and that he needs to let someone else take over. C) Offer to remain with his partner while he takes a break. D) Suggest that the client's mother might be of more help. Answer: D Explanation: A) Insisting that the father leave does not reassure him about the care the woman will receive in his absence. B) Telling him that he is ineffective does not reassure him about the care the woman will receive in his absence. C) Support persons frequently are reluctant to leave the laboring woman to take care of their own needs. The laboring woman often fears being alone during labor. Even though there is a support person available, the woman's anxiety may be decreased when the nurse remains with her while he takes a break. D) Suggesting that the client's mother take his place does not reassure him about the care the woman will receive in his absence. Page Ref: 527 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

10) By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? A) Recognizing the client as an active participant in her own care. B) Attempting to correct any misinformation the client might have received. C) Acting as an advocate for the client. D) Establishing rapport with the client. Answer: A Explanation: A) Understanding the couple's expectations and plans helps the nurse provide optimal nursing care and facilitate the best possible birth experience. B) Any misinformation the family has can be corrected, but that is not the primary focus. C) The nurse might use the information about plans and expectations to act as an advocate for the client as the labor progresses, but this is not the primary rationale for inquiring about them. D) Rapport and a therapeutic relationship are important for all nurse-client interactions, but are not best addressed by asking about plans and expectations for the birth. Page Ref: 499 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Summarize the importance of incorporating family expectations and cultural beliefs into the nursing care plan. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

11) The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "These questions are asked of all women. It's no big deal." B) "I'd prefer that your partner ask me all the questions, not you." C) "A client's preferences for her birth are important for me to understand." D) "Many women have beliefs about childbearing that affect these choices." E) "I'm gathering information that the nurses will use after the birth." Answer: C, D Explanation: A) Although this information is asked of all clients, it is purposefully gathered. B) It is not therapeutic communication to tell the partner not to ask questions. C) The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth. D) The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth. E) The information gathered will be used during the labor and birth, not after delivery. Page Ref: 502 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Summarize the importance of incorporating family expectations and cultural beliefs into the nursing care plan. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

12) The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? A) Check fetal heart tones. B) Encourage the mother to go for a walk. C) Change bed linens. D) Call the physician. Answer: A Explanation: A) When the membranes rupture, the nurse notes the color and odor of the amniotic fluid and the time of rupture and immediately auscultates the FHR. B) If there has been a rupture of membranes, the laboring client should not be allowed to walk. C) The bed linens can be changed after assessing the heart rate. D) The physician does not need to be called after rupture of the membranes unless there is a change in the status of the fetus or client. Page Ref: 503 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

13) The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? A) Encourage the husband to remain in the room. B) Keep the client on bed rest at this time. C) Apply an internal fetal scalp electrode. D) Obtain a clean-catch urine specimen. Answer: B Explanation: A) It is unknown from the given information whether it is culturally appropriate for the client's husband to remain in the room for the labor and birth. B) Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse. C) An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This client has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present. D) A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid contamination might falsely increase the reading of protein present. Page Ref: 506 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

14) The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client? A) Encourage the client to vocalize during contractions. B) Perform vaginal exams only between contractions. C) Provide a CD of soft music with sounds of nature. D) Offer to teach the partner how to massage tense muscles. Answer: D Explanation: A) Some clients want to vocalize during labor, and some vocalize only when they perceive that they are losing control. The client should determine whether vocalization is desirable for her. B) Vaginal exams are performed between contractions for all laboring clients in order to decrease discomfort. C) The nurse should ask the client what type of music she would like to listen to instead of making assumptions. D) Massage is helpful for many clients, especially during latent and active labor. Massage can increase relaxation and therefore decrease tension and pain. Page Ref: 508 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Discuss nursing interventions to meet the care needs of the laboring woman and her partner during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

15) The nurse is reviewing the contents of the birthing unit's emergency pack for use in case of a precipitous birth. Which item(s) should the nurse ensure is (are) included in the pack? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Sterile drape B) Bulb syringe C) Two sterile clamps D) Sterile gloves E) Forceps Answer: A, B, C, D Explanation: A) A small drape is included that can be placed under the woman's buttocks to provide a sterile field. B) A bulb syringe is needed to clear mucus from the newborn's mouth. C) Two sterile clamps (Kelly or Rochester) are needed to clamp the umbilical cord before applying a cord clamp. D) Sterile gloves are a basic element of a typical birthing unit emergency pack. E) Forceps are not required during a precipitous birth. Page Ref: 525 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 11 Delineate management of a nurse-managed precipitous labor and birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

16) Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? A) Massage the fundus until firm B) Express retained clots C) Increase the intravenous solution D) Call the physician Answer: A Explanation: A) When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm. B) Expressing retained clots is not the nurse's first action. C) Increasing the intravenous solution is not a priority in this case. D) The physician does not need to be notified unless either the uterus does not respond to massage or the bleeding does not decrease. Page Ref: 521 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

17) Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently? A) A full bladder impedes oxygen flow to the fetus. B) Frequent voiding prevents bruising of the bladder. C) Frequent voiding encourages sphincter control. D) A full bladder can impede fetal descent. Answer: D Explanation: A) Oxygen flow to the fetus is not impacted by a full bladder. B) Frequent voiding has nothing to do with bruising of the bladder. C) Frequent voiding has nothing to do with sphincter control. D) The woman should be encouraged to void because a full bladder can interfere with fetal descent. If the woman is unable to void, catheterization may be necessary. Page Ref: 504 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth. 18) The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? A) Hyperventilation B) Seizure auras C) Imminent birth D) Anxiety Answer: A Explanation: A) These symptoms all are consistent with hyperventilation. B) Seizure auras do not have these symptoms. C) Imminent birth does not have these symptoms. D) Anxiety does not have these symptoms. Page Ref: 508 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth. 17 Copyright © 2020 Pearson Education, Inc.

19) A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful? A) Talk to the client the entire time. B) Turn on the television to distract the client. C) Stand next to the bed with hands on the railing next to the client. D) Sit silently in the room away from the bed. Answer: C Explanation: A) Talking might irritate the client. B) Turning on the television might irritate the client. C) Standing next to the bed is supportive without being irritating. The laboring woman fears being alone during labor. The woman's anxiety may be decreased when the nurse remains with her. D) Sitting silently away from the client can lead to her feeling abandoned. Page Ref: 527 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

20) The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done? A) To contract the uterus and minimize bleeding B) To decrease breast milk production C) To decrease maternal blood pressure D) To increase maternal blood pressure Answer: A Explanation: A) Oxytocin is given to contract the uterus and minimize bleeding. B) Oxytocin does not have an effect on breast milk production. C) Oxytocin does not have an effect on maternal blood pressure. D) Oxytocin does not have an effect on maternal blood pressure. Page Ref: 520 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety, and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

21) A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? A) A soaked perineal pad since the last 15-minute check B) An edematous perineum C) The client experiencing tremors D) A fundus located at the umbilicus Answer: A Explanation: A) If the perineal pad becomes soaked in a 15-minute period, or if blood pools under the buttocks, continuous observation is necessary. As long as the woman remains in bed during the first hour, bleeding should not exceed saturation of one pad. B) An edematous perineum is a normal postpartal finding. C) Tremors are a normal postpartal finding. D) A fundus located at the umbilicus is a normal postpartal finding. Page Ref: 523 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

22) The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score? A) 7 B) 8 C) 9 D) 10 Answer: B Explanation: A) The Apgar score would be higher; only the skin color needs to be subtracted from the score. B) The strong cry earns 2 points. The crying with foot sole stimulation earns 2 points. The limb flexion and resistance earn 2 points each. Bluish color earns 0 points. The Apgar score is 8. C) The Apgar score would be lower than 9 because of the skin color. D) Ten is a perfect score. The nurse needs to subtract for skin color. Page Ref: 517 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

23) Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply? A) "I'm checking the blood vessels in the cord to see whether it has one artery and one vein." B) "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein." C) "I'm checking the blood vessels in the cord to see whether it has two veins and one artery." D) "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins." Answer: B Explanation: A) A normal umbilical cord does not have one artery and one vein. B) Two arteries and one vein are present in a normal umbilical cord. C) A normal umbilical cord does not have two veins and one artery. D) A normal umbilical cord does not have two arteries and two veins. Page Ref: 518 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

24) At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score? A) 7 B) 8 C) 9 D) 10 Answer: C Explanation: A) The Apgar score would be higher than 7. B) The Apgar score would be higher than 8. C) Two points each are scored in each of the categories of heart rate, respiratory effort, muscle tone, and reflex irritability. One point is scored in the category of skin color. The total Apgar would be 9. D) The infant has cyanotic limbs, so the Apgar score cannot be perfect. Page Ref: 517 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 8. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

25) Upon delivery of the newborn, what nursing intervention most promotes parental attachment? A) Placing the newborn under the radiant warmer. B) Placing the newborn on the mother's abdomen. C) Allowing the mother a chance to rest immediately after delivery. D) Taking the newborn to the nursery for the initial assessment. Answer: B Explanation: A) Removing the baby from the mother does not promote attachment. B) As the baby is placed on the mother's abdomen or chest, she frequently reaches out to touch and stroke her baby. When the newborn is placed in this position, the father or partner also has a very clear, close view and can reach out to touch the baby. C) Removing the baby from the mother does not promote attachment. D) Removing the baby from the mother does not promote attachment. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Discuss the components of care for the woman during the third stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

26) A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action? A) Determine who might be the father of the baby for paternity testing. B) Ask the client what kind of birthing experience she would like to have. C) Assess blood pressure and check for proteinuria. D) Obtain a Social Services referral to discuss adoption. Answer: C Explanation: A) Paternity testing is a lower priority than the physiologic well-being of the client and fetus. B) A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences. C) Preeclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority. D) It would be inappropriate to discuss adoption or parenting during labor, especially with an adolescent who did not know she was pregnant prior to the onset of labor. The nurse should wait until after the birth to have this discussion. Page Ref: 523 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Explore the nurse's role in providing sensitive, developmentally responsive care to adolescent parents. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

27) As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? A) Cultural background B) Plans for keeping the infant C) Support persons D) Developmental level Answer: D Explanation: A) Cultural background is important to planning anyone's care. B) It is important to first determine the client's developmental level when planning nursing care for the mother who is keeping her infant. C) Support persons are important to planning anyone's care. D) Because her cognitive development is incomplete, the younger adolescent may have fewer problem-solving capabilities. The very young woman needs someone to rely on at all times during labor. She may be more childlike and dependent than older teens. Page Ref: 523 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 10 Explore the nurse's role in providing sensitive, developmentally responsive care to adolescent parents. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

28) An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Skin color: Body blue with pinkish extremities B) Umbilical cord: two veins and one artery C) Respiration rate of 30-60 irregular D) Temperature of above 36.5°C (97.8°F) E) Sole creases that involve the heel Answer: C, D, E Explanation: A) This is not correct. Skin color would be body pink with bluish extremities. B) This is not correct. The umbilical cord would have two arteries and one vein. C) Normal findings would include a respiration rate of 30-60 irregular. D) Normal findings would include temperature of above 36.5°C (97.8°F). E) Normal findings would include sole creases that involve the heel. Page Ref: 518 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

29) A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do? A) Go to the nurse's station and immediately call the physician. B) Run to the delivery room for an emergency birth pack. C) Stay with the client and ask auxiliary personnel for assistance. D) Hold back the infant's head forcibly until the physician arrives for the delivery. Answer: C Explanation: A) The nurse can direct auxiliary personnel to contact the physician. B) The nurse can direct auxiliary personnel to retrieve the emergency birth pack. C) If birth is imminent, the nurse must not leave the client alone. D) With one hand, the nurse should apply gentle pressure against the fetal head to maintain flexion and prevent it from popping out rapidly. The nurse does not hold the head back forcibly. Page Ref: 525 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 20. Understand one's role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks they pose to self and patients. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Delineate management of a nurse-managed precipitous labor and birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

30) The nurse has completed an initial physical assessment for a client admitted to the birthing unit. Which action should the nurse take next? A) Obtain the client's social history B) Document the physical assessment findings C) Report findings to the physician D) Perform interventions for pain management Answer: A Explanation: A) Once initial physical assessments are performed, the nurse can then take a detailed social history that provides a comprehensive view of both the woman's social habits and psychologic factors that may affect her birth experience. B) Documenting the physical assessment findings may be performed after the initial physical assessment is performed and social history is obtained. C) It may not be necessary to report findings to the physician in the absence of other complicating factors. D) Interventions for pain management may not be needed at this time. Additionally, effective pain management may depend on the client's social history. Page Ref: 501 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Discuss the components of a social history and its function in caring for the laboring woman. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

31) The nurse has taken a detailed social history from a client admitted to the birthing unit. Which insights may the nurse gain as a result of this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Social habits B) Psychologic factors C) Presence of HIV D) Readiness for discharge E) Need for bed rest Answer: A, B Explanation: A) The nurse may gain a view of both the woman's social habits and psychologic factors that may affect her birth experience. B) The nurse may gain a view of both the woman's social habits and psychologic factors that may affect her birth experience. C) The presence of HIV may only be detected by specific testing. D) The readiness for discharge cannot be determined at the time of obtaining a detailed social history. E) The need for bed rest is determine by the physical, not social, assessment. Page Ref: 501 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 3 Discuss the components of a social history and its function in caring for the laboring woman. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

32) A newborn has the following applied to the umbilical cord.

What should the nurse instruct the new parents about regarding this device? A) It has to stay intact for at least one week B) It is removed in 24 hours if the cord has dried C) It eliminates the need to wash the infant's abdomen D) It is removed by cutting the tissue beneath the clamp Answer: B Explanation: B) The clamp is removed in the newborn nursery approximately 24 hours after birth if the cord has dried. The clamp does not stay intact for one week. The clamp does not eliminate the need to wash the infant's abdomen. A plastic device is used when removing the clamp. The tissue beneath the clamp is not cut. Page Ref: 515 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

33) The nurse determines that a newborn has the following findings: Heart rate: 88 beats per minute Respirations: 24 per minute and irregular Muscle tone: Minor movement of lower extremities Reflex response: Grimace Skin color: Pink body, blue extremities If using the following table, what action should the nurse take at this time? Table 21-5 The Apgar Scoring System SCORE SIGN 0 Heart rate

Absent

Respiration

Absent

Muscle tone

Flaccid

Reflex response

Absent

Skin color Pale or blue Source: Data from Apgar, V. (1966).

1 Slow; less than 100 beats/min Slow; irregular Some flexion of extremities Grimace; noticeable facial movement Pink body, blue extremities

A) Begin resuscitation B) Stimulate the infant C) Document the findings D) Nasopharyngeal suctioning

2 Greater than 100 beats/min Good breathing with crying Active movement of extremities Vigorous cry; coughs; sneezes; pulls away when touched Pink body and extremities

Answer: B Explanation: B) The infant's Apgar score is 5. An Apgar score between 4 and 7 indicates the need for stimulation. A score under 4 indicates the need for resuscitation. A score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning. The nurse needs to do more than document the findings. Page Ref: 517 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize immediate nursing care of the newborn following birth. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

34) The nurse is observed performing the following with a patient:

What information will this assessment technique provide to the nurse? A) Assesses for bladder distention B) Estimates the weight of the uterus C) Determines the height of the fundus D) Evaluates the remaining placenta contents Answer: C Explanation: C) This is a technique used to palpate the fundus to determine if it needs to be massaged to reduce bleeding and enhance healing after delivery. This technique is not used to assess for bladder distention, estimate the weight of the uterus, or to evaluate for remaining placenta contents. Page Ref: 522 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment; Nursing Process. Learning Outcome: 6 Describe nursing interventions for promoting the woman's comfort during each stage of labor. MNL LO: Demonstrate use of the nursing process in the care of the family in childbirth.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 22 Pharmacologic Pain Management 1) The nurse is caring for a client in labor who has a history of physical dependence on narcotics. Which consideration should the nurse take with regard to the administration of naloxone (Narcan)? A) Inducing withdrawal symptoms B) Prolonging respiratory depression C) Exacerbating pruritis D) Increasing the risk for fetal depression Answer: A Explanation: A) Administering naloxone (Narcan) to a client who is physically dependent on narcotics may induce withdrawal symptoms, which will adversely affect her and her baby. B) Naloxone (Narcan) is used to correct respiratory depression, and does not prolong it. C) Naloxone is an opiate antagonist, and is not expected to exacerbate the side effects of opioids such as pruritis. D) Fetal depression is not expected to occur with the use of naloxone (Narcan). Page Ref: 534 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify how opioid abuse, dependence, and addiction affects women's options for pharmacologic pain relief in labor and birth. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

2) An analgesic medication has been administered intramuscularly to a client in labor. How would the nurse evaluate if the medication was effective? A) The client dozes between contractions. B) The client is moaning during contractions. C) The contractions decrease in intensity. D) The contractions decrease in frequency. Answer: A Explanation: A) If the client dozes between contractions, the analgesic is effective. Analgesics decrease discomfort and increase relaxation. B) Analgesics decrease the discomfort of contractions. C) Contractions will not decrease in intensity. D) Contractions will not decrease in frequency. Page Ref: 529 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Describe the use of systemic analgesics to promote pain relief during labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

3) A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? A) That a mild analgesic be administered B) An epidural C) A local anesthetic block D) Nonpharmacologic methods of pain relief Answer: D Explanation: A) The client does not have an established labor pattern, and analgesics given for pain relief could prolong labor or stop the process. B) The client does not have an established labor pattern, and an epidural given for pain relief could prolong labor or stop the process. C) The pudendal block technique provides perineal anesthesia for the second stage of labor, birth, and episiotomy repair. D) For this pattern of labor, nonpharmacologic methods of pain relief should be suggested. These can include back rubs, providing encouragement, and clean linens. Page Ref: 529 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the nurse's role in supporting pharmaceutical pain relief measures in labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

4) Two hours after an epidural infusion has begun, a client complains of itching on her face and neck. What should the nurse do? A) Remove the epidural catheter and apply a Band-Aid to the injection site. B) Offer the client a cool cloth and let her know the itching is temporary. C) Recognize that this is a common side effect, and follow protocol for administration of Benadryl. D) Call the anesthesia care provider to re-dose the epidural catheter. Answer: C Explanation: A) Removing the epidural catheter does not address the side effects of the medication. B) Using a cool cloth does not address the side effects of the medication. C) Itching is a side effect of the medication used for an epidural infusion. Benadryl, an antihistamine, can be administered to manage pruritus. D) The anesthesia care provider would not re-dose, as that would continue or worsen the side effects of the medication. Page Ref: 543 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

5) A client has just been admitted for labor and delivery. She is having mild contractions lasting 30 seconds every 15 minutes. The client wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the client understands which of the following? A) In order to respect her wishes, no medication will be given. B) Pain relief will allow a more enjoyable birth experience. C) The use of medications allows the client to rest and be less fatigued. D) Maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia. Answer: D Explanation: A) It is important to respect the client's wishes when possible. Once the effects are explained, it is still the client's choice whether to receive medication. B) That pain relief can lead to a more enjoyable experience might be the view of the nurse, but not of the mother. C) While pain relief can allow the mother to be less fatigued, that might not be the mother's first priority. D) The nurse can explain to the client that, although pharmacologic agents do affect the fetus, so does the pain and stress experienced by the laboring mother. If the woman's pain and anxiety are more than she can cope with, the adverse physiologic effects on the fetus may be as great as would occur with the administration of a small amount of an analgesic agent. Once the effects are explained, however, it is still the client's choice whether to receive medication. Page Ref: 530 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. C. 8. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the nurse's role in supporting pharmaceutical pain relief measures in labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

6) A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? A) Spinal B) Pudendal C) General D) Epidural Answer: A Explanation: A) Following the birth, the woman may be kept flat. Although the effectiveness of the supine position to avoid headache following a spinal is controversial, the physician's orders may include lying flat for 6-12 hours. B) It is not necessary to keep the postpartum client in bed for 6-12 hours after receiving a pudendal. C) The decision to keep the postpartum client in bed after receiving a general anesthesia depends on the client. D) It is not usually necessary to keep the postpartum client in bed for 6-12 hours after receiving an epidural. Page Ref: 547 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Summarize possible complications of regional anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

7) Toward the end of the first stage of labor, a pudendal block is administered transvaginally. What will the nurse anticipate the client's care will include? A) Monitoring for hypotension every 15 minutes B) Monitoring FHR every 15 minutes C) Monitoring for bladder distention D) No additional assessments Answer: D Explanation: A) There is no need for any additional monitoring of the mother. B) There is no need for any additional monitoring of the fetus. C) There is no need to monitor for bladder distension. D) Because a pudendal block is done using a local anesthetic, there is no need for additional monitoring of the mother or the fetus. Page Ref: 548 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

8) Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do? A) Be used in place of preoperative sedation B) Result in neonatal respiratory depression C) Prevent the need for anesthesia with an episiotomy D) Enhance uterine contractions Answer: B Explanation: A) Analgesics do not take the place of preoperative sedation. B) Analgesia given too late is of no value to the woman and may cause neonatal respiratory depression. C) Local anesthetic is needed for an episiotomy. D) Analgesics do not enhance uterine contractions. Page Ref: 531 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

9) After nalbuphine hydrochloride (Nubain) is administered, labor progresses rapidly, and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? A) Fentanyl (Sublimaze) B) Butorphanol tartrate (Stadol) C) Naloxone (Narcan) D) Pentobarbital (Nembutal) Answer: C Explanation: A) Fentanyl would not reverse the effects of the Nubain. B) Stadol would not reverse the effects of the Nubain. C) Narcan is useful for respiratory depression caused by nalbuphine (Nubain). Respiratory depression in the mother or fetus/newborn can be improved by the administration of naloxone (Narcan), which is a specific antagonist for this agent. D) Nembutal would not reverse the effects of the Nubain. Page Ref: 534 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the use of systemic analgesics to promote pain relief during labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

10) The nurse has presented a session on pain relief options to a prenatal class. Which statement indicates that additional teaching is needed? A) "An epidural can be continuous or can be given in one dose." B) "A spinal is usually used for a cesarean birth." C) "Pudendal blocks are effective when a vacuum is needed." D) "Local anesthetics provide good labor pain relief." Answer: D Explanation: A) Epidurals can be given either as a bolus or as a continuous infusion. B) Spinals are anesthesia, and are commonly used for cesarean birth. C) The advantages of pudendal block are ease of administration and absence of maternal hypotension. It also allows the use of low forceps or vacuum extraction for birth. D) Local anesthetics are not used for labor pain relief. They are used prior to episiotomy and for laceration repair. Page Ref: 549 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss the nurse's role in supporting pharmaceutical pain relief measures in labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

11) What is the major adverse side effect of epidural anesthesia? A) Maternal hypotension B) Decrease in variability of the FHR C) Vertigo D) Decreased or absent respiratory movements Answer: A Explanation: A) The major adverse effect of epidural anesthesia is maternal hypotension caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers blood pressure. B) A decrease in variability of the FHR is a fetal side effect of benzodiazepines. C) Vertigo is a side effect of the drug Nubain. D) Meperidine has multiple fetal side effects, including decreased or absent respiratory movements. Page Ref: 539 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Summarize possible complications of regional anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

12) Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position? A) On her right side in the center of the bed with her back curved B) Lying prone with a pillow under her chest C) On her left side with the bottom leg straight and the top leg slightly flexed D) Sitting on the edge of the bed Answer: D Explanation: A) This position is not consistent with access to the epidural spaces. B) This position is not consistent with access to the epidural spaces. C) This position is not consistent with access to the epidural spaces. D) The woman is positioned on her left or right side, at the edge of the bed with the assistance of the nurse, with her legs slightly flexed, or she is asked to sit on the edge of the bed. Page Ref: 540 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the nurse's role in supporting pharmaceutical pain relief measures in labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

13) The laboring client brought a written birth plan indicating that she wanted to avoid pain medications and an epidural. She is now at 6 cm and states, "I can't stand this anymore! I need something for pain! How will an epidural affect my baby?" What is the nurse's best response? A) "The narcotic in the epidural will make both you and the baby sleepy." B) "It is unlikely that an epidural will decrease your baby's heart rate." C) "Epidurals tend to cause low blood pressure in babies after birth." D) "I can't get you an epidural, because of your birth plan." Answer: B Explanation: A) It is rare for sedation to occur from absorption of the medications of a continuous epidural. B) Maternal hypotension results in uteroplacental insufficiency in the fetus, which is manifested as late decelerations on the fetal monitoring strip. The risk of hypotension can be minimized by hydrating the vascular system with 500 to 1000 mL of IV solution before the procedure and changing the woman's position and/or increasing the IV rate afterward. C) Mothers can experience hypotension after the epidural is administered, but babies do not develop hypotension after birth as a result of a labor epidural. D) A birth plan is what the client hopes for prior to the onset of labor, but it can be modified at any time. Page Ref: 542 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 14. Appreciate shared decision-making with empowered patients and families, even when conflicts occur. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

14) Upon the client's admission to the birthing unit, the nurse performs a careful assessment to determine whether the client has a history of physical dependence on narcotics. For which complication related to analgesic administration is the nurse preparing? A) Respiratory depression B) Urinary retention C) Fetal depression D) Pruritis Answer: A Explanation: A) Respiratory depression may require the use of naloxone (Narcan) to reverse the effects of narcotic agents. If the client has a history of physical dependence on narcotics, naloxone (Narcan) may induce withdrawal symptoms, which will adversely affect the client and her baby. B) Naloxone (Narcan) is given to correct respiratory depression, sedation, and hypotension, but not for urinary retention. C) Naloxone (Narcan) is given to correct respiratory depression, sedation, and hypotension, but not for fetal depression. D) Naloxone (Narcan) is given to correct respiratory depression, sedation, and hypotension, but not for pruritis. Page Ref: 534 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Identify how opioid abuse, dependence, and addiction affects women's options for pharmacologic pain relief in labor and birth. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

15) During a labor and delivery class, a client asks the nurse, "Why would I be placed under general anesthesia during delivery?" What should the nurse include in the response? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Perceived lack of time for regional anesthesia B) Contraindications for regional anesthesia C) Failure of regional anesthesia D) Refusal of regional anesthesia E) Provider preference over regional anesthesia Answer: A, B, C, D Explanation: A) Perceived lack of time is a common indication for general anesthesia. B) When regional anesthesia is contraindicated, general anesthesia is commonly used. C) Failure of regional anesthesia is a common indication for general anesthesia. D) Patient refusal of regional anesthesia is a common indication for general anesthesia. E) Provider preference is not a common indication of general anesthesia. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the indication for the use of general anesthesia in labor and birth. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

16) The nurse knows that which of the following are advantages of spinal block? Note: Credit will be given only if all correct answers and no incorrect answers are selected. Select all that apply. A) Intense blockade of sympathetic fibers B) Relative ease of administration C) Maternal compartmentalization of the drug D) Immediate onset of anesthesia E) Larger drug volume Answer: B, C, D Explanation: A) The primary disadvantage of spinal block is intense blockade of sympathetic fibers, resulting in a high incidence of hypotension. B) One of the advantages of spinal block is the relative ease of administration. C) One of the advantages of spinal block is the maternal compartmentalization of the drug. D) One of the advantages of spinal block is the immediate onset of anesthesia. E) One of the advantages of spinal block is a smaller drug volume, not a larger one. Page Ref: 546 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

17) For what common side effects of epidural anesthesia should the nurse watch? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Elevated maternal temperature B) Urinary retention C) Nausea D) Long-term back pain E) Local itching Answer: A, B, C, E Explanation: A) Elevated maternal temperature is a potential side effect of epidural anesthesia. B) Urinary retention is a potential side effect of epidural anesthesia. C) Nausea is a potential side effect of epidural anesthesia. D) Long-term back pain should not result from an epidural. E) Pruritus may occur at any time during the epidural infusion. It usually appears first on the face, neck, or torso and is generally the result of the agent used in the epidural infusion. Benadryl, an antihistamine, can be administered to manage pruritus. Page Ref: 543 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Summarize possible complications of regional anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

18) A client dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure was 120/80 before the procedure and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to increase her BP? A) Epinephrine B) Terbutaline C) Ephedrine D) Epifoam Answer: C Explanation: A) Epinephrine is used to relieve bronchospasm, or during anaphylactic reactions. B) Terbutaline is used as a tocolytic. C) Ephedrine is the medication of choice to increase maternal blood pressure. D) Epifoam is a topical anesthetic. Page Ref: 545 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Summarize possible complications of regional anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

19) A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor? A) Nausea B) Bladder distention C) Uterine atony D) Hypertension Answer: B Explanation: A) The epidural is discontinued after delivery, decreasing the likelihood of nausea. B) Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention. C) Uterine atony is not a result of epidurals. D) Hypotension, not hypertension, is an early side effect of epidurals. Page Ref: 544 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Summarize possible complications of regional anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

20) When general anesthesia is necessary for a cesarean delivery, what should the nurse be prepared to do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Administer an antacid to the client. B) Place a wedge under the client's thigh. C) Apply cricoid pressure to the client during anesthesia intubation. D) Preoxygenate the client for 3-5 minutes before anesthesia. E) Place a Foley catheter in the client's bladder. Answer: A, C, D, E Explanation: A) Prophylactic antacid therapy is given to reduce the acidic content of the stomach before general anesthesia. B) Before the induction to anesthesia, the woman should have a wedge placed under her hip to displace the uterus and avoid vena caval compression in the supine position. C) During the process of rapid induction of anesthesia, the nurse applies cricoid pressure. D) The woman should be preoxygenated with 3 to 5 minutes of 100% oxygen. E) Urinary retention can be treated with the placement of an indwelling Foley catheter. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the nurse's role in supporting pharmaceutical pain relief measures in labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

21) The client at 39 weeks' gestation is undergoing a cesarean birth due to breech presentation. General anesthesia is being used. Which situation requires immediate intervention? A) The baby's hands and feet are blue at 1 minute after birth. B) The fetal heart rate is 70 prior to making the skin incision. C) Clear fluid is obtained from the baby's oropharynx. D) The neonate cries prior to delivery of the body. Answer: B Explanation: A) Acrocyanosis is an expected finding at 1 minute of age. B) Fetal bradycardia occurs when the fetal heart rate falls below 110 beats/minute during a 10minute period of continuous monitoring. When fetal bradycardia is accompanied by decreased variability, it is considered ominous and could be a sign of fetal compromise. C) Clear fluid from the baby's oropharynx is an expected finding. D) A primary danger of general anesthesia is fetal depression. Crying after delivery of just the head indicates that no neonatal depression has occurred. Page Ref: 551 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Describe the nurse's role in caring for a woman experiencing major complications of general anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

22) The nurse is providing preoperative teaching to a client for whom a cesarean birth under general anesthesia is scheduled for the next day. Which statement by the client indicates that she requires additional information? A) "General anesthesia can be accomplished with inhaled gases." B) "General anesthesia usually involves administering medication into my IV." C) "General anesthesia will provide good pain relief after the birth." D) "General anesthesia takes effect faster than an epidural." Answer: C Explanation: A) General anesthesia can be accomplished via inhalation, intravenous injection, or a combination of the two. B) General anesthesia can be accomplished via inhalation, intravenous injection, or a combination of the two. C) General anesthesia provides no pain relief after birth, as regional anesthesia does. D) General anesthesia takes effect very quickly. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the indication for the use of general anesthesia in labor and birth. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

23) A cesarean section is ordered for a pregnant client. Because the client is to receive general anesthesia, what is the primary danger with which the nurse is concerned? A) Fetal depression B) Vomiting C) Maternal depression D) Uterine relaxation Answer: A Explanation: A) A primary danger of general anesthesia is fetal depression. The depression in the fetus is directly proportional to the depth and duration of the anesthesia. B) Vomiting is not a primary concern. C) Maternal depression is not a primary danger of general anesthesia. D) Uterine relaxation has nothing to do with general anesthesia. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 7 Describe the nurse's role in caring for a woman experiencing major complications of general anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

24) A cesarean section is ordered for the laboring client with whom the nurse has worked all shift. The client will receive general anesthesia. The nurse knows that potential complications of general anesthesia include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Fetal depression that is directly proportional to the depth and duration of the anesthesia B) Poor fetal metabolism of anesthesia, which inhibits use with preterm infants C) Uterine relaxation D) Increased gastric motility E) Itching of the face and neck Answer: A, B, C Explanation: A) A primary danger of general anesthesia is fetal depression, because the medication reaches the fetus in about 2 minutes. The depression is directly proportional to the depth and duration of anesthesia. B) The poor fetal metabolism of general anesthetic agents is similar to that of analgesic agents administered during labor. General anesthesia is not advocated when the fetus is considered to be at high risk, particularly in preterm birth. C) Most general anesthetic agents cause some degree of uterine relaxation. D) Pregnancy results in decreased gastric motility, and the onset of labor halts the process almost entirely. Food eaten hours earlier may remain undigested in the stomach. E) Itching of the face and neck is not associated with general anesthesia. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe the nurse's role in caring for a woman experiencing major complications of general anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

25) The client with a normal pregnancy had an emergency cesarean birth under general anesthesia 2 hours ago. The client now has a respiratory rate of 30, pale blue nail beds, a pulse rate of 110, and a temperature of 102.6°F, and is complaining of chest pain. The nurse understands that the client most likely is experiencing which of the following? A) Pulmonary embolus B) Pneumococcal pneumonia C) Pneumonitis D) Gastroesophageal reflux disease Answer: C Explanation: A) Pulmonary embolus does not cause fever. B) General anesthesia does not cause pneumococcal pneumonia. C) Even when food and fluids have been withheld, the gastric juice produced during fasting is highly acidic and can produce chemical pneumonitis if aspirated. This pneumonitis is known as Mendelson syndrome. The signs and symptoms are chest pain, respiratory distress, cyanosis, fever, and tachycardia. Women undergoing emergency cesarean births appear to be at considerable risk for adverse events. D) Gastroesophageal reflux disease does not cause a fever or cyanosis. Page Ref: 550 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Describe the nurse's role in caring for a woman experiencing major complications of general anesthesia. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

26) The nurse is inducing the labor of a client with severe preeclampsia. As labor progresses, fetal intolerance of labor develops. The induction medication is turned off, and the client is prepared for cesarean birth. Which statement should the nurse include in her preoperative teaching? A) "Because of your preeclampsia, you are at higher risk for hypotension after an epidural anesthesia." B) "Because of your preeclampsia, you might develop hypertension after a spinal anesthesia." C) "Because of your preeclampsia, your baby might have decreased blood pressure after birth." D) "Because of your preeclampsia, your husband will not be allowed into the operating room." Answer: A Explanation: A) Pregnancies complicated by preeclampsia are high-risk situations. The woman with mild preeclampsia usually may have the analgesia or anesthesia of choice, although the incidence of hypotension with epidural anesthesia is increased. If hypotension occurs with the epidural block, it provides further stress on an already compromised cardiovascular system. B) Hypertension is not associated with spinal anesthesia. C) Preeclampsia does not affect the baby's blood pressure. D) The presence of preeclampsia does not mean the husband cannot be present at the birth. Page Ref: 551 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Identify contraindications to specific types of analgesia and anesthesia for high-risk mothers. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

27) The nurse is caring for a laboring client with thrombocytopenia. During labor, it is determined that the client requires a cesarean delivery. The nurse is preparing the client for surgery, and should instruct the client that the recommended method of anesthesia is which of the following? A) General anesthesia B) Epidural anesthesia C) Spinal anesthesia D) Regional anesthesia Answer: A Explanation: A) General anesthesia will be recommended. Women with thrombocytopenia should avoid regional blocks. B) Women with thrombocytopenia should avoid regional blocks. C) Women with thrombocytopenia should avoid regional blocks. D) Women with thrombocytopenia should avoid regional blocks. Page Ref: 552 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

28) The nurse is performing an assessment on a client admitted to the birthing unit. Which assessment finding(s) contraindicate(s) an epidural block? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal refusal B) Local infection of the skin on the lower back C) Coagulation disorder D) Long-term NSAID use E) Previous back surgery Answer: A, B, C Explanation: A) Maternal refusal is an absolute contraindication to an epidural block. B) Local infection is an absolute contraindication to an epidural block. C) Coagulation disorders are an absolute contraindication to an epidural block. D) Long-term NSAID use may be cause for concern that needs to be evaluated on an individual basis. It is not considered a contraindication for an epidural block. E) Previous back surgery may be cause for concern that needs to be evaluated on an individual basis. It is not considered a contraindication for an epidural block. Page Ref: 540 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify contraindications to specific types of analgesia and anesthesia for high-risk mothers. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

29) A patient is labor is prescribed to receive nalbuphine 10 mg/70 kg intravenously now. The patient weighs 198 lbs. How many mg of medication should the nurse provide this patient? (Round to the nearest tenth decimal point.) Answer: 12.9 mg Explanation: First calculate the patient's weight in kg by dividing the weight in lb by 2.2 or 198/2.2 = 90 kg. Then set up the equation 10 mg/70 kg = x/90 kg. When cross-multiplying, the equation will be 10/70 = x/90; 70x = 900. Then solve for x by dividing 900/70 = 12.85 mg. When rounding to the nearing tenth decimal point the dose should be 12.9 mg. Page Ref: 534 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Nursing Process. Learning Outcome: 3 Describe the use of systemic analgesics to promote pain relief during labor. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

30) The nurse is preparing to instruct a patient in the third trimester of pregnancy on various methods to control pain during labor, and selects the following diagram. For which type of pain control is the nurse planning to instruct the client?

A) Lumbar spinal block B) Pudendal block C) Lumbar epidural block D) Local infiltration Answer: C Explanation: C) A lumbar epidural block is placed within the epidural space and affects a larger area of nerves to include the uterus, cervix, vagina, and perineum. In this diagram the dark area demonstrates the peridural (epidural) space and nerves affected, and the gray tube represents a continuous plastic catheter. A lumbar sympathetic (spinal) block relieves uterine pain only. A pudendal block relieves perineal pain only. Local infiltration affects the perineum only. Page Ref: 536 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

31) A patient in labor is being prepared for an epidural. Where should the nurse indicate the location of the epidural space on the diagram below?

1. A 2. B 3. C 4. D Answer: 2, 3 Explanation: The epidural space lies between the dura mater and the ligamentum flavum, extending from the base of the skull to the end of the sacral canal. Page Ref: 538 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

32) The nurse is reviewing the procedure for a continuous lumbar epidural block with a patient in the 3rd trimester of pregnancy. When reviewing this information what does the following diagram demonstrate to the patient?

A) Preparation of the skin prior to the insertion of the catheter B) Status of the vertebra when the patient is in the correct position C) The length of the needle to be inserted in the subarachnoid space D) Vertebrae rotated forward when the patient is side-lying without a pillow Answer: D Explanation: D) This picture diagrams the position that the vertebrae need to be in for insertion of the epidural. Preparation of the skin prior to the insertion of the catheter would not be completed with a needle and syringe. The length of the needle to be inserted is not usually a part of patient teaching about the procedure. The vertebrae are not rotated forward in this picture. Page Ref: 541 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

33) A patient is having the following anesthesia provided. What is the purpose of this type of anesthesia?

A) Repair of an episiotomy B) Delivery of the placenta C) Insertion of a urinary catheter D) Intrapartum vaginal examination Answer: A Explanation: A) This is a picture of local infiltration anesthesia which is used to repair an episiotomy. This anesthesia is not used to deliver the placenta, insert a urinary catheter, or conduct an intrapartum vaginal examination. Page Ref: 549 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 4 Compare the major types of regional analgesia and anesthesia, including the area affected, advantages, disadvantages, techniques, and nursing implications. MNL LO: Demonstrate understanding of pharmacologic pain management for the laboring woman.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 23 Childbirth at Risk: Prelabor Onset Complications 1) A client is admitted to the labor and delivery unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. What is this client at risk for? A) Gestational diabetes B) Placenta previa C) Abruptio placentae D) Placenta accreta Answer: C Explanation: A) Gestational diabetes is not an issue with this client. B) Placenta previa is not an issue with this client. C) Abruptio placentae is more frequent in pregnancies complicated by smoking, premature rupture of membranes, multiple gestation, advanced maternal age, cocaine use, chorioamnionitis, and hypertension. D) Placenta accreta is not an issue with this client. Page Ref: 565 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

2) The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? A) "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." B) "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." C) "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." D) "If I have amniocentesis, I might rupture the membranes again." Answer: C Explanation: A) Multifetal gestation increases the risk for PPROM. B) A urinary tract infection (UTI) increases the risk for PPROM. C) There is no evidence that bed rest in a subsequent pregnancy decreases the risk for PPROM. D) Amniocentesis increases the risk for PPROM. Page Ref: 562 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

3) A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect? A) Blood pressure B) Temperature C) Pulse D) Respiration Answer: B Explanation: A) Blood pressure can assist in the diagnosis of infection, but is not the primary vital sign. B) Rupture of membranes places the mother at risk for infection. The temperature is the primary and often the first indication of a problem. C) Pulse can assist in the diagnosis of infection, but is not the primary vital sign. D) Respirations can assist in the diagnosis of infection, but are not the primary sign. Page Ref: 561 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

4) The nurse admits into the labor area a client who is in preterm labor. What assessment finding would constitute a diagnosis of preterm labor? A) Cervical effacement of 30% or more B) Cervical change of 0.5 cm per hour C) 2 contractions in 30 minutes D) 8 contractions in 1 hour Answer: D Explanation: A) Cervical effacement of 80% or more would define preterm labor. B) A cervical change of at least 1 cm per hour would define preterm labor. C) Uterine contractions every 5 minutes for 20 minutes would define preterm labor. D) 8 contractions in a 60-minute period does define a diagnosis of preterm labor. Page Ref: 556 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Analyze the implications and maternal and fetal risks of preterm labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

5) During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be? A) To help the fetal head descend faster B) To use gravity and manipulation to relieve compression on the cord C) To facilitate dilation of the cervix with prostaglandin gel D) To prevent head compression Answer: B Explanation: A) The fetal head's descent would put additional pressure on the umbilical cord and reduce blood flow and oxygenation to the fetus. B) The top priority is to relieve compression on the umbilical cord to allow blood flow to reach the fetus. It is because some obstetric maneuvers to relieve cord compression are complicated that cesarean birth is sometimes necessary. C) Further dilatation of the cervix is unnecessary in light of a possible cesarean section. D) Head compression is not a concern in the case of prolapsed umbilical cord. The cord is what is compressed. Page Ref: 576 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

6) A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be? A) Perform a vaginal exam B) Notify the physician C) Place the client in a left lateral position D) Administer oxygen at 2 L per nasal cannula Answer: A Explanation: A) Prolapsed umbilical cord can occur when the membranes rupture. The fetus is more likely to experience variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord. A vaginal exam is the best way to confirm. B) A vaginal exam should be performed before the physician is notified. C) Positioning will not relieve the decreased heart rate if the cord is compromised. D) Oxygen will not relieve the decreased heart rate if the cord is compromised. Page Ref: 579, 581 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

7) The nurse has received end-of-shift reports in the high-risk maternity unit. Which client should the nurse see first? A) The client at 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement B) The client at 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations C) The client at 35 weeks' gestation with grade I abruptio placentae in labor who has a strong urge to push D) The client at 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously Answer: A Explanation: A) Assessment of the woman with placenta previa must be ongoing to prevent or treat complications that are potentially lethal to the mother and fetus. Painless, bright red vaginal bleeding is the best diagnostic sign of placenta previa. This client is the highest priority. B) Late decelerations are an abnormal finding, but put only the fetus at risk. This client is not the highest priority. C) Grade I abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority. D) Although pregnancy-induced hypertension puts a woman at risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority. Page Ref: 570 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

8) A client in her second trimester is complaining of spotting. Causes for spotting in the second trimester are diagnosed primarily through the use of which of the following? A) A non-stress test B) A vibroacoustic stimulation test C) An ultrasound D) A contraction stress test Answer: C Explanation: A) A non-stress test is used to assess the well-being of the fetus. B) A vibroacoustic stimulation test is used to assess the well-being of the fetus. C) Indirect diagnosis is made by locating the placenta via tests that require no vaginal examination. The most commonly employed diagnostic test is the transabdominal ultrasound scan. D) A contraction stress test is used to assess the well-being of the fetus. Page Ref: 568 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Describe the clinical therapy for premature rupture of membranes and preterm labor in determining hospital-based and community-based nursing management of the woman and her fetus-newborn. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

9) The nurse is performing a comprehensive assessment on a client admitted to the birthing unit with abruptio placentae. Which finding(s) contribute(s) to this condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) History of domestic violence B) Presence of uterine fibroids C) Alcohol consumption during pregnancy D) Hypertension E) Gestational diabetes mellitus Answer: A, B, C, D Explanation: A) Domestic violence contributes to the development of abruptio placentae. B) The presence of fibroids contributes to the development of abruptio placentae. C) Alcohol consumption contributes to the development of abruptio placentae. D) Maternal hypertension is the most common cause of abruptio placentae. E) Gestational diabetes mellitus is not considered a finding that contributes to abruptio placentae. Page Ref: 565 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the differences between developmental and degenerative placental problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

10) The nurse is planning an in-service educational program to talk about disseminated intravascular coagulation (DIC). The nurse should identify which conditions as risk factors for developing DIC? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Diabetes mellitus B) Abruptio placentae C) Fetal demise D) Multiparity E) Preterm labor Answer: B, C Explanation: A) Diabetes does not cause the release of thromboplastin that triggers DIC. B) As a result of the damage to the uterine wall and the retroplacental clotting with covert abruption, large amounts of thromboplastin are released into the maternal blood supply, which in turn triggers the development of disseminated intravascular coagulation (DIC) and the resultant hypofibrinogenemia. C) Perinatal mortality associated with abruptio placentae is approximately 25%. If fetal hypoxia progresses unchecked, irreversible brain damage or fetal demise may result. D) Multiparity does not cause the release of thromboplastin that triggers DIC. E) Preterm labor does not cause the release of thromboplastin that triggers DIC. Page Ref: 567 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

11) The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes which of the following? A) Limiting vaginal exams to only one per 24-hour period. B) Evaluating the fetal heart rate with an internal monitor. C) Monitoring for blood loss, pain, and uterine contractibility. D) Assessing blood pressure every 2 hours. Answer: C Explanation: A) Vaginal exams are contraindicated because the exam can stimulate bleeding. B) Fetal heart rate monitoring will be done with an external, not internal, fetal monitor. C) Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety. D) Blood pressure measurements every 2 hours are unnecessary. Page Ref: 569 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

12) A client is admitted to the labor and delivery unit in active labor. What nursing diagnoses might apply to the client with suspected abruptio placentae? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Fluid Volume, Deficient, related to hypovolemia secondary to excessive blood loss B) Tissue Perfusion: Peripheral, Ineffective, related to blood loss secondary to uterine atony following birth C) Anxiety related to concern for own personal status and the baby's safety D) Knowledge, Deficient related to lack of information about inherited genetic defects E) Alteration in Respiratory Function related to blood loss Answer: A, B, C Explanation: A) Maternal and perinatal fetal mortality are concerns due to hypoxia. B) Maternal and perinatal fetal mortality are concerns due to blood loss. C) This mother would be anxious for herself and her baby. D) Abruptio placentae is a premature separation of the placenta, not a genetic abnormality. E) Respiratory function is not related to the blood loss. Also, this is not a nursing diagnosis. Page Ref: 568 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

13) What is the most significant cause of neonatal morbidity and mortality? A) Amenorrhea B) Posttraumatic stress disorder C) Prematurity D) Endometriosis Answer: C Explanation: A) Amenorrhea the absence of menses in a woman and does not affect neonatal morbidity or mortality. B) Posttraumatic stress disorder does not affect neonatal morbidity or mortality. C) The most significant cause of neonatal morbidity and mortality is prematurity and its associated complications such as respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage. D) Endometriosis is a condition of a woman characterized by the presence of endometrial tissue outside the uterine cavity, and it does not affect neonatal morbidity or mortality. Page Ref: 563 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 1 Analyze the implications and maternal and fetal risks of preterm labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

14) What is the most significant maternal risk factor for preterm birth? A) Previous preterm birth B) Smoking C) Stress D) Substance abuse Answer: A Explanation: A) The most significant maternal risk factor for preterm birth is a previous preterm birth. B) Modifiable risk factors, such as smoking, substance abuse, stress, alcohol use, and other behavioral factors are not the most significant maternal risk factors for preterm birth. C) Modifiable risk factors, such as smoking, substance abuse, stress, alcohol use, and other behavioral factors are not the most significant maternal risk factors for preterm birth. D) Modifiable risk factors, such as smoking, substance abuse, stress, alcohol use, and other behavioral factors are not the most significant maternal risk factors for preterm birth. Page Ref: 555 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Analyze the implications and maternal and fetal risks of preterm labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

15) A client admitted to the birthing unit with placenta previa asks the nurse, "What is the cause of my condition?" Which statement should be included in the nurse's response? A) "The placenta is improperly implanted in the lower uterus." B) "The placenta has separated prematurely." C) "The placenta has grown too large." D) "The placenta has prolapsed and is being compressed." Answer: A Explanation: A) This statement correctly describes placenta previa, when the placenta implants low in the uterus or over the cervix. B) This statement describes abuptio placentae, another placental complication. C) Placenta previa is not when the placenta has grown too large; this statement should not be used by the nurse. D) Placenta previa is not when the placenta becomes prolapsed and is being compressed; this statement should not be used by the nurse. Page Ref: 568 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the differences between developmental and degenerative placental problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

16) The nurse is performing an assessment on a client in the birthing unit who has acquired cervical insufficiency. Which other finding(s) may contribute to the client's condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Inflammation B) Infection C) Cervical trauma D) Cone biopsy E) HPV positivity Answer: A, B, C, D Explanation: A) Acquired cervical insufficiency may be related to inflammation. B) Acquired cervical insufficiency may be related to infection. C) Acquired cervical insufficiency may be related to cervical trauma. D) Acquired cervical insufficiency may be related to cone biopsy. E) Acquired cervical insufficiency is not related to HPV positivity. Page Ref: 576 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the causes and risk factors of cervical insufficiency. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

17) The nurse on the birthing unit is collecting the obstetric history of a client at risk for cervical insufficiency. Which findings increase the client's risk for this condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Multiple gestations B) Previous preterm births C) Progressively earlier births with each subsequent pregnancy D) Cervical manipulation E) Prolonged labors Answer: A, B, C, D Explanation: A) Multiple gestations increase the risk for cervical insufficiency. B) Previous preterm births increase the risk for cervical insufficiency. C) Progressively earlier births with each subsequent pregnancy increase the risk for cervical insufficiency. D) Cervical manipulation increases the risk for cervical insufficiency. E) Short labors, not prolonged labors, increase the risk for cervical insufficiency. Page Ref: 573 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the causes and risk factors of cervical insufficiency. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

18) The home health nurse is visiting a client at 18 weeks who is pregnant with twins. Which nursing action is most important? A) Teach the client about foods that are good sources of protein. B) Assess the client's blood pressure in her upper right arm. C) Determine whether the pregnancy is the result of infertility treatment. D) Collect a cervicovaginal fetal fibronectin (fFN) specimen. Answer: A Explanation: A) A daily intake of 4000 kcal (minimum) and 135 g protein is recommended for a woman with normal-weight twins. B) Blood pressure can be assessed in either arm. C) The cause of the multifetal pregnancy does not impact nursing care. D) Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time. Page Ref: 578 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinical therapy in determining community-based and hospital-based nursing care of the woman with a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

19) When counseling a newly pregnant client at 8 weeks' gestation with twins, the nurse teaches the woman about the need for increased caloric intake. What would the nurse tell the woman that the minimum recommended intake should be? A) 2500 kcal and 120 grams protein B) 3000 kcal and 150 grams protein C) 4000 kcal and 135 grams protein D) 5000 kcal and 190 grams protein Answer: C Explanation: A) 2500 kcal and 120 grams protein is less than the recommended caloric and protein intake for a twin-gestation pregnancy. B) 3000 kcal and 150 grams protein is lower in calories but higher in protein than is recommended for a twin-gestation pregnancy. C) 4000 kcal and 135 grams protein is the recommended caloric and protein intake in a twingestation pregnancy. D) 5000 kcal and 190 grams protein is more than recommended caloric and protein intake for a twin-gestation pregnancy. Page Ref: 578 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinical therapy in determining community-based and hospital-based nursing care of the woman with a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

20) Intervention to reduce preterm birth can be divided into primary prevention and secondary prevention. What does secondary prevention include? A) Diagnosis and treatment of infections B) Cervical cerclage C) Progesterone administration D) Antibiotic treatment and tocolysis Answer: D Explanation: A) Primary prevention includes diagnosis and treatment of infections, cervical cerclage, and progesterone administration. B) Primary prevention includes diagnosis and treatment of infections, cervical cerclage, and progesterone administration. C) Primary prevention includes diagnosis and treatment of infections, cervical cerclage, and progesterone administration. D) Secondary prevention strategies are antibiotic treatment and tocolysis. Page Ref: 559 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Describe the clinical therapy for premature rupture of membranes and preterm labor in determining hospital-based and community-based nursing management of the woman and her fetus-newborn. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

21) The client is carrying monochorionic-monoamniotic twins. The nurse teaches the client what this is, and the implications of this finding. The nurse knows that teaching is successful when the client states which of the following? A) "My babies came from two eggs." B) "About two thirds of twins have this amniotic sac formation." C) "My use of a fertility drug led to this issue." D) "My babies have a lower chance of surviving to term than fraternal twins do." Answer: D Explanation: A) Monochorionic-monoamniotic twins lie in the same amniotic sac. B) About 2% of twins are of this type. C) The majority of twins conceived through in vitro fertilization are fraternal (dizygotic) because multiple fertilized ova are inserted into the uterus, and are not monochorionic-monoamniotic twins. D) Monochorionic-monoamniotic twins are both in one amniotic sac. There is an increased risk of umbilical cords becoming tangled or knotted and a higher incidence of fetal demise. Page Ref: 575 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinical therapy in determining community-based and hospital-based nursing care of the woman with a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

22) The nurse on the birthing unit is caring for a client who has an amputated cervix and is about to undergo a cerclage procedure. Which type of cerclage procedure should the nurse anticipate? A) Abdominal cerclage B) Rescue cerclage C) Emergency cerclage D) Elective cerclage Answer: A Explanation: A) An abdominal cerclage approach may be required for women with an amputated cervix. B) A rescue cerclage is one that is placed for emergent reasons, when dilatation and effacement have already occurred. C) An emergency cerclage is one that is placed for emergent reasons, when dilatation and effacement have already occurred. D) An elective, or cervical, cerclage will not be performed for a client who has an amputated cervix. Page Ref: 574 Cognitive Level: Analyzing Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Describe the clinical therapies and appropriate nursing interventions for the mother with cervical insufficiency and her unborn fetus. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

23) Slowly removing some amniotic fluid is a treatment for hydramnios. What consequence can occur with the withdrawal of fluid? A) Preterm labor B) Prolapsed cord C) Preeclampsia D) Placenta previa Answer: B Explanation: A) Preterm labor is not a known consequence of amniotic fluid reduction. B) A needle or a fetal scalp electrode is used to make a small puncture in the amniotic sac. There is a risk that the force of the fluid could make a larger hole in the amniotic sac, thus increasing the risk of a prolapsed cord. C) Preeclampsia is not a known consequence of amniotic fluid reduction. D) Placenta previa would not be a result of amniotic fluid reduction. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Describe the identification of the woman with hydramnios and the maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

24) The nurse is admitting a client who was diagnosed with hydramnios. The client asks why she has developed this condition. The nurse should explain that hydramnios is sometimes associated with which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Rh sensitization B) Postmaturity syndrome C) Renal malformation or dysfunction D) Maternal diabetes E) Large-for-gestational-age infants Answer: A, D Explanation: A) Hydramnios is associated with Rh sensitization. B) Postmaturity is associated with oligohydramnios. C) Renal malformation or dysfunction is associated with oligohydramnios. D) Hydramnios is associated with maternal diabetes. E) Large-for-gestational-age infants are not associated with hydramnios. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Describe the identification of the woman with hydramnios and the maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

25) The nurse is admitting a client with possible hydramnios. When is hydramnios most likely suspected? A) Hydramnios is most likely suspected when there is less amniotic fluid than normal for gestation. B) Hydramnios is most likely suspected when the fundal height increases disproportionately to the gestation. C) Hydramnios is most likely suspected when the woman has a twin gestation. D) Hydramnios is most likely suspected when the quadruple screen comes back positive. Answer: B Explanation: A) Hydramnios occurs when there is more amniotic fluid than normal for gestation. B) Hydramnios should be suspected when the fundal height increases out of proportion to the gestational age. C) Hydramnios is not suspected simply because of a twin gestation. D) A positive quadruple screen is not indicative of hydramnios. Page Ref: 579 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Compare the clinical therapy and nursing management of the woman with hydramnios and the woman with oligohydramnios. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

26) If oligohydramnios occurs in the first part of pregnancy, the nurse knows that there is a danger of which of the following? A) Major congenital anomalies B) Fetal adhesions C) Maternal diabetes D) Rh sensitization Answer: B Explanation: A) Major congenital anomalies are associated with hydramnios. B) If oligohydramnios occurs in the first part of pregnancy, there is a danger of fetal adhesions (one part of the fetus may adhere to another part). C) Maternal diabetes is associated with hydramnios. D) Rh sensitization is associated with hydramnios. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Describe the identification of the woman with oligohydramnios and the maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

27) When caring for a laboring client with oligohydramnios, what should the nurse be aware of? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased risk of cord compression B) Decreased variability C) Labor progress is often more rapid than average D) Presence of periodic decelerations E) During gestation, fetal skin and skeletal abnormalities can occur Answer: A, B, D, E Explanation: A) During the labor and birth, the lessened amounts of fluid reduce the cushioning effect for the umbilical cord, and cord compression is more likely to occur. B) The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasing baseline, decreased variability, or presence of periodic decelerations). C) Labor progress may be slower, not faster, than average due to the decreased amniotic fluid volume. Fetal movement can be impaired as a result of inadequate amniotic fluid volume. D) The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasing baseline, decreased variability, or presence of periodic decelerations). E) During the gestational period, fetal skin and skeletal abnormalities may occur because fetal movement is impaired as a result of inadequate amniotic fluid volume. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Describe the identification of the woman with oligohydramnios and the maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

28) The nurse knows that a baby born to a mother who had oligohydramnios could show signs of which of the following? A) Respiratory difficulty B) Hypertension C) Heart murmur D) Decreased temperature Answer: A Explanation: A) Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. B) Hypertension has no relation to oligohydramnios. C) Heart murmur has no relation to oligohydramnios. D) Decreased temperature has no relation to oligohydramnios. Page Ref: 579 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Compare the clinical therapy and nursing management of the woman with hydramnios and the woman with oligohydramnios. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

29) The client at 38 weeks' gestation has been diagnosed with oligohydramnios. Which statement indicates that teaching about the condition has been effective? A) "My gestational diabetes might have caused this problem to develop." B) "When I go into labor, I should come to the hospital right away." C) "This problem was diagnosed with blood and urine tests." D) "Women with this condition usually do not have a cesarean birth." Answer: B Explanation: A) Hydramnios, not oligohydramnios, is associated with such maternal disorders as diabetes. B) The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid. The client with oligohydramnios should come to the hospital in early labor. C) Oligohydramnios is diagnosed when the largest vertical pocket of amniotic fluid visible on ultrasound examination is 5 cm or less. D) The fetus is continually monitored during labor and birth. In the event that the fetal heart rate tracing is nonreassuring, late decelerations occur, and birth is not imminent, a cesarean birth may be performed. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 11 Compare the clinical therapy and nursing management of the woman with hydramnios and the woman with oligohydramnios. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

30) A patient in preterm labor is prescribed magnesium sulfate 6 grams intravenous infusion now, followed by 5 grams per hour. The pharmacy prepares an infusion of 500 mL lactated Ringer's solution with 100 grams of magnesium sulfate. If the patient receives the loading dose and 3 hours of the medication, how many total mL of the infusion did the patient receive? Answer: 105 mL Explanation: The solution is 100 grams/500 mL or 1 gram in every 5 mL of solution. If the loading dose is 6 grams, then the patient received 6 grams x 5 mL =30 mL. For each hourly dose of 5 grams, the patient received 5 grams x 5 mL = 25 mL. Since the patient received the dose of 5 grams for 3 hours, then the patient received 25 mL x 3 = 75 mL. With the loading dose of 30 mL plus the three hours of infusion equaling 75 mL, the patient received 105 mL of the infusion. Page Ref: 559 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 3 Describe the clinical therapy for premature rupture of membranes and preterm labor in determining hospital-based and community-based nursing management of the woman and her fetus-newborn. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

31) A pregnant patient is diagnosed with premature separation of the placenta. The nurse provides the patient with the following diagram. What amount of placenta separation is this patient experiencing?

A) Central B) Marginal C) Complete D) Anticipated Answer: C Explanation: C) This diagram demonstrates complete separation with massive vaginal bleeding. In central separation the placenta separates centrally, and the blood is trapped between the placenta and the uterine wall. Entrapment of the blood results in concealed bleeding. In marginal separation blood passes between the fetal membranes and the uterine wall and escapes vaginally. Separation begins at the periphery of the placenta; this marginal sinus rupture may or may not become more severe. Anticipated separation is not a type of placental separation. Page Ref: 566 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

32) The nurse is preparing teaching material for a pregnant patient with the following type of placenta previa. What information should the nurse provide the patient about this health problem?

A) Internal os is partially covered by the placenta B) Internal os is covered completely by the placenta C) Edge of the placenta is at the margin of the internal os D) Placenta is implanted in the lower segment but does not reach the os Answer: A Explanation: A) The diagram is of a partial placenta previa. The internal os is partially covered by the placenta. In total placenta previa the internal os is covered completely by the placenta. In marginal placenta previa the edge of the placenta is at the margin of the internal os. In low-lying placenta previa the placenta is implanted in the lower segment but does not reach the os, although it is in close proximity of it. Page Ref: 569 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

33) A pregnant patient is scheduled to have the procedure depicted in the diagram performed. What should the nurse explain is the purpose for this procedure?

A) Correct marginal placenta previa B) Prevent preterm cervical dilatation and pregnancy loss C) Reduce the risk of developing central abruptio placentae D) Assist the fetus to rotate into the appropriate position for delivery Answer: B Explanation: B) Cerclage is a surgical procedure in which a stitch is placed in the cervix to prevent a spontaneous abortion or premature birth. After placement, the string is tightened and secured anteriorly. This procedure is not used to correct marginal placenta previa, reduce the risk of developing central abruptio placentae, or help with fetal rotation for delivery. Page Ref: 573 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Describe the clinical therapies and appropriate nursing interventions for the mother with cervical insufficiency and her unborn fetus. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

34) A patient pregnant with twins late in the 3rd trimester has an ultrasound that shows the position of the fetuses as follows. What should the nurse expect will be planned for this patient?

A) Cesarean birth B) Vaginal delivery C) Spinal block during labor D) Continuous lumbar epidural Answer: A Explanation: A) Many practitioners choose to deliver any nonvertex presentation via cesarean birth. In 20% of cases, twin A is nonvertex and requires a cesarean birth. Approximately 40% of twins present in a vertex/vertex presentation. More than 80% of twins in vertex/vertex presentation are born vaginally. Since the patient will need a cesarean birth, spinal block and continuous lumbar epidural will not be indicated. Page Ref: 577 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinical therapy in determining community-based and hospital-based nursing care of the woman with a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 24 Childbirth at Risk: Labor-Related Complicatons 1) What would be a normal cervical dilatation rate in a first-time mother ("primip")? A) 1.5 cm per hour B) Less than 1 cm cervical dilatation per hour C) 1 cm per hour D) Less than 0.5 cm per hour Answer: A Explanation: A) Dilatation in a "multip" is about 1.5 cm per hour. B) Less than 1 cm cervical dilatation per hour is prolonged labor. C) Cervical dilatation in a first-time mother is just over 1 cm per hour. D) Dystocia is a rate of cervical dilatation of less than 0.5 cm per hour. Page Ref: 585 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss dysfunctional labor patterns. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications. 2) Dystocia encompasses many problems in labor. What is the most common? A) Meconium-stained amniotic fluid B) Dysfunctional uterine contractions C) Cessation of contractions D) Changes in the fetal heart rate Answer: B Explanation: A) Meconium-stained amniotic fluid is a sign of nonreassuring fetal status. B) The most common problem is dysfunctional (or uncoordinated) uterine contractions that result in a prolongation of labor. C) Cessation of contractions is a symptom of possible uterine rupture. D) Changes in the fetal heart rate (FHR) are a sign of nonreassuring fetal status. Page Ref: 584 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss dysfunctional labor patterns. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications. 1 Copyright © 2020 Pearson Education, Inc.

3) Risk factors for tachysystole include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Cocaine use B) Placental abruption C) Low-dose oxytocin titration regimens D) Uterine rupture E) Smoking Answer: A, B, D Explanation: A) Cocaine use is a risk factor for tachysystole. B) Placental abruption is a risk factor for tachysystole. C) High-dose oxytocin titration regimens are a risk factor for tachysystole. D) Uterine rupture is a risk factor for tachysystole. E) Smoking is not risk factor for tachysystole. Page Ref: 584 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss dysfunctional labor patterns. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

4) A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for? A) Oxytocin induction of labor B) Amnioinfusion C) Increased intravenous infusion D) Cesarean section Answer: A Explanation: A) Oxytocin is the drug of choice for labor augmentation or labor induction and may be administered as needed for hypotonic labor patterns. B) Amnioinfusion would not change the ineffective labor pattern. C) Increasing the IV infusion would not change the ineffective labor pattern. D) Because CPD has been ruled out, a cesarean section is not anticipated. Page Ref: 586 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss dysfunctional labor patterns. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

5) Nonreassuring fetal status often occurs with a tachysystole contraction pattern. Intrauterine resuscitation measures may become warranted and can include which of the following measures? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Position the woman on her right side. B) Apply oxygen via face mask. C) Call the anesthesia provider for support. D) Increase intravenous fluids by at least 500 mL bolus. E) Call the physician/CNM to the bedside. Answer: B, C, D Explanation: A) The nurse would position the woman on her left side. B) The nurse would apply oxygen via face mask. C) The nurse would call the anesthesia provider for support. D) The nurse would increase intravenous fluids by at least 500 mL bolus. E) The nurse would not call the physician/CNM to the bedside. Page Ref: 585 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss dysfunctional labor patterns. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

6) The nurse is performing a vaginal exam on a client who was admitted to the birthing unit after her membranes ruptured, and discovers a cord prolapse. Which intervention is priority at this time? A) Pushing the presenting fetal part upward B) Administering oxygen C) Initiating intravenous fluid D) Inserting an indwelling bladder catheter Answer: A Explanation: A) Pushing the presenting fetal part upward is a life-saving measure that relieves pressure on the umbilical cord and supports fetal gas exchange. B) Administering oxygen is performed, but at a later time. C) Initiating intravenous fluid is performed, but at a later time. D) Inserting an indwelling bladder catheter may be later used to fill the woman's bladder and relieve pressure on the umbilical cord, but this should not be done in place of pushing the presenting fetal part upward. Page Ref: 603 Cognitive Level: Applying Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Discuss the interventions needed in caring for a woman with a prolapsed umbilical cord. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

7) While caring for a client admitted to the birthing unit, the nurse suspects that the client may be experiencing a uterine rupture. Which assessment finding should the nurse expect to appear first? A) Nonreassuring fetal heart rate B) Constant abdominal pain C) Loss of fetal station D) Cessation of contractions Answer: A Explanation: A) A nonreassuring fetal heart rate is commonly the earliest warning sign of a possible uterine rupture. B) Constant abdominal pain is a finding that may be present, but is not commonly the earliest sign of uterine rupture. C) Loss of fetal station is a finding that may be present, but is not commonly the earliest sign of uterine rupture. D) Cessation of contractions is a finding that may be present, but is not commonly the earliest sign of uterine rupture. Page Ref: 604 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify the signs and symptoms associated with a uterine rupture. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

8) What are the primary complications of placenta accreta? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal hemorrhage B) Insomnia C) Failure of the placenta to separate following birth of the infant D) Autonomic dysreflexia E) Shoulder dystocia Answer: A, C Explanation: A) The primary complications of placenta accreta are maternal hemorrhage and failure of the placenta to separate following birth of the infant. B) Insomnia is not a complication of placenta accreta. C) The primary complications of placenta accreta are maternal hemorrhage and failure of the placenta to separate following birth of the infant. D) Autonomic dysreflexia is a rare complication that can occur in women with a spinal cord injury. E) The most significant complication in macrosomia is shoulder dystocia. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

9) Risk factors for labor dystocia include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Tall maternal height B) Labor induction C) Small-for-gestational-age (SGA) fetus D) Malpresentation E) Prolonged latent phase Answer: B, D, E Explanation: A) Short maternal height, not tall, is a risk factor of dystocia. B) Labor induction is a risk factor of dystocia. C) Large-for-gestational-age (FGA) fetus, not small, is a risk factor of dystocia. D) Malpresentation is a risk factor of dystocia. E) Prolonged latent phase is a risk factor of dystocia. Page Ref: 584 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

10) In succenturiate placenta, one or more accessory lobes of fetal villi have developed on the placenta, with vascular connections of fetal origin. What is the gravest maternal danger? A) Cord prolapse B) Postpartum hemorrhage C) Paroxysmal hypertension D) Brachial plexus injury Answer: B Explanation: A) Cord prolapse is not considered a danger of succenturiate placenta. B) The gravest maternal danger is postpartum hemorrhage if this minor lobe is severed from the placenta and remains in the uterus. C) Paroxysmal hypertension is a symptom of autonomic dysreflexia. D) Brachial plexus injury is an injury due to improper or excessive traction applied to the fetal head during birth. Page Ref: 600 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

11) The nurse knows that the maternal risks associated with postterm pregnancy include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Polyhydramnios B) Maternal hemorrhage C) Maternal anxiety D) Forceps-assisted delivery E) Perineal damage Answer: B, C, D, E Explanation: A) Polyhydramnios is not associated with postterm pregnancy. B) Maternal symptoms and complications in postterm pregnancy may include maternal hemorrhage. C) Maternal symptoms and complications in postterm pregnancy may include maternal anxiety. D) Maternal symptoms and complications in postterm pregnancy may include an operative vaginal birth with forceps or vacuum extractor. E) Maternal symptoms and complications in postterm pregnancy may include perineal trauma and damage. Page Ref: 587 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the impact of postterm pregnancy on the childbearing family. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

12) The client is at 42 weeks' gestation. Which order should the nurse question? A) Obtain biophysical profile today. B) Begin nonstress test now. C) Schedule labor induction for tomorrow. D) Have the client return to the clinic in 1 week. Answer: D Explanation: A) A biophysical profile is a commonly used assessment for the postterm fetus. B) The nonstress test is a commonly used assessment for the postterm fetus. C) Most practitioners consider induction at 41 gestational weeks to reduce maternal and fetalnewborn risks associated with postterm pregnancy. D) Many practitioners use twice-weekly testing, providing the amniotic fluid level is normal. One week is too long a period between assessments. Page Ref: 588 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Describe the impact of postterm pregnancy on the childbearing family. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

13) During labor, the fetus was in a brow presentation, but after a prolonged labor, the fetus converted to face presentation and was delivered vaginally with forceps assist. What should the nurse explain to the parents? A) The infant will need to be observed for meconium aspiration. B) Facial edema and head molding will subside in a few days. C) The infant will be given prophylactic antibiotics. D) Breastfeeding will need to be delayed for a day or two. Answer: B Explanation: A) There is no mention of meconium-stained fluid that would cause the nurse to assess for meconium aspiration. B) Any facial edema and head molding that result from the use of forceps at birth will subside in a few days. C) There is no reason to place the infant on antibiotics. D) There is no reason to delay breastfeeding. Page Ref: 592 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

14) The multiparous client at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold maneuvers indicate the fetus is in a transverse lie with a shoulder presentation. Which physician order is most important? A) Artificially rupture membranes. B) Apply internal fetal scalp electrode. C) Monitor maternal blood pressure every 15 minutes. D) Alert surgical team of urgent cesarean. Answer: D Explanation: A) Artificial rupture of the membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. B) An internal fetal scalp electrode cannot be applied until membranes have ruptured. C) The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way. D) This is the highest priority because vaginal birth is impossible with a transverse lie. Labor should not be allowed to continue, and a cesarean birth should be done quickly. Page Ref: 596 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

15) The nurse should anticipate the labor pattern for a fetal occiput posterior position to be which of the following? A) Shorter than average during the latent phase B) Prolonged as regards the overall length of labor C) Rapid during transition D) Precipitous Answer: B Explanation: A) Overall labor is often prolonged, not shorter. B) Occiput posterior (OP) position of the fetus is the most common fetal malposition and occurs when the head remains in the direct OP position throughout labor. This can prolong the overall length of labor. C) Overall labor is often prolonged, not more rapid. D) Overall labor is often prolonged, not precipitous. Page Ref: 589 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

16) Maternal risks of occiput posterior (OP) malposition include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Blood loss greater than 1000 mL B) Postpartum infection C) Anal sphincter injury D) Higher rates of vaginal birth E) Instrument delivery Answer: B, C, E Explanation: A) Blood loss greater than 500 mL is a maternal risk of OP. B) Postpartum infection is a maternal risk of OP. C) Anal sphincter injury is a maternal risk of OP. D) Higher rates of cesarean birth are a maternal risk of OP. E) Instrument delivery is a maternal risk of OP. Page Ref: 589 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

17) If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist? A) Call a second physician to assist. B) Prepare for an immediate cesarean delivery. C) Assist the woman into McRoberts maneuver. D) Utilize fundal pressure to push the fetus out. Answer: C Explanation: A) The vaginal delivery of a macrosomic fetus does not require a second physician. B) Although a cesarean might be necessary, it would not be an immediate need. C) The McRoberts maneuver is thought to change the maternal pelvic angle and therefore reduce the force needed to extract the shoulders, thereby decreasing the incidence of brachial plexus stretching and clavicular fracture. D) Fundal pressure should not be performed, because this can further wedge the shoulder against the suprapubic bone. Page Ref: 598 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

18) While performing a uterine assessment on a client in the birthing unit, the nurse notes a loss of fetal station and a change in uterine shape. The client reports constant abdominal pain, uterine tenderness, and is exhibiting signs of shock. Which condition should the nurse suspect? A) Uterine rupture B) Anaphylactoid syndrome of pregnancy C) Circumvallate placenta D) Breech presentation Answer: A Explanation: A) The assessment findings are consistent with uterine rupture, which may also include a nonreassuring fetal heart rate, hematuria, and cessation of contractions. B) Anaphylactoid syndrome of pregnancy is characterized by shortness of breath, hypoxia, cyanosis, and cardiovascular and respiratory collapse. C) Circumvallate placenta may result in antepartum hemorrhage, prematurity, and abnormal bleeding during or following the third stage of labor. D) Assessment findings consistent with breech presentation include palpation of the fetal sacrum in the lower part of the maternal abdomen and fetal heart tones present above the umbilicus on auscultation. Page Ref: 604 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify the signs and symptoms associated with a uterine rupture. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

19) The nurse is caring for a client experiencing a uterine rupture. Which outcome demonstrates that the plan of care has been effective for the client? A) The mother remains hemodynamically stable throughout emergency cesarean birth. B) The mother has additional knowledge regarding the problems, implications, and treatment plans. C) The FHR remains in normal range with supportive measures. D) The family is able to cope successfully with fetal or neonatal anomalies, if they exist. Answer: C Explanation: A) An emergency cesarean birth is warranted in the case of a client experiencing a uterine rupture. Hemodynamic stability is a major goal of interventions performed for a client with a uterine rupture. B) Knowledge deficit is not a priority nursing diagnosis for a client experiencing a uterine rupture. C) In the case of a uterine rupture, fetal heart rate anomalies are often already present. D) Uterine rupture is not indicative of fetal or neonatal anomalies. Page Ref: 604 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Identify complications related to uterine rupture. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

20) True postterm pregnancies are frequently associated with placental changes that cause a decrease in uterine-placental-fetal circulation. Complications related to alterations in placenta functioning include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased fetal oxygenation B) Increased placental blood supply C) Reduced nutritional supply D) Macrosomia E) Risk of shoulder dystocia Answer: C, D, E Explanation: A) Decreased, not increased, fetal oxygenation is a complication related to alternations in placenta functioning. B) Reduced, not increased, placental blood supply is a complication related to alternations in placenta functioning. C) Reduced nutritional supply is a complication related to alternations in placenta functioning. D) Macrosomia is a complication related to alternations in placenta functioning. E) Risk of shoulder dystocia is a complication related to alternations in placenta functioning. Page Ref: 587 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the impact of postterm pregnancy on the childbearing family. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

21) The nurse examines the client's placenta and finds that the umbilical cord is inserted at the placental margin. The client comments that the placenta and cord look different than they did for her first two births. The nurse should explain that this variation in placenta and cord is called what? A) Placenta accreta B) Circumvallate placenta C) Succenturiate placenta D) Battledore placenta Answer: D Explanation: A) In placenta accreta, the chorionic villi attach directly to the myometrium of the uterus. B) A circumvallate placenta has a double fold of chorion and amnion that form a ring around the umbilical cord, on the fetal side of the placenta. C) In succenturiate placenta, one or more accessory lobes of fetal villi will develop on the placenta. D) In battledore placenta, the umbilical cord is inserted at or near the placental margin. Page Ref: 600 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

22) A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be? A) Perform a vaginal exam. B) Notify the physician. C) Place the client in a left lateral position. D) Administer oxygen at 2 L per nasal cannula. Answer: A Explanation: A) A drop in fetal heart rate accompanied by variable decelerations is consistent with a prolapsed cord. The nurse would assess for prolapsed cord via vaginal examination. B) The vaginal exam should be done before the physician is notified. C) Repositioning the client will not relieve the decreased heart rate if the cord is compromised. D) Administering oxygen will not relieve the decreased heart rate if the cord is compromised. Page Ref: 602 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

23) The nurse is caring for a client in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time? A) Assess the odor of the amniotic fluid. B) Perform Leopold maneuvers. C) Obtain an order for pain medication. D) Complete a sterile vaginal exam. Answer: D Explanation: A) Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority. B) This assessment is not called for at this time. C) Pain medication is a low priority at this time. D) Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. The nurse would assess for prolapsed cord via vaginal examination. Page Ref: 602 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

24) During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Intravenous access B) Cesarean delivery C) Immediate vaginal delivery D) McRoberts maneuver E) A crash cart Answer: A, B, E Explanation: A) When an amniotic fluid embolism is suspected, intravenous access is obtained as quickly as possible. B) Shortness of breath, cyanosis, and hypoxia are symptoms of an amniotic fluid embolus, which necessitates immediate cesarean delivery. C) The client is only 4 cm, so vaginal delivery will not take place immediately. D) McRoberts maneuver is used with shoulder dystocia. E) The chances of a code are high, so the crash cart needs to be available. Page Ref: 604 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Discuss the identification, management, and nursing care of women with anaphylactoid syndrome of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

25) On assessment, a laboring client is noted to have cardiovascular and respiratory collapse and is unresponsive. What should the nurse suspect? A) An amniotic fluid embolus B) Placental abruption C) Placenta accreta D) Retained placenta Answer: A Explanation: A) Cardiovascular and respiratory collapse are symptoms of an amniotic fluid embolus and cor pulmonale. B) Placental abruption does not have any of these symptoms. C) Placenta accreta does not have any of these symptoms. D) Retention of the placenta beyond 30 minutes after birth is termed retained placenta and does not have any of these symptoms. Page Ref: 604 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Discuss the identification, management, and nursing care of women with anaphylactoid syndrome of pregnancy. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

26) A 26-year-old client is having her initial prenatal appointment. The client reports to the nurse that she suffered a pelvic fracture in a car accident 3 years ago. The client asks whether her pelvic fracture might affect her ability to have a vaginal delivery. What response by the nurse is best? A) "It depends on how your pelvis healed." B) "You will need to have a cesarean birth." C) "Please talk to your doctor about that." D) "You will be able to delivery vaginally." Answer: A Explanation: A) Women with a history of pelvic fractures may also be at risk for cephalopelvic disproportion (CPD). B) Not all clients will be able to deliver vaginally, but not all will need cesarean birth. C) It is not therapeutic to tell a client to talk to someone else. D) Not all clients will be able to deliver vaginally, but not all will need cesarean birth. Page Ref: 605 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Delineate the effects of pelvic contractures on labor and birth. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

27) A fetal weight is estimated at 4490 grams in a client at 38 weeks' gestation. Counseling should occur before labor regarding which of the following? A) Mother's undiagnosed diabetes B) Likelihood of a cesarean delivery C) Effectiveness of epidural anesthesia with a large fetus D) Need for early delivery Answer: B Explanation: A) There is a possibility of undiagnosed diabetes, but that is not the current concern because the client is close to delivery. B) The likelihood of a cesarean delivery with a fetus over 4000 grams is high. This should be discussed with the client before labor. C) The weight of the fetus has no bearing on the effectiveness of epidural anesthesia. D) The client is already at term, so it is too late to discuss an early delivery. Page Ref: 597 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss the implications of macrosomia and hydrocephalus on the woman and the fetus. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

28) A woman has been in labor for 16 hours. Her cervix is dilated to 3 cm and is 80% effaced. The fetal presenting part is not engaged. The nurse would suspect which of the following? A) Breech malpresentation B) Fetal demise C) Cephalopelvic disproportion (CPD) D) Abruptio placentae Answer: C Explanation: A) A breech presentation would not prevent the presenting part from becoming engaged. B) Fetal demise would not prevent the presenting part from becoming engaged. C) Cephalopelvic disproportion (CPD) prevents the presenting part from becoming engaged. D) Abruptio placentae has specific complications; however, it would not prevent engagement of the presenting part. Page Ref: 605 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 9 Delineate the effects of pelvic contractures on labor and birth. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

29) What is one of the most common initial signs of nonreassuring fetal status? A) Meconium-stained amniotic fluid B) Cyanosis C) Dehydration D) Arrest of descent Answer: A Explanation: A) The most common initial signs of nonreassuring fetal status are meconiumstained amniotic fluid and changes in the fetal heart rate (FHR). B) Cyanosis is not a common sign of nonreassuring fetal status. C) Dehydration is not a common sign of nonreassuring fetal status. D) Arrest of descent is not a common sign of nonreassuring fetal status. Page Ref: 588 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 11 Discuss complications of the third and fourth stages of labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

30) The client gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. What should the nurse prepare to do? A) Start an IV of lactated Ringer's. B) Apply anti-embolism stockings. C) Bottle-feed the infant. D) Send the placenta to pathology. Answer: A Explanation: A) In women who do not have an epidural in place, intravenous sedation may be required because of the discomfort caused by the procedure. An IV is necessary. B) Anti-embolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, anti-embolism stockings are not needed for this client. C) The client's partner or family member, or a nursery nurse, can feed the infant. Preparation for manual removal of the placenta is a higher priority at this time. D) The placenta might be sent to pathology after it is removed, but preparing the client for manual removal of the placenta now is a higher priority. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 11 Discuss complications of the third and fourth stages of labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

31) The client delivered 30 minutes ago. Her blood pressure and pulse are stable. Vaginal bleeding is scant. The nurse should prepare for which procedure? A) Abdominal hysterectomy B) Manual removal of the placenta C) Repair of perineal lacerations D) Foley catheterization Answer: B Explanation: A) Abdominal hysterectomy is not required. B) Retention of the placenta beyond 30 minutes after birth is termed retained placenta. Manual removal of the placenta is then performed. C) Repair of perineal lacerations would not ensue until after the placenta was delivered. D) There is no indication of urinary retention that requires a Foley catheter. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 11 Discuss complications of the third and fourth stages of labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

32) Lacerations of the cervix or vagina may be present when bright red vaginal bleeding persists in the presence of a well-contracted uterus. The incidence of lacerations is higher among which of the following childbearing women? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Over the age of 35 B) Have not had epidural block C) Have had an episiotomy D) Have had a forceps-assisted or vacuum-assisted birth E) Nulliparous Answer: C, D, E Explanation: A) The incidence of lacerations is higher among childbearing women who are younger. B) The incidence of lacerations is higher among childbearing women who have had an epidural block. C) The incidence of lacerations is higher among childbearing women who undergo an episiotomy. D) The incidence of lacerations is higher among childbearing women who undergo forcepsassisted or vacuum-assisted birth. E) The incidence of lacerations is higher among childbearing women who are nulliparous. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Identify complications related to uterine rupture. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

33) After delivery, it is determined that there is a placenta accreta. Which intervention should the nurse anticipate? A) 2 L oxygen by mask B) Intravenous antibiotics C) Intravenous oxytocin D) Hysterectomy Answer: D Explanation: A) Use of oxygen will not assist in the separation of the placenta. B) Use of intravenous antibiotics will not assist in the separation of the placenta. C) Use of intravenous oxytocin will not assist in the separation of the placenta. D) The primary complication of placenta accreta is maternal hemorrhage and failure of the placenta to separate following birth of the infant. An abdominal hysterectomy may be the necessary treatment, depending on the amount and depth of involvement. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

34) What is required for any woman receiving oxytocin (Pitocin)? A) CPR B) Continuous electronic fetal monitoring C) Administering oxygen by mask D) Nonstress test Answer: B Explanation: A) CPR is not required for a woman receiving oxytocin. B) Continuous electronic fetal monitoring (EFM) is required for any woman receiving oxytocin (Pitocin). C) Administering oxygen by mask is not required for a woman receiving oxytocin. D) Nonstress test is not required for a woman receiving oxytocin. Page Ref: 586 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss dysfunctional labor patterns. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

35) The client has delivered a 4200 g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best? A) "The episiotomy extended and tore through your rectal mucosa." B) "The episiotomy extended and tore up near your vaginal mucous membrane." C) "The episiotomy extended and tore into the muscle layer." D) "The episiotomy extended and tore through your anal sphincter." Answer: D Explanation: A) A fourth degree laceration is through the rectal mucosa. B) A first degree laceration is through the vaginal mucous membrane. C) A second degree laceration involves skin and muscle. D) A third degree laceration includes the anal sphincter. Page Ref: 606 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss the implications of macrosomia and hydrocephalus on the woman and the fetus. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

36) A fetus has a brow cephalic presentation. Which head shape should the nurse expect when the infant is delivered? A)

Answer: C Explanation: C) In a brow presentation the head is molded forward. Choice 1 is an occiput anterior presentation. Choice 2 is an occiput posterior presentation. Choice 4 is face presentation. Page Ref: 586 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

37) A laboring patient is attempting a vaginal birth. An episiotomy has already been performed and the healthcare provider is prepared to extend the episiotomy if necessary. What is this fetus's most likely presentation? A)

Answer: C Explanation: C) In a brow presentation, the forehead of the fetus becomes the presenting part and the head is slightly extended instead of flexed, which results in the head entering the birth canal with the widest diameter of the head (occipitomental) foremost. If a vaginal birth is attempted, the woman will probably need an episiotomy and may require extension of the episiotomy at the moment of birth. In a normal cephalic presentation, the occiput is the presenting part, and the head is flexed with the chin on the chest. The military presentation is probably the least difficult for the woman and fetus. In most cases, as soon as the head reaches the pelvic floor, flexion occurs and a vaginal birth results. In a face presentation, the face of the fetus is the presenting part. The fetal neck is hyperextended. Page Ref: 591 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

38) During an intrapartum vaginal examination the following is palpated. In which type of presentation is this fetus?

A) Breech B) Shoulder C) Occiput face D) Occiput brow Answer: A Explanation: A) On vaginal examination of a breech presentation the nurse may feel the anal sphincter. The tissue of the fetal buttocks feels soft. In a shoulder presentation the nurse may feel the acromion process as the fetal presenting part. In the occiput face presentation the nurse may palpate the nose. In the occiput brow presentation the nurse may palpate the forehead. Page Ref: 594 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Summarize various types of fetal malposition and malpresentation and possible associated problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

39) A patient's placenta it is identified as having a double fold of chorion and amnion that formed a ring around the umbilical cord on the fetal side of the placenta. What should the nurse expect when examining this placenta? A)

Answer: B Explanation: B) A circumvallate placenta has a double fold of chorion and amnion that forms a ring around the umbilical cord, on the fetal side of the placenta. Choice 1: In a succenturiate placenta, one or more accessory lobes of fetal villi develops on the placenta. Choice 3: In a battledore placenta, the umbilical cord is inserted at or near the placental margin. Choice 4: In a velamentous insertion of the umbilical cord, the vessels of the umbilical cord divide some distance from the placenta in the placental membranes. Page Ref: 601 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 5 Analyze the implications of abnormal placenta and umbilical cord variations. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

40) During an intrapartum vaginal examination the following is assessed. In which position should the patient be placed at this time?

A) Supine B) Side-lying C) Lithotomy D) Knee-chest Answer: D Explanation: D) The knee-chest position is used to relieve cord compression during a cord prolapse emergency. The supine, side-lying, or lithotomy positions are not beneficial to the fetus in cord prolapse. Page Ref: 603 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 6 Discuss the interventions needed in caring for a woman with a prolapsed umbilical cord. MNL LO: Demonstrate use of the nursing process in the care of the woman with labor-related complications.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 25 Birth-Related Procedures 1) The client is undergoing an emergency cesarean birth for fetal bradycardia. The client's partner has not been allowed into the operating room. What can the nurse do to alleviate the partner's emotional distress? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Allow the partner to wheel the baby's crib to the newborn nursery. B) Allow the partner to be near the operating room where the newborn's first cry can be heard. C) Have the partner wait in the client's postpartum room. D) Encourage the partner to be in the nursery for the initial assessment. E) Teach the partner how to take the client's blood pressure. Answer: A, B, D Explanation: A) Effective measures include allowing the partner to take the baby to the nursery. B) Effective measures include allowing the partner to be in a place near the operating room, where the newborn's first cry can be heard. C) The nurse should involve the partner in postpartum care in the recovery room, not have the partner wait in the client's postpartum room. D) Effective measures include involving the partner in postpartum care, such as being present for the initial assessment. E) The nurse must take the blood pressure as part of assessing the client. Page Ref: 633 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. C. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

2) The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed to perform which procedure? A) A version B) An amniotomy C) Leopold maneuvers D) A ballottement Answer: A Explanation: A) Version, or turning the fetus, is a procedure used to change the fetal presentation by abdominal or intrauterine manipulation. B) Amniotomy is the artificial rupture of membranes. C) Leopold maneuvers are a series of palpations performed to determine fetal position. D) Ballottement occurs when the fetus floats away and then returns to touch an examiner's hand during a vaginal exam. Page Ref: 609 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Contrast the methods of external cephalic version and internal version and the related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

3) A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? A) To provide analgesia B) To relax the uterus C) To induce labor D) To prevent hemorrhage Answer: B Explanation: A) Terbutaline has no analgesic effect. B) Terbutaline is administered to achieve uterine relaxation. C) Terbutaline does not induce labor. D) Terbutaline does not prevent hemorrhage. Page Ref: 611 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Contrast the methods of external cephalic version and internal version and the related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

4) The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? A) Previous birth by cesarean B) Frank breech ballotable C) 37 weeks, complete breech D) Failed ECV last week Answer: A Explanation: A) Any previous uterine scar is a contraindication to ECV. Prior scarring of the uterus may increase the risk of uterine tearing or uterine rupture. B) There is no contraindication to ECV for this client. C) ECV is not attempted until 36 or 37 weeks. There is no contraindication for ECV for this client. D) Although this client is less likely to have a successful ECV this week if it was unsuccessful last week, there is no contraindication to attempting the procedure. Page Ref: 611 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Contrast the methods of external cephalic version and internal version and the related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

5) A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? A) Maternal temperature, BP, and pulse B) Estimation of fetal birth weight C) Fetal presentation, position, station, and heart rate D) Biparietal diameter Answer: C Explanation: A) Maternal vital signs do not affect the decision to perform an amniotomy. B) Fetal birth weight does not affect the decision to perform an amniotomy. C) Before an amniotomy is performed, the fetus is assessed for presentation, position, station, and FHR. D) Biparietal diameter does not affect the decision to perform an amniotomy. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the use of amniotomy in current maternal-newborn care. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

6) Amniotomy as a method of labor induction has which of the following advantages? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The danger of a prolapsed cord is decreased. B) There is usually no risk of hypertonus or rupture of the uterus. C) The intervention can cause a decrease in pain. D) The color and composition of amniotic fluid can be evaluated. E) The contractions elicited are similar to those of spontaneous labor. Answer: B, D, E Explanation: A) The danger of a prolapsed cord is increased once the membranes have ruptured, especially if the fetal presenting part is not firmly pressed down against the cervix. B) There is usually no risk of hypertonus or rupture of the uterus, and this is an advantage of amniotomy. C) The intervention can cause an increase in pain, making labor more difficult to manage. D) The color and composition of amniotic fluid can be evaluated, and this is an advantage of amniotomy. E) The contractions elicited are similar to those of spontaneous labor, and this is an advantage of amniotomy. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the use of amniotomy in current maternal-newborn care. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

7) A laboring client's obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response? A) Contractions elicited are similar to those of spontaneous labor. B) Amniotomy decreases the chances of a prolapsed cord. C) Amniotomy reduces the pain of labor and makes it easier to manage. D) The client will not need an episiotomy. Answer: A Explanation: A) Contractions after amniotomy are similar to those of spontaneous labor. B) A disadvantage of amniotomy is the increased chance of prolapsed cord, especially if the fetal presenting part is not well applied against the cervix. C) A disadvantage of amniotomy is that it can increase pain and make labor more difficult to manage. D) There is no correlation between amniotomy and episiotomy. Page Ref: 621 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the use of amniotomy in current maternal-newborn care. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

8) After inserting prostaglandin gel for cervical ripening, what should the nurse do? A) Apply an internal fetal monitor. B) Insert an indwelling catheter. C) Withhold oral intake and start intravenous fluids. D) Place the client in a supine position with a right hip wedge. Answer: D Explanation: A) An internal fetal monitor cannot be applied until adequate cervical dilatation has occurred. B) The client should void on her own and not need a catheter. C) Until labor begins, there is no rationale for withholding all intake. D) After the gel, intravaginal insert, or tablet is inserted, the woman is instructed to remain lying down with a rolled blanket or hip wedge under her right hip to tip the uterus slightly to the left for the first 30 to 60 minutes to maintain the cervical ripening agent in place. Page Ref: 614 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare methods for inducing labor, explaining their advantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

9) Under which circumstances would the nurse remove prostaglandin from the client's cervix? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Contractions every 5 minutes B) Nausea and vomiting C) Uterine tachysystole D) Cardiac tachysystole E) Baseline fetal heart rate of 140-148 Answer: B, C, D Explanation: A) Contractions every 5 minutes are consistent with the plan of induction. B) A reason to remove prostaglandin from a client's cervix is the presence of nausea and vomiting. C) A reason to remove prostaglandin from a client's cervix is uterine tachysystole. D) A reason to remove prostaglandin from a client's cervix is cardiac tachysystole. E) This is a good heart rate and would not warrant removing the prostaglandin. Page Ref: 615 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Compare methods for inducing labor, explaining their advantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

10) The nurse knows that the Bishop scoring system for cervical readiness includes which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Fetal station B) Fetal lie C) Fetal presenting part D) Cervical effacement E) Cervical softness Answer: A, D, E Explanation: A) Fetal station is one of the components evaluated by the Bishop scoring system. B) Fetal lie is not one of the components evaluated by the Bishop scoring system. C) The presenting part is not one of the components evaluated by the Bishop scoring system. D) Cervical effacement is one of the components evaluated by the Bishop scoring system. E) Cervical consistency is one of the components evaluated by the Bishop scoring system. Page Ref: 616 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Compare methods for inducing labor, explaining their advantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

11) The nurse knows that a contraindication to the induction of labor is which of the following? A) Placenta previa B) Isoimmunization C) Diabetes mellitus D) Premature rupture of membranes Answer: A Explanation: A) Placenta previa is a contraindication to the induction of labor. B) Isoimmunization is an indication for induction. C) Diabetes mellitus is an indication for induction. D) Premature rupture of membranes is an indication for induction. Page Ref: 614 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare methods for inducing labor, explaining their advantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

12) Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important? A) Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. B) Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. C) Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). D) Prepare to induce labor after administering a tap water enema. Answer: C Explanation: A) 100 mcg every 2 hours is too much medication administered too frequently. B) The client must remain recumbent for 2 hours after administration of dinoprostone (Prepidil) vaginal gel, during which time she is continuously monitored. C) Pitocin should not administered less than 4 hours after the last Cytotec dose. D) Enemas are not routinely used in labor. This order is not expected. Page Ref: 612 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare methods for inducing labor, explaining their advantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

13) The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? A) Apply an internal fetal monitor. B) Monitor the client using electronic fetal monitoring. C) Withhold oral intake and start intravenous fluids. D) Place the client in an upright, sitting position. Answer: B Explanation: A) An internal fetal monitor cannot be applied until adequate cervical dilatation has occurred and the membranes are ruptured. B) The client should be monitored using electronic fetal monitoring for at least 30 minutes and up to 2 hours after placement to assess the contraction pattern and the fetal status. C) Until labor begins, there is no rationale for withholding oral intake. D) The client is placed in a reclining position and bed rest is maintained to prevent the medication from leaking from the vagina. Page Ref: 613 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Compare methods for inducing labor, explaining their advantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

14) The nurse is caring for a client who is about to receive an amnioinfusion. For which complication(s) should the nurse monitor the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Umbilical cord prolapse B) Amniotic fluid embolism C) Uterine rupture D) Amnionitis E) Abruptio placentae Answer: A, B, C Explanation: A) Umbilical cord prolapse is a rare, but serious risk factor for the client receiving an amnioinfusion. B) Amniotic fluid embolism is a rare, but serious risk factor for the client receiving an amnioinfusion. C) Uterine rupture is a rare, but serious risk factor for the client receiving an amnioinfusion. D) The presence of amnionitis is a contraindication to amnioinfusion, but is not a condition that results from amnioinfusion. E) The presence of abruptio placentae is a contraindication to amnioinfusion, but is not a condition that results from amnioinfusion. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the use of transcervical intrapartum amnioinfusion. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

15) The client is having fetal heart rate decelerations. An amnioinfusion has been ordered to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? A) Early decelerations B) Moderate decelerations C) Late decelerations D) Variable decelerations Answer: D Explanation: A) Early decelerations require no intervention. B) Moderate is not a descriptor used to identify decelerations. C) Late decelerations are consistent with head compression. Amnioinfusion does not relieve head compression. D) When cord compression is suspected, amnioinfusion (AI) may be considered. AI helps to prevent the possibility of variable decelerations by increasing the volume of amniotic fluid. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the use of transcervical intrapartum amnioinfusion. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

16) The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? A) "Because I have a midline episiotomy, I should keep my perineum clean." B) "I can use an ice pack to relieve some the pain from the episiotomy." C) "I can take ibuprofen (Motrin) when my perineum starts to hurt." D) "The tear I have through my rectum is unrelated to my episiotomy." Answer: D Explanation: A) A complication associated with an episiotomy is infection. Perineal hygiene is important when a client has an episiotomy to prevent infection and facilitate healing. B) Pain relief measures may begin immediately after birth with application of an ice pack to the perineum. C) Healing episiotomies can be very painful, and pain medication should be provided for clients experiencing pain. D) This statement is incorrect. The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum. Page Ref: 623 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale for each, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

17) The client requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. How does the nurse respond? A) "The episiotomy goes straight back toward your rectum." B) "The episiotomy is from your vagina toward the urethra." C) "The episiotomy is cut diagonally away from your vagina." D) "The episiotomy extends from your vagina into your rectum." Answer: C Explanation: A) A midline episiotomy is straight back from the vagina toward the rectum. B) Episiotomies are not cut anteriorly toward the urethra. C) A mediolateral episiotomy is angled from the vaginal opening toward the buttock. It begins in the midline of the posterior fourchette and extends at a 45-degree angle downward to the right or left. D) Extension into the rectum is a fourth-degree laceration. Page Ref: 623 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale for each, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

18) The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? A) "I'll get you one right away." B) "You only need to use one ice pack." C) "You need to leave it off for at least 20 minutes and then reapply." D) "I'll bring you an extra so that you can change it when you are ready." Answer: C Explanation: A) Providing an additional ice pack before 20 minutes have passed would increase the perineal edema. B) More than one ice pack must be used in order to apply ice for 20 minutes on followed by 20 minutes off. C) For optimal effect, the ice pack should be applied for 20 to 30 minutes and removed for at least 20 minutes before being reapplied. D) An ice pack that is provided now for use in 20 minutes would melt before being used. Page Ref: 623 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Teaching and Learning. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale for each, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

19) Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? A) Mediolateral B) Episiorrhaphy C) Midline D) Medical Answer: C Explanation: A) Major perineal trauma is more likely to occur if a midline episiotomy is performed. B) Episiorrhaphy is the repair of the episiotomy. C) Major perineal trauma is more likely to occur if a midline episiotomy is performed. The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum. D) Medical is not a type of episiotomy. Page Ref: 622 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale for each, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

20) The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring client who will have a forceps delivery. Which action or assessment finding requires intervention? A) Regional anesthesia is administered via pudendal block. B) The client is instructed to push between contractions. C) Fetal heart tones are consistently between 110 and 115. D) The client's bladder is emptied using a straight catheter. Answer: B Explanation: A) Adequate anesthesia must be given for the type of forceps procedure anticipated. Low forceps may be done with a pudendal block; however, midforceps or a rotation of more than 45 degrees requires an epidural, spinal-epidural, or general anesthesia. B) During the contraction, as the forceps are applied, the woman should avoid pushing. C) Fetal heart tones between 110 and 115 are normal. No intervention is needed. D) The maternal bladder should be emptied. Page Ref: 626 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types of forceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

21) The need for forceps has been determined. The client's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate? A) Input B) Low C) Mid D) Outlet Answer: B Explanation: A) Input is not a term associated with the use of forceps. B) Low forceps are applied when the leading edge of the fetal head is at +2 station. C) Midforceps are applied when the fetal head is engaged. D) Outlet forceps are applied when the fetal skull has reached the perineum. Page Ref: 625 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types of forceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

22) What type of forceps are designed to be used with a breech presentation? A) Midforceps B) Piper C) Low D) High Answer: B Explanation: A) The criterion for midforceps application is that the fetal head must be engaged, but the leading edge of the fetal skull is above a plus 2 (+2) station. B) Piper forceps are designed to be used with a breech presentation. They are applied after the birth of the body, when the fetal head is still in the birth canal and assistance is needed. C) The criterion for low forceps application is that the leading edge of the fetal skull must be at a station of plus 2 (+2) or below, but not on the pelvic floor. D) High forceps are not indicated in current obstetric practice. Page Ref: 625 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types of forceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

23) The physician has determined the need for forceps. The nurse should explain to the client that the use of forceps is indicated because of which of the following? A) Her support person is exhausted B) Premature placental separation C) To shorten the first stage of labor D) To prevent fetal distress Answer: B Explanation: A) Exhaustion of the support person is not an indication for use of forceps. B) Fetal conditions indicating the need for forceps include premature placental separation, prolapsed umbilical cord, and nonreassuring fetal status. C) Forceps may be used electively to shorten the second stage of labor and spare the woman's pushing effort, or when regional anesthesia has affected the woman's motor innervation, and she cannot push effectively. D) Indications for the use of forceps include premature placental separation and a nonreassuring fetal heart rate. Using forceps does not prevent fetal distress. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types of forceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

24) The physician/CNM opts to use a vacuum extractor for a delivery. What does the nurse understand? A) There is little risk with vacuum extraction devices. B) There should be further fetal descent with the first two "pop-offs." C) Traction is applied between contractions. D) The woman often feels increased discomfort during the procedure. Answer: B Explanation: A) The risk of complications rises with the use of a vacuum extraction device. B) If more than three "pop-offs" occur (the suction cup pops off the fetal head), the procedure should be discontinued. C) The physician/CNM applies traction in coordination with uterine contractions, not between contractions. D) If adequate regional anesthesia has been administered, the woman feels only pressure during the procedure. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications, procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

25) The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal? A) The head is delivered after eight "pop-offs" during contractions. B) A cephalohematoma is present on the fetal scalp. C) The location of the vacuum is apparent on the fetal scalp after birth. D) Positive pressure is applied by the vacuum extraction during contractions. Answer: C Explanation: A) Use of the vacuum extraction for eight contractions is too many. If more than three "pop-offs" occur, the procedure should be discontinued. B) A cephalohematoma is a complication of vacuum extraction birth and is not an expected finding. C) The parents need to be informed that the caput (chignon) on the baby's head will disappear within 2 to 3 days. D) Negative pressure is suction, which is needed to facilitate the birth. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications, procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

26) The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? A) "A small cup will be put onto the baby's head, and a gentle suction will be applied." B) "I can stop pushing and just rest if the vacuum extractor is used." C) "The baby's head might have some swelling from the vacuum cup." D) "The vacuum will be applied for a total of ten minutes or less." Answer: B Explanation: A) The vacuum extractor is a small cup-shaped device that is applied to the fetal scalp. B) Vacuum extraction is an assistive delivery. The physician/CNM applies traction in coordination with uterine contractions. C) The vacuum extractor might leave some swelling ("chignon") on the scalp where the device is placed. D) Research indicates that negative suction applied for more than 10 minutes is associated with a greater incidence of scalp injury. Page Ref: 628 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications, procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

27) The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? A) Elation, euphoria, and talkativeness B) A sense of failure and loss C) Questions about whether or not to circumcise D) Uncertainty surrounding the baby's name Answer: B Explanation: A) Elation, euphoria, and talkativeness are expected after birth. B) Clients who participate in childbirth classes that stress the normalcy of birth may feel a sense of loss or failure if an intervention is used during their labor or birth. C) Decisions on circumcision and naming are often encountered after birth, and are not correlated with the use of intervention. D) Decisions on circumcision and naming are often encountered after birth, and are not correlated with the use of intervention. Page Ref: 626 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications, procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

28) The nurse is reviewing charts of clients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased healthcare costs in clients undergoing cesarean birth by request? A) Increased abnormal placenta implantation in subsequent pregnancies B) Decreased use of general anesthesia with greater use of epidural anesthesia C) Prolonged anemia, requiring blood transfusions every few months D) Coordination of career projects of both partners leading to increased income Answer: A Explanation: A) Repeat cesarean births are associated with greater risks, including increased incidence of abnormal placentation in subsequent pregnancies and increased risk of mortality secondary to surgery, which would contribute to increased healthcare costs. B) Which anesthesia method is used is not a significant factor in healthcare costs of cesarean birth by request. C) Prolonged anemia is not a complication of cesarean birth by request. D) The income of the couple does not affect healthcare costs directly. Page Ref: 634 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: V. 10. Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

29) After being in labor for several hours with no progress, a client is diagnosed with CPD (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? A) Transverse B) Infraumbilical midline C) Classic D) Vertical Answer: A Explanation: A) The transverse incision is made across the lowest and narrowest part of the abdomen and is the most common lower uterine segment incision. B) The infraumbilical midline incision is a type of vertical incision, which carries an increased risk of uterine rupture with subsequent pregnancy, labor, and birth. C) The classic vertical incision, which is made into the upper uterine segment, was the method of choice for many years but is nearly never performed in modern obstetrics. It carries an increased risk of uterine rupture with subsequent pregnancy, labor, and birth. D) The classic vertical incision, which is made into the upper uterine segment, was the method of choice for many years but is nearly never performed in modern obstetrics. It carries an increased risk of uterine rupture with subsequent pregnancy, labor, and birth. Page Ref: 630 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

30) The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? A) "The next time I have a baby, I can try to deliver vaginally." B) "The risk of rupturing my uterus is too high for me to have any more babies." C) "Every time I have a baby, I will have to have a cesarean delivery." D) "I can only have one more baby." Answer: C Explanation: A) This client will not be able to deliver vaginally in future pregnancies. B) There could be a risk of uterine rupture if the client were allowed to labor with the next pregnancy. C) A classic uterine incision is made in the upper uterine segment and is associated with an increased risk of rupture in subsequent pregnancy, labor, and birth. Therefore, subsequent deliveries will be done by cesarean. D) The number of subsequent pregnancies is not limited to one. Page Ref: 630 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

31) In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the client is draped for surgery? A) Maternal temperature B) Maternal urine output C) Vaginal exam D) Fetal heart tones Answer: D Explanation: A) The supine position would not cause an abnormality in maternal temperature. B) The supine position would not cause an abnormality in maternal urine output. C) There is no indication that a vaginal exam should be performed. D) Ascertain fetal heart rate (FHR) before surgery and during preparation, because fetal hypoxia can result from aortocaval compression. Page Ref: 632 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

32) A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that the client requires more information about VBAC? A) "I can try a vaginal birth because my uterine incision is a low segment transverse incision." B) "The vertical scar on my skin doesn't mean that the scar on my uterus goes in the same direction." C) "There is about a 90% chance of giving birth vaginally after a cesarean." D) "Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there." Answer: C Explanation: A) Only low segment transverse uterine incisions are recommended for attempting a VBAC. B) Abdominal skin incisions and uterine incisions are not always the same. C) Women whose previous cesarean was performed because of nonrecurring indications have been reported to have approximately a 60% to 80% chance of success with VBAC. D) VBAC should be attempted only in facilities that have in-house anesthesia personnel available for emergency cesarean births if warranted. Page Ref: 634 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Examine the risks, guidelines, and nursing care of the woman undergoing vaginal birth after cesarean birth (VBAC) or a trial of labor after cesarean birth (TOLAC). MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

33) The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? A) "Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC." B) "My first baby was in a breech position, so for this pregnancy, I can try a VBAC if the baby is head-down." C) "Because my hospital is so small and in a rural area, they won't let me attempt a VBAC." D) "The rate of complications from VBAC is lower than the rate of complications from a cesarean." Answer: A Explanation: A) Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding whether VBAC is advisable. The classic vertical incision was commonly done in the past and is associated with increased risk of uterine rupture in subsequent pregnancies and labor. B) Nonrecurring conditions such as any non-vertex presentation might make VBAC a viable option as long as this pregnancy is vertex. C) For a VBAC to be safely attempted, the facilities must have in-house anesthesia personnel available for emergency cesarean births if warranted. Many small and rural hospitals do not have surgical and anesthesia staff available at night or on weekends and holidays, and therefore do not allow clients to have VBACs. D) The incidence of uterine rupture is 0.1% to 0.7%. Page Ref: 634 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Examine the risks, guidelines, and nursing care of the woman undergoing vaginal birth after cesarean birth (VBAC) or a trial of labor after cesarean birth (TOLAC). MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

34) The healthcare provider of a laboring patient is considering a mediolateral episiotomy. On the following diagram, identify where this incision should be made.

A) A B) B C) C D) D Answer: B Explanation: B) The mediolateral episiotomy begins in the midline of the posterior fourchette (to avoid incision into the Bartholin gland) and extends at a 45-degree angle downward to the right or left (the direction depending on the handedness of the clinician). Page Ref: 624 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. | Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale for each, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

35) The healthcare provider asks for forceps to aid in the delivery of a fetus that is engaged, but the leading edge is at +1. Which type of forceps should be handed to the healthcare provider for this delivery? A)

Answer: B Explanation: B) The criterion for midforceps application is that the fetal head must be engaged (largest diameter of the head reaches or passes through the pelvic inlet), but the leading edge (presenting part) of the fetal skull is above a plus 2 (+2) station (for example, +1, 0, —1, —2). When midforceps are used, the goal is to apply traction and, frequently, to rotate the head and facilitate the vaginal birth. Kielland forceps are used for midforceps rotations. Elliot and Simpson forceps are used as outlet forceps. Piper forceps are used to provide traction and flexion of the after-coming head of a fetus in breech presentation. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types of forceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

36) Forceps are being used to deliver the fetus of a laboring patient, as identified in the diagram. In which direction should the healthcare provider use the forceps to guide the fetus for delivery?

A) Upward and outward B) Downward and outward C) Midline and towards the left D) Midline and toward the right Answer: B Explanation: B) During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal. Upward, midline, or towards the left or right do not follow the direction of the birth canal. Page Ref: 627 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types of forceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

37) The spouse of a laboring patient is concerned that the baby is taking too long to be delivered and he has overhead some discussion about using a vacuum. Which diagram should the nurse show the spouse to explain the procedure being discussed? A)

Answer: D Explanation: D) For vacuum extractor traction the cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. Choice 1 is a diagram of a forceps delivery. Choice 2 is a diagram showing locations of episiotomies. Choice 3 is a diagram showing the location of the incision for a classic cesarean section. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications, procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

38) A patient is scheduled to have the following type of incision for a cesarean birth. What advantage should the nurse explain to the patient that this type of incision has?

A) Easier to repair B) Less blood loss C) Expedites delivery of multiple fetuses D) Less likely to rupture with future pregnancies Answer: C Explanation: C) A lower uterine segment vertical incision (Sellheim) is preferred for multiple gestations. The lower uterine segment transverse incision (Kerr) is the most commonly used and easiest to repair, has less blood loss, and is less likely to rupture with future pregnancies. Page Ref: 631 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birth-related procedures.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 26 Physiologic Responses of the Newborn to Birth 1) The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Respiratory rate of 66 breaths per minute B) Periodic breathing with pauses of 25 seconds C) Synchronous chest and abdomen movements D) Grunting on expiration E) Nasal flaring Answer: B, D, E Explanation: A) Immediately after birth and for the next 2 hours, the normal respiratory rate is 60 to 70 breaths per minute. B) Periodic breathing with pauses longer than 20 seconds (apnea) is an abnormal finding that should be reported to the physician. C) Abdominal movements that are synchronous with the chest movements are normal. D) Grunting on expiration is an abnormal finding that should be reported to the physician. E) Nasal flaring is an abnormal finding that should be reported to the physician. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Review the significant developments of the fetal respiratory system. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

2) A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? A) Call the physician. B) Administer oxygen. C) Document the finding. D) Place the newborn under the radiant warmer. Answer: C Explanation: A) The apical pulse rate is within normal range. There is no need to call the physician. B) There is no need to administer oxygen at this time. C) An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep. D) There is no need to place the infant in a radiant warmer. Page Ref: 643 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Summarize the cardiopulmonary changes that must occur for the newborn to successfully transition to extrauterine life. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

3) The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? A) Respiratory rate 60 and irregular in depth and rhythm B) Pulse rate 145, cardiac murmur heard C) Mean blood pressure 55 mmHg D) Pauses in respiration lasting 30 seconds Answer: D Explanation: A) The respiratory rate is normal. The normal newborn respiratory rate is 30 to 60 breaths per minute. Initial respirations may be largely diaphragmatic, shallow, and irregular in depth and rhythm. B) This pulse rate is normal. The average resting heart rate in the first week of life is 110 to 160 beats/min. Cardiac murmurs are often present in the initial newborn period as transition from fetal to neonatal circulation occurs. C) This is a normal finding in an infant 1 hour old. The average mean blood pressure is 31 to 61 mmHg in full-term resting newborns. D) Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Review the significant developments of the fetal respiratory system. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

4) The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? A) 60 breaths per minute B) 70 breaths per minute C) 64 breaths per minute D) 20 breaths per minute Answer: D Explanation: A) The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute. B) The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute. C) The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute. D) If respirations drop below 20 when the baby is at rest the primary care provider should be notified. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Review the significant developments of the fetal respiratory system. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

5) Marked changes that occur in the cardiopulmonary system at birth include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Closure of the foramen ovale B) Closure of the ductus venosus C) Mean blood pressure of 31 to 61 mmHg in full-term resting newborns D) Increased systemic vascular resistance and decreased pulmonary vascular resistance E) Opening of the ductus arteriosus Answer: A, B, D Explanation: A) Closure of the foramen ovale is a function of changing arterial pressures. B) Closure of the ductus venosus is related to mechanical pressure changes that result from severing the cord, redistribution of blood, and cardiac output. C) The average mean blood pressure of 31 to 61 mmHg in full-term resting newborns is a normal finding, but not a marked change in the cardiopulmonary system. D) Increased systemic vascular resistance and decreased pulmonary vascular resistance; with the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. The combination of vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance. E) Functional closure, not opening, of the ductus arteriosus in the well newborn starts at 10 to 15 hours after birth. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Summarize the cardiopulmonary changes that must occur for the newborn to successfully transition to extrauterine life. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

6) The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? A) "My baby isn't getting enough iron from my breast milk." B) "Babies undergo physiologic anemia of infancy." C) "This results from dilution because of the increased plasma volume." D) "Delaying the cord clamping did not cause this to happen." Answer: A Explanation: A) At 2 months of age, infants increase their plasma volume, which results in physiologic anemia. This condition is not related to iron in the breast milk. B) This initial decline in hemoglobin creates a phenomenon known as physiologic anemia of the newborn. C) Hemoglobin values fall, mainly from a decrease in red cell mass rather than from the dilutional effect of increasing plasma volume. D) Early or delayed cord clamping does not affect hemoglobin levels at this age. Page Ref: 644 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Explain the differences in fetal and adult hemoglobin and why this is important in transition to extrauterine life. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

7) Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? A) Fewer infants require blood transfusion for anemia B) Fewer infants require blood transfusion for high blood pressure C) Increase in the incidence of intraventricular hemorrhage D) Increase in incidence of infant breastfeeding Answer: A Explanation: A) Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for anemia. B) Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for low blood pressure. C) Delayed umbilical cord clamping shows a significant reduction in the incidence of intraventricular hemorrhage. D) Delayed umbilical cord clamping does not impact the incidence of breastfeeding. Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Explain the differences in fetal and adult hemoglobin and why this is important in transition to extrauterine life. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

8) In utero, what is the organ responsible for gas exchange? A) Umbilical vein B) Placenta C) Inferior vena cava D) Right atrium Answer: B Explanation: A) From the placenta, highly oxygenated blood flows through the umbilical vein. B) In utero, the placenta is the organ of gas exchange. C) From the placenta, highly oxygenated blood flows through the umbilical vein. A small amount of blood perfuses the liver, with the majority of blood volume flowing through the inferior vena cava and to the right atrium. D) From the placenta, highly oxygenated blood flows through the umbilical vein. A small amount of blood perfuses the liver, with the majority of blood volume flowing through the inferior vena cava and to the right atrium. Page Ref: 639 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Review the significant developments of the fetal respiratory system. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

9) A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Newborns have less subcutaneous fat than do adults. B) Infants have a thick epidermis layer. C) Newborns have a large body surface to weight ratio. D) Infants have increased total body water. E) Newborns have more subcutaneous fat than do adults. Answer: A, C, D Explanation: A) Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's decreased subcutaneous fat. B) Preterm infants have increased heat loss via evaporation due to thin skin. C) Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's large body surface to weight ratio. D) Preterm infants have increased heat loss via evaporation due to increased total body water. E) Newborns do not have more subcutaneous fat than adults. Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

10) The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "We should keep our home air-conditioned so the baby doesn't overheat." B) "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." C) "When we change the baby's diaper, we should change any wet clothing or blankets, too." D) "If the baby's body temperature gets too low, he will warm himself up without any shivering." E) "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." Answer: B, C, D, E Explanation: A) Because of the risk of hypothermia and possible cold stress, minimizing heat loss in the newborn after birth is essential. B) The newborn is particularly prone to heat loss by evaporation immediately after birth and during baths; thus drying the newborn is critical. C) Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. D) Nonshivering thermogenesis (NST), an important mechanism of heat production unique to the newborn, is the major mechanism through which heat is produced. E) A decrease in the environmental temperature of 2°C is a drop sufficient to double the oxygen consumption of a term newborn and can cause the newborn to show signs of respiratory distress. Page Ref: 646 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

11) The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? A) Placing the newborn away from air currents B) Pre-warming the examination table C) Drying the newborn thoroughly D) Removing wet linens from the isolette Answer: C Explanation: A) Placing the newborn away from air currents reduces heat loss by convection, which is not the most common form of heat loss. B) Pre-warming the examination table reduces heat loss by conduction, which is not the most common form of heat loss. C) The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus drying the newborn is critical. D) Removing wet linens from the isolette that are not in direct contact with the newborn reduces heat loss by radiation, which is not the most common form of heat loss. Page Ref: 646 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

12) The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? A) Conjugated bilirubin is eliminated in the conjugated state. B) Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. C) Total bilirubin is the sum of the direct and indirect levels. D) Hyperbilirubinemia is a decreased total serum bilirubin level. Answer: C Explanation: A) The (direct) conjugated bilirubin progresses down the intestines, where bacteria transform it into urobilinogen (urine bilirubin). Even after the bilirubin has been conjugated and bound, it can be changed back to unconjugated bilirubin via the enterohepatic circulation. B) Fetal unconjugated bilirubin crosses the placenta to be excreted, so the fetus does not need to conjugate bilirubin. C) Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin. D) Hyperbilirubinemia is an elevated total serum bilirubin level. Page Ref: 648 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

13) A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? A) Stool characteristics B) Fluid intake C) Skin color D) Bilirubin level Answer: C Explanation: A) The stool characteristic of green coloration indicates excretion of bilirubin. B) Breastfeeding is implicated in jaundice in some newborns. Breast milk jaundice occurs in approximately 2% to 4% of term infants with an onset of 4 to 7 days of life. C) Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Inspection of the skin would be the first step in assessing for jaundice. D) Bilirubin is primarily the metabolic end product of erythrocyte (RBC) breakdown. Conjugation, or the changing of bilirubin into an excretable form, is the conversion of the yellow lipid-soluble pigment (unconjugated, indirect) into water-soluble pigment (excretable, direct). Page Ref: 648 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

14) The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? A) Physiologic jaundice is normal, and peaks at this age. B) The newborn's liver is not working as well as it should. C) The baby is yellow because the bowels are not excreting bilirubin. D) The yellow color indicates that brain damage might be occurring. Answer: A Explanation: A) Physiologic jaundice occurs soon after birth. Bilirubin levels peak at 3 to 5 days in term infants. B) The liver of an infant is not fully mature at this point. C) The liver of an infant conjugates the bilirubin, which is then excreted through the bowels. D) Unmonitored and untreated severe hyperbilirubinemia may progress to excessive levels that are associated with bilirubin neurotoxicity. An infant with severe jaundice would have a high level of yellow skin color, but this infant is only slightly yellow. Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

15) The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? A) "Jaundice is uncommon in newborns." B) "Some newborns require phototherapy." C) "Jaundice is a medical emergency." D) "Jaundice is always a sign of liver disease." Answer: B Explanation: A) Physiologic jaundice is a normal process that can occur after 24 hours of life and develops in more than 60% of term newborns and 80% of preterm neonates. B) Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a sign of liver disease. Physiologic jaundice might require phototherapy. C) Physiologic jaundice is a normal process that can occur after 24 hours of life in about half of healthy newborns. It is not a medical emergency. D) Physiologic jaundice is not a sign of liver disease. Page Ref: 648 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

16) Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? A) Monitor urine for amount and characteristics. B) Encourage late feedings to promote intestinal elimination. C) All infants should be routinely monitored for iron intake. D) Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above. Answer: D Explanation: A) Monitor stool for amount and characteristics. Bilirubin is eliminated in the feces. B) Encourage early feedings to promote intestinal elimination and bacterial colonization, and to provide the caloric intake necessary for hepatic binding proteins to form. C) All infants should be routinely monitored for the development of jaundice. D) Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above; cold stress results in acidosis. Page Ref: 649 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

17) Clinical risk factors for severe hyperbilirubinemia include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) African American ethnicity B) Female gender C) Cephalohematoma D) Bruising E) Assisted delivery with vacuum or forceps Answer: C, D, E Explanation: A) A clinical risk factor for severe hyperbilirubinemia includes Asian ethnicity. B) A clinical risk factor for severe hyperbilirubinemia includes male gender. C) A clinical risk factor for severe hyperbilirubinemia includes cephalohematoma. D) A clinical risk factor for severe hyperbilirubinemia includes bruising. E) A clinical risk factor for severe hyperbilirubinemia includes assisted delivery with vacuum or forceps. Page Ref: 649 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

18) The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? A) "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." B) "The infant received too many red blood cells after delivery because the cord was not clamped immediately." C) "The yellow color of your baby's skin indicates that you are breastfeeding too often." D) "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." Answer: A Explanation: A) Physiologic jaundice is a common occurrence, and peaks at 3 to 5 days in term infants. The reduction in hepatic activity, along with a relatively large bilirubin load, decreases the liver's ability to conjugate bilirubin and increases susceptibility to jaundice. B) The conjugation of bilirubin has nothing to do with cord clamping. C) Prevention and treatment of early breastfeeding jaundice includes encouraging frequent (every 2 to 3 hours) breastfeeding. D) Direct bilirubin is excreted into the bile ducts and duodenum. The conjugated bilirubin then progresses down the intestines, where bacteria transform it into urobilinogen and stercobilinogen. Stercobilinogen is not reabsorbed, but is excreted as a yellow-brown pigment in the stools. Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the reasons a newborn may develop hyperbilirubinemia and the nursing interventions that can decrease the probability of jaundice. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

19) Which of the following is the primary carbohydrate in the breastfeeding newborn? A) Glucose B) Fructose C) Lactose D) Maltose Answer: C Explanation: A) Glucose is not the primary carbohydrate in the breastfeeding newborn. B) Fructose is not the primary carbohydrate in the breastfeeding newborn. C) Lactose is the primary carbohydrate in the breastfeeding newborn and is generally easily digested and well absorbed. D) Newborns have trouble digesting starches (changing more complex carbohydrates into maltose), so they should not eat them until after the first 6 months of life. Page Ref: 651 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and excellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

20) At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? A) This weight loss is excessive. B) This weight loss is within normal limits. C) This weight gain is excessive. D) This weight gain is within normal limits. Answer: A Explanation: A) This newborn has lost more than 10% of the birth weight; this weight loss is excessive. Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns. B) This weight loss is greater than the expected 5% to 10%. C) This is not a weight gain. D) This is not a weight gain. Page Ref: 651 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

21) A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? A) "I can't believe he can already digest fats, carbohydrates, and proteins." B) "It is amazing that his whole digestive tract can move things along at birth." C) "Incredibly, his stomach capacity was already a cupful when he was born." D) "He will lose some weight but then miraculously regain it by about 10 days." Answer: C Explanation: A) At birth, neonates can digest fats, simple carbohydrates, and proteins. B) The stomach empties intermittently, starting within a few minutes of the beginning of a feeding and ending between 2 and 4 hours after feeding. C) The newborn's stomach has a capacity of 50 to 60 mL. D) Following birth, caloric intake is often insufficient for weight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns. Page Ref: 651 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

22) A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "There might be a possible food allergy." C) "Your newborn has diarrhea." D) "This is a normal occurrence." Answer: D Explanation: A) It is not necessary for the client to take her newborn to the pediatrician. B) The green color of stool is not due to food allergies. C) The green color of stool is not due to diarrhea. D) The newborn's stools change from meconium (thick, tarry, black) to transitional stools (thinner, brown to green). Page Ref: 651 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

23) A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Restlessness B) Pain C) Kidney distention D) Adequacy of fluid intake E) Lethargy Answer: A, B, D Explanation: A) A newborn who has not voided by 48 hours after birth should be assessed for restlessness. B) A newborn who has not voided by 48 hours after birth should be assessed for pain. C) A newborn who has not voided by 48 hours after birth should be assessed for bladder distention, not kidney distention. D) A newborn who has not voided by 48 hours after birth should be assessed for adequacy of fluid intake. E) A newborn who has not voided by 48 hours after birth should be assessed for restlessness, not lethargy. Page Ref: 652 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Relate the development of the newborn kidney to the newborn's ability to maintain adequate fluid and electrolyte balance. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

24) The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? A) "Our baby was born with kidneys that are too small." B) "A baby's kidneys don't concentrate urine well for several months." C) "Feeding our baby frequently will help the kidneys function." D) "Kidney function in an infant is very different from that in an adult." Answer: A Explanation: A) Size of the kidneys is rarely an issue. B) The ability to concentrate urine fully is attained by 3 months of age. C) Feeding practices may affect the osmolarity of the urine but have limited effect on concentration of the urine. D) The neonate's ability to dilute urine is fully developed, but concentrating ability is limited. Page Ref: 652 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Relate the development of the newborn kidney to the newborn's ability to maintain adequate fluid and electrolyte balance. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

25) The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? A) A shift of intracellular water to extracellular spaces. B) Loss of meconium stool. C) A shift of extracellular water to intracellular spaces. D) The sleep-wake cycle. Answer: A Explanation: A) A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss. B) Loss of meconium stool does not effect this amount of weight loss. C) A shift of intracellular water to extracellular space and insensible water loss account for the 5% to 10% weight loss. D) The sleep-wake cycle does not effect this amount of weight loss. Page Ref: 651 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

26) Which of the following would be considered normal newborn urinalysis values? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Color bright yellow B) Bacteria 0 C) Red blood cells (RBC) 0 D) White blood cells (WBC) more than 4-5/hpf E) Protein less than 5-10 mg/dL Answer: B, C, E Explanation: A) Urine color should be pale yellow. B) Bacteria value should be 0. C) Red blood cells (RBC) should be 0. D) White blood cells (WBC) should be less than 2-3/hpf. E) Protein less than 5-10 mg/dL would be considered normal. Page Ref: 652 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Relate the development of the newborn kidney to the newborn's ability to maintain adequate fluid and electrolyte balance. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

27) The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? A) "Newborns have immature immune function at birth, and illness is very hard to detect." B) "Your mothering skills will improve with time. You should take the newborn class." C) "Your baby didn't get enough active acquired immunity from you during the pregnancy." D) "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old." Answer: A Explanation: A) The immune responses in neonates are usually functionally impaired when compared with adults. B) This response does not address the physiology of neonatal infection, and is not therapeutic because it is blaming. C) The pregnant woman forms antibodies in response to illness or immunization called active acquired immunity. Neonatal defense against infections in utero or after delivery is dependent on maternal immunity. D) When antibodies are transferred to the fetus in utero, passive acquired immunity results because the fetus does not produce the antibodies itself. Page Ref: 652 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Describe basic newborn immunologic responses. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

28) Which nonspecific immune mechanism helps the ability of antibodies and phagocytic cells to clear pathogens from an organism? A) Complement B) Coagulation C) Inflammatory response D) Phagocytosis Answer: A Explanation: A) Complement helps or "complements" the ability of antibodies and phagocytic cells to clear pathogens from an organism. B) Coagulation is the process by which blood forms a clot. C) Inflammatory response is the complex biologic response of vascular tissues to harmful stimuli such as pathogens, damaged cells or irritants. D) Phagocytosis is a major mechanism to remove pathogens and cell debris. Page Ref: 652 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Describe basic newborn immunologic responses. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth. 29) Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? A) Enable T or B cells to respond to antigens B) Repress responses to specific B or T lymphocytes to antigens C) Kill foreign or virus-infected cells D) Remove pathogens and cell debris Answer: C Explanation: A) Helper activated T cells enable T or B cells to respond to antigens. B) Suppressor activated T cells repress responses to specific B or T lymphocytes to antigens. C) Cytotoxic activated T cells kill foreign or virus-infected cells. D) Phagocytosis is a major mechanism to remove pathogens and cell debris. Page Ref: 653 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Describe basic newborn immunologic responses. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

30) The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? A) Habituation B) Orientation C) Self-quieting D) Reactivity Answer: B Explanation: A) Habituation is the newborn's ability to process and respond to complex stimulation. B) Orientation is the newborn's ability to be alert to, follow, and fixate on complex visual stimuli that have a particular appeal and attraction. The newborn prefers the human face and eyes, and bright shiny objects. C) Self-quieting is the ability of newborns to use their own resources to quiet and comfort themselves. D) The newborn usually shows a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity separated by a sleep phase. Page Ref: 655 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the physiologic and behavioral characteristics of newborn neurologic functioning, patterns of behavior during periods of reactivity, and possible nursing interventions. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

31) A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? A) "Babies have several sleep and alert states. Keep watching and you'll notice them." B) "You might have noticed that your child was in an alert awake state for an hour after birth." C) "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." D) "Birth is hard work for babies. It takes them a week or two to recover and become more awake." Answer: C Explanation: A) Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. B) Although this statement is true, it does not respond to the father's question about sleeping now. C) Teaching the parents how to recognize the two sleep stages helps them tune in to their infant's behavioral states. D) Recovery from the birth process only takes a day or two. The newborn usually shows a predictable pattern of behavior during the first several hours after birth. Page Ref: 654 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Explain the physiologic and behavioral characteristics of newborn neurologic functioning, patterns of behavior during periods of reactivity, and possible nursing interventions. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

32) A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? A) "Don't worry. Babies go through a lot of these little phases." B) "Your son is in the sleep phase. He'll wake up soon." C) "Your son is exhausted from being born, and will sleep 6 more hours." D) "Your breastfeeding efforts have caused excessive fatigue in your son." Answer: B Explanation: A) Although this infant's behavior is expected, nurses must avoid using clichés in therapeutic communication. B) The first period of reactivity lasts approximately 30 minutes after birth. During this period the newborn is awake and active and may appear hungry and have a strong sucking reflex. After approximately half an hour, the newborn's activity gradually diminishes, and the heart rate and respirations decrease as the newborn enters the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours. C) Six hours of sleep at this point is not an expected finding. D) Breastfeeding does not cause fatigue in a normal term newborn. Page Ref: 654 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Explain the physiologic and behavioral characteristics of newborn neurologic functioning, patterns of behavior during periods of reactivity, and possible nursing interventions. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

33) The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? A) "My baby will be able to focus on my face when she is about a month old." B) "My baby might startle a little if a loud noise happens near him." C) "Newborns prefer sour tastes." D) "Our baby won't have a sense of smell until she is older." Answer: B Explanation: A) Newborns can focus on faces, eyes, and shiny objects at birth. B) Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex are ways to soothe the newborn. The settled newborn is then able to attend to and interact with the environment. C) Newborns can distinguish between sweet and sour at 3 days of age. Sugar, for example, increases sucking, and newborns tend to have a preference for sweet tastes. D) Newborns develop the sense of smell rapidly and can differentiate their mother by smell within the first week of life. Page Ref: 655 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Describe the normal sensory/perceptual abilities and behavioral states present in the newborn period and the associated nursing care. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

34) The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? A) "Sleep and alert states cycle throughout the day." B) "We can best bond with our child during an alert state." C) "About half of the baby's sleep time is in active sleep." D) "Babies sleep during the night right from birth." Answer: D Explanation: A) Sleep and alert states are noticeable behaviors in infants, beginning immediately after birth with the first period of alert activity. B) Bonding between infant and parents takes place with interaction during alert states. C) About 45% to 50% of the newborn's total sleep is active sleep, 35% to 45% is quiet sleep, and 10% is transitional between these two periods. D) Over time, the newborn's sleep-wake patterns become diurnal, that is, the newborn sleeps at night and stays awake during the day. Page Ref: 654 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Describe the normal sensory/perceptual abilities and behavioral states present in the newborn period and the associated nursing care. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

35) The nurse is explaining the process of how a newborn adapts to breathing after delivery. In which order should the nurse review the following diagrams? 1.

Answer: 3, 1, 4, 2 Explanation: In Diagram 3, fetal alveoli are filled to functional residual capacity with fetal lung fluid. Fetal lung fluid is produced by the alveoli, fills the airways, and eventually enters the amniotic fluid. Diagram 1 shows how after fetal chest compression, one third of the fetal lung fluid is squeezed out, allowing air to enter passively as the chest recoils. Diagram 4 shows how with each subsequent breath, the lungs expand, facilitating the movement of the remaining fetal lung fluid into the capillaries and lymphatic system. Pulmonary blood flow is increasing. Diagram 2 shows normal alveoli after removal of fetal lung fluid and dilatation of pulmonary arteries. Surfactant has lined the inside of the alveoli to prevent collapse. Page Ref: 639 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Review the significant developments of the fetal respiratory system. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

36) The nurse is explaining the processes of infant heat loss to a new mother. Which diagram should the nurse use to describe the process of convection? A)

Answer: B Explanation: B) Convection is the loss of heat from the warm body surface to cooler air currents, as shown in Diagram 2. Air-conditioned rooms, air currents with a temperature below the infant's skin temperature, unwarmed oxygen by mask, and removal of the infant from an incubator for procedures increase convective heat loss of the newborn. Conduction is the loss of heat to a cooler surface by direct skin contact, as shown in Diagram 1. Chilled hands, cool scales, cold examination tables, and cold stethoscopes can cause heat loss by conduction. Evaporation is the loss of heat incurred when water is converted to a vapor, as shown in Diagram 3. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; therefore, drying the newborn is critical. Radiation losses occur when body heat is transferred to cooler surfaces and objects that are not in direct contact with the body, as shown in Diagram 4. The walls of a room or of an incubator are potential causes of heat loss by radiation, even if the ambient temperature of the incubator is within the neutral thermal range for the infant. Page Ref: 646 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Relate the process of thermogenesis and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

37) The nurse is instructing a new mother on the amount and frequency of bottle-feeding for her newborn. The mother plans to use formula that is available in 6-ounce cans. If the infant ingests 25 mL for each of 8 feedings per day, how many cans of formula should the mother have available for a week? (Round to the nearest whole number.) Answer: 8 cans Explanation: One ounce is equal to 30 mL. For a 6-ounce can, the amount of formula is 30 x 6 or 180 mL. For one day, the infant will ingest 25 mL x 8 feedings or 200 mL. For 7 days the infant will ingest 200 mL x 7 = 1400 mL. To determine the number of cans of formula needed divide the weekly total of 1400 mL by 180 mL or 1400/180 = 7.78 or 8 cans of formula is needed. Page Ref: 651 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth. 38) At birth, a newborn weighs 8 pounds 4 ounces. When discussing the infant's weight over the next week, what is the maximum amount of weight the mother should expect that the infant will lose? (Calculate to the first decimal point.) Answer: 13.2 ounces Explanation: The maximum amount of weight loss over the first 5 to 10 days of extrauterine life is 10%. If the infant weighs 8 pounds 4 ounces, this weight in ounces is 132 ounces. Multiply this weight by 10% to find that the mother can expect the infant to lose 13.2 ounces. When converted to pounds and ounces, the infant should not weight less than 7 pounds 5 ounces. Page Ref: 651 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

39) During a home visit the mother of a 2 week old newborn is concerned that the baby always seems to be "wet" and wonders if this is normal. The newborn weighs 4 kg. How many mL of fluid should the nurse explain that the infant makes each day? (Round to the nearest whole number.) Answer: 100 mL Explanation: The newborn voids 5 to 25 times every 24 hours, with a volume of 25 mL/kg/day. If the newborn weighs 4 kg then the amount of urine produced every day is 25 mL x 4 = 100 mL. Page Ref: 652 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 6 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. MNL LO: Demonstrate understanding of the physiological responses of the newborn to birth.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 27 Nursing Assessment of the Newborn 1) A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? A) Arm recoil B) Square window sign C) Scarf sign D) Popliteal angle Answer: A Explanation: A) Arm recoil is slower in healthy but fatigued newborns after birth; therefore, arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth. B) The square window sign does not have to be assessed after the first hour of birth. C) The scarf sign does not have to be assessed after the first hour of birth. D) The popliteal angle does not have to be assessed after the first hour of birth. Page Ref: 665 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Identify the major assessment time periods for the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

2) Before drying off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? A) Amount and area of vernix coverage B) Creases on the sole C) Size of the areola D) Body surface temperature Answer: A Explanation: A) Drying the baby after birth will disturb the vernix and potentially alter the gestational age criterion. The nurse should document the amount and areas of vernix coverage before drying the newborn. B) Creases on the sole are not affected by drying the newborn. C) The size of the areola is not affected by drying the newborn. D) Body surface temperature is not part of the Ballard gestational assessment tool. Page Ref: 664 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

3) A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The mass appeared on the second day after birth. B) The mass appears larger when the newborn cries. C) The head appears asymmetrical. D) The mass appears on only one side of the head. E) The mass overrides the suture line. Answer: A, D Explanation: A) A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days. B) A cephalohematoma does not increase in size when the newborn cries. C) Molding causes the head to appear asymmetrical because of the overriding of cranial bones during labor and birth. D) Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. E) Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. Page Ref: 675 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

4) The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? A) Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline B) Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body C) Ear cartilage folded over, lanugo present over much of the body, slow recoil time D) 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension Answer: C Explanation: A) Full sole creases and nails beyond the fingertips are seen in term infants; a scarf sign beyond the midline is characteristic of a preterm infant. B) Testes in the upper scrotum and rugae-covered scrotum are seen in term infants. Vernix covering the body is an indication of a preterm infant. C) Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. D) 1 cm breast bud, peeling skin, the presence of adipose tissue so that veins are not visible, and rapid recoil of the legs and arms are all indications of term or post-term infants. Page Ref: 661 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

5) The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? A) Lanugo mainly gone, little vernix across the body B) Prominent clitoris, enlarging minora, anus patent C) Full areola, 5 to 10 mm bud, pinkish-brown in color D) Skin opaque, cracking at wrists and ankles, no vessels visible Answer: B Explanation: A) Lanugo and vernix disappear as the infant approaches term. B) At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they nearly cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. C) Areolas develop greater size with advancing gestational age. D) The skin of a preterm infant is translucent, and vessels are visible through the skin. Page Ref: 664 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

6) The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A) Chest circumference 31.5 cm, head circumference 33.5 cm B) Chest circumference 30 cm, head circumference 29 cm C) Chest circumference 38 cm, head circumference 31.5 cm D) Chest circumference 32.5 cm, head circumference 36 cm Answer: A Explanation: A) The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. B) The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. C) The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. D) The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. Page Ref: 669 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

7) A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? A) 2 months B) 2 weeks C) 1 year D) 4 months Answer: D Explanation: A) It usually takes a little longer than 2 months for transient strabismus to disappear. B) Transient strabismus lasts longer than 2 weeks. C) Transient strabismus generally does not last 1 year. D) Transient strabismus is caused by poor neuromuscular control of the eye muscles and gradually regresses in 3 to 4 months. Page Ref: 676 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

8) The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? A) A normal position B) A possible chromosomal abnormality C) Facial paralysis D) Prematurity Answer: A Explanation: A) The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn. B) Low-set ears could indicate a chromosomal abnormality. C) This ear position is not indicative of facial paralysis. D) This ear position is not indicative of prematurity. Page Ref: 678 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

9) The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? A) Cephalohematoma B) Mongolian spots C) Telangiectatic nevi D) Molding Answer: A Explanation: A) A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. They may be associated with physiologic jaundice, because there are extra red blood cells being destroyed within the cephalohematoma. B) Mongolian spots are macular areas of bluish-black pigmentation on the dorsal area of the buttocks. C) Telangiectatic nevi are pale pink or red spots found on the eyelids, nose, lower occipital bone, or nape of the neck. D) Molding is caused by overriding of the cranial bones. Page Ref: 675 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

10) The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? A) "His head is molded from fitting through the birth canal. It will become more round." B) "We refer to that as 'cone head,' which is a temporary condition that goes away." C) "It might mean that your baby sustained brain damage during birth, and could have delays." D) "I think he looks just like you. Your head is much the same shape as your baby's." Answer: A Explanation: A) This statement is accurate and directly answers the father's question. B) Although nursing staff might refer to a molded head as "cone head" and the shape is temporary, it is better to be more specific in explaining why the head is shaped as it is. In addition, this answer does not answer the "why" question posed by the father. C) A molded head shape does not indicate brain damage. Molding is normal and transient. D) Although this might be true, it is better to give a factual answer that does not imply that the father's head is abnormally shaped. This answer could be perceived as insulting. Page Ref: 674 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

11) The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? A) Place a gloved finger in the newborn's mouth. B) Take the vital signs. C) Wait until the newborn stops crying. D) Place a hot water bottle in the isolette. Answer: A Explanation: A) Vital sign assessments are most accurate if the newborn is at rest, so measure pulse and respirations first if the baby is quiet. To soothe a crying baby, the nurse should place a moistened, unpowdered, gloved finger in the baby's mouth, and then complete the assessment while the baby suckles. B) Crying increases heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. C) Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might cause too long a delay. D) A hot water bottle should not be placed next to the newborn because of the risk for burns. Page Ref: 678 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

12) The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A) Brazelton Neonatal Behavioral Assessment Scale B) New Ballard Score C) Dubowitz gestational age scale D) Ortolani maneuver Answer: A Explanation: A) Brazelton Neonatal Behavioral Assessment Scale is an assessment tool that identifies the newborn's repertoire of behavioral responses to the environment and documents the newborn's neurologic adequacy and capabilities. B) Ballard developed the estimation of gestational age by maturity rating. C) The Dubowitz assessment tool assesses physical characteristics and neurological or neuromuscular development. D) The Ortolani maneuver is an assessment technique to evaluate for hip dislocation or hip instability. Page Ref: 684 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

13) The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? A) "I'm checking to make sure the baby has all of its parts." B) "This assessment looks at both physical aspects and the nervous system." C) "This assessment checks the baby's brain and nerve function." D) "Don't worry. We perform this check on all the babies." Answer: B Explanation: A) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. B) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. C) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. D) Nurses must always use therapeutic communication and giving a "don't worry" answer dismisses the client's question or concern. Page Ref: 659 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

14) The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? A) Notify the physician. B) Elevate the newborn's head. C) Document the findings in the chart. D) Assess for hypothermia immediately. Answer: C Explanation: A) A physician would be notified only if findings were abnormal. B) There is no indication that the newborn's head should be elevated. C) Documentation is the appropriate first step. The average circumference of the head at birth is 32 to 37 cm, and average chest circumference ranges from 30 to 35 cm. D) None of the findings indicates hypothermia. No data on temperature are given. Page Ref: 669 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

15) The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? A) "The white spots on my baby's nose are called milia, and are harmless." B) "The whitish cheeselike substance in the creases is vernix, and will be absorbed." C) "The red spots with a white center on my baby are abnormal acne." D) "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician." Answer: C Explanation: A) Milia are exposed sebaceous glands, and appear as white spots, often across the nose. B) Disappearance of the protective vernix caseosa promotes skin desquamation. C) Red spots with white or yellow centers are erythema toxicum. The peak incidence is at 24 to 48 hours of life. The condition rarely presents at birth or after 5 days of life. The cause is unknown, and no treatment is necessary. D) Jaundice is a yellowish discoloration of skin and mucous membranes. Any jaundice noted before 24 hours of age should be reported to the physician or nurse practitioner. Page Ref: 672 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

16) During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? A) Nevus vasculosus B) Nevus flammeus C) Telangiectatic nevi D) A Mongolian spot Answer: C Explanation: A) Nevus vasculosus is a strawberry hemangioma. B) Nevus flammeus is a port-wine stain hemangioma. C) Telangiectatic nevi (stork bites) appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck. D) Congenital dermal melanocytosis (Mongolian blue spots) are macular areas of bluish black or gray-blue pigmentation commonly found on the dorsal area and the buttocks but may be anywhere on the body. Page Ref: 673 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 2. Communicate patient values, preferences, and expressed needs to other members of the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

17) The mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." B) "Bring your infant to the clinic immediately." C) "This is due to overriding of the cranial bones during labor." D) "Your baby must be dehydrated." Answer: A Explanation: A) This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks. B) There is no reason to bring the infant to the clinic. C) Overriding of the cranial bones is referred to as molding, and diminishes within a few days following birth. D) Fontanelles can be depressed when the infant is dehydrated. Page Ref: 675 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

18) Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? A) Caput succedaneum B) Cephalohematoma C) Molding D) Depressed fontanelles Answer: A Explanation: A) Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction. B) Cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. C) The head may appear asymmetric in the newborn who had a vertex presentation. This asymmetry (molding) is caused by the overriding of the cranial bones during labor and birth. D) A depressed fontanelle indicates dehydration. Page Ref: 675 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

19) The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? A) Adducting the foot and listening for a click. B) Moving the foot to midline and determining resistance. C) Extending the foot and observing for pain. D) Stimulating the sole of the foot. Answer: B Explanation: A) Adducting the foot and listening for a click is not a typical assessment. B) Clubfoot is suspected when the foot does not turn to a midline position or align readily. C) Extending the foot and observing for pain does not confirm or rule out clubfoot. D) Stimulating the sole of the foot elicits the plantar grasp reflex, and is not an appropriate assessment for clubfoot. Page Ref: 682 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

20) A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The fontanelles can swell with crying. B) The fontanelles might be depressed. C) The fontanelles can pulsate with the heartbeat. D) The fontanelles might bulge. E) The fontanelles can swell when stool is passed. Answer: A, C, E Explanation: A) Newborn fontanelles can swell when the newborn cries. B) Depressed fontanelles indicate dehydration. C) Newborn fontanelles can pulsate with the heartbeat. D) Bulging fontanelles signify increased intracranial pressure. E) Newborn fontanelles can swell when the newborn passes a stool. Page Ref: 688 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

21) The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? A) The student nurse listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles. B) The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. C) The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. D) The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids. Answer: C Explanation: A) The head should be assessed before the bowel sounds. B) The respiratory rate should be assessed first, when the infant is at rest and undisturbed. C) Neonatal assessment proceeds in a head-to-toe fashion. D) The sclera and eye assessment should be done prior to assessing genitals. Page Ref: 668 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

22) Approximately what percentage of the newborn's body weight is water? A) 5% to 10% B) 90% to 95% C) 70% to 75% D) 50% to 60% Answer: C Explanation: A) During the initial newborn period, term newborns have a physiologic weight loss of about 5% to 10% because fluid shifts. B) Approximately 70% to 75% of the newborn's body weight is water. C) Approximately 70% to 75% of the newborn's body weight is water. D) Approximately 70% to 75% of the newborn's body weight is water. Page Ref: 668 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

23) What condition is due to poor peripheral circulation? A) Acrocyanosis B) Mottling C) Harlequin sign D) Jaundice Answer: A Explanation: A) Acrocyanosis is a bluish discoloration of the hands and feet that may be present in the first 24 hours after birth and is due to poor peripheral circulation, which results in vasomotor instability and capillary stasis, especially when the baby is exposed to cold. B) Mottling is a lacy pattern of dilated blood vessels under the skin and occurs as a result of general circulation fluctuations. C) Harlequin sign (clown) color change is a deep color that develops over one side of the newborn's body while the other side remains pale, so that the skin resembles a clown's suit. D) Jaundice is a yellowish discoloration of skin and mucous membranes first detectable on the face and the mucous membranes of the mouth. Page Ref: 671 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

24) The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Lanugo abundant over shoulders and back B) Plantar creases over entire sole C) Pinna of ear springs back slowly when folded. D) Vernix well distributed over entire body E) Testes are pendulous, and the scrotum has deep rugae Answer: B, E Explanation: A) Vernix and lanugo both disappear as the infant reaches term. B) Sole (plantar) creases are reliable indicators of gestational age in the first 12 hours of life. C) The pinna's springing back slowly indicates prematurity. By term, the newborn's pinna is firm, stands away from the head, and springs back quickly from the folding. D) Vernix and lanugo both disappear as the infant reaches term. E) By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae. Page Ref: 661, 663 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

25) The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? A) Ortolani maneuver B) Palmar grasping reflex C) Clavicle D) Tonic neck reflex Answer: C Explanation: A) Ortolani maneuver is an assessment technique that rules out the possibility of hip dislocation or hip instability. B) Palmar grasping reflex is elicited by stimulating the newborn's palm with a finger or object; the newborn grasps and holds the object or finger firmly enough to be lifted momentarily from the crib. C) When the Moro reflex is elicited, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle for a possible fracture. D) Tonic neck reflex (fencer position) is elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. Page Ref: 678 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Identify the newborn reflexes that are present at birth. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

26) The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? A) At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. B) When the corner of the mouth is touched, the infant turns the head that direction. C) The infant blinks when the exam light is turned on over the face and body. D) The right arm is flaccid while the infant brings the left arm and fist upward to the head. Answer: D Explanation: A) This is the normal resting posture of the infant. B) This is the rooting reflex, a normal finding in a newborn. C) Blinking in response to bright lights is an expected finding. D) Asymmetrical movement is not an expected finding, and could indicate neurological abnormality. Muscle tone should be symmetric and diminished muscle tone and flaccidity requires further evaluation. Page Ref: 683 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the components of a newborn neurologic assessment and the neurologic/neuromuscular characteristics of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

27) Which of the following are important behaviors to assess in the neurologic assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) State of alertness B) Active posture C) Quality of muscle tone D) Cry E) Motor activity Answer: A, C, D, E Explanation: A) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. B) Resting posture is assessed, not active posture. C) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. D) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. E) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. Page Ref: 683 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Describe the components of a newborn neurologic assessment and the neurologic/neuromuscular characteristics of the newborn. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

28) The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? A) "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." B) "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still." C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." D) "I can get my baby to turn his head toward the right if I lift his right arm over his head." Answer: C Explanation: A) This is the Moro or startle reflex, and occurs when the infant is startled by a sudden movement or a loud noise. B) Stepping reflex happens when a newborn who is held upright with one foot touching a flat surface puts one foot in front of the other and "walks." C) This is the Palmar grasp reflex and is elicited by stimulating the newborn's palm with a finger or object. D) This is the tonic neck reflex and is elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. Page Ref: 667 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Identify the newborn reflexes that are present at birth. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

29) The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse? A) "Every baby is different. This is just one variation of normal that we see on a regular basis." B) "This baby might not have a rooting or sucking reflex because she is premature." C) "When she is wide awake and alert, she will probably root and suck even if she is early." D) "She might be too tired from the birthing process and need a couple of days to recover." Answer: B Explanation: A) Although each baby is unique and different from siblings, this response is not accurate. B) Preterm babies may have suppressed or absent root and suck reflexes. C) This statement is true of term infants, but this infant is preterm. D) Although birth is stressful even to term newborns, and some require a day or two of recovery to become fully alert, this infant is preterm. Page Ref: 691 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Identify the newborn reflexes that are present at birth. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

30) The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "The behavioral assessment should be done as soon after birth as possible." B) "The behavioral assessment can be performed without input from parents." C) "The behavioral assessment might be incomplete in a 1-hour home visit." D) "The behavioral assessment includes orientation and motor activity." E) "The behavioral assessment can detect neurological impairments." Answer: A, B Explanation: A) Because the first few days after birth are a period of behavioral disorganization, the complete assessment should be done on the third day after birth. B) Parental input is required. It provides a way for the healthcare provider, in conjunction with the parents (primary caregivers), to identify and understand the individual newborn's states, temperament, capabilities, and individual behavior patterns. C) A full behavioral assessment includes the nurse observing the newborn's sleep-wake patterns, which is not likely to take place in a 1-hour home visit. D) Orientation to visual and auditory clues and motor activity are portions of the behavioral assessment. E) The behavioral assessment can detect neurological impairments. Page Ref: 684 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

31) The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? A) "Some babies are easier to deal with than others." B) "We are lucky to have a baby with a calm disposition." C) "Our baby spends more time in the active alert phase." D) "Cuddliness is a social behavior that some babies have." Answer: D Explanation: A) Calling the baby easy or difficult is a judgment that does not explain the baby's behavior. B) Describing the baby as calm is a judgment that does not explain the baby's behavior. C) The active alert phase of the sleep-awake cycle is characterized by motor activity. It does not explain the baby's behavior D) According to Brazelton Neonatal Behavioral Assessment Scale, cuddliness can be an indicator of personality. Page Ref: 684 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

32) The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? A) "Your baby will respond to you the most if you look directly into his eyes and talk to him." B) "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." C) "If the sound level around your baby is high, the baby will wake up and be fussy or cry." D) "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy." Answer: A Explanation: A) The parents' visual (en face) and auditory (soft, continuous voice) presence stimulates their infant to orient to them. B) Although each infant is unique, there are certain predictable norms to observe for when assessing for neurological normalcy or impairment. C) Some infants become overstimulated when excessive noise is present, but more habituate to the sound and sleep. D) Cuddling is a social behavior that correlates with personality, but it has not been linked to any prenatal activities. Page Ref: 684 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

33) The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? A) Mother of a 2-week-old infant who doesn't make eye contact when talked to B) Father of a 1-week-old infant who sleeps through the noise of an older sibling C) Father of a 6-day-old infant who responds more to mother's voice than to father's voice D) Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand Answer: A Explanation: A) This is an abnormal finding. Orientation to the environment is determined by an ability to respond to cues given by others and by a natural ability to fix on and to follow a visual object horizontally and vertically. Inability or lack of response may indicate visual or auditory problems. B) Sleeping though noise is habituation, and is an expected behavior. C) The newborn can discriminate the individual characteristics of the human voice and is especially sensitive to sound levels within the normal conversation range. D) Self-consolatory behaviors such as sucking on fists, thumbs, or fingers are normal findings. Page Ref: 684 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

34) The newborn's cry should have which of the following characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Medium pitch B) Shrillness C) Strength D) High pitch E) Lusty Answer: A, C, E Explanation: A) The newborn's cry should be strong, lusty, and of medium pitch. B) A high-pitched, shrill cry is abnormal and may indicate neurologic disorders or hypoglycemia. C) The newborn's cry should be strong, lusty, and of medium pitch. D) A high-pitched, shrill cry is abnormal and may indicate neurologic disorders or hypoglycemia. E) The newborn's cry should be strong, lusty, and of medium pitch. Page Ref: 686 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

35) At 3 weeks a newborn weighs 8 lbs. 1 ounce. What percent of this body weight should the nurse explain to the mother as being water? (Calculate the average weight in ounces to the first decimal point.) Answer: 93.5 ounces Explanation: Approximately 70% to 75% of the newborn's body weight is water. First determine the infant's weight in ounces by multiplying 8 x 16 ounces = 128 ounces + 1 ounce = 129 ounces. Then multiply the weight in ounces by 70% and then by 75%: 129 ounces x 70% = 90.3 ounces; 129 ounces x 75% = 96.75. Then add the values of 70% and 75% and divide by 2 to determine the average: 90.3 + 96.75 = 187.05/2 = 93.525 ounces. To determine this weight in pounds divide by 16, or 93.525/16 = 5.84 of the infant's weight is water. To determine the weight in pounds and ounces: .84/100 = x/16; 1344 = 100x; 1344/100 = 13.44 ounces. The percentage of the infant's weight that is water is 5 pounds, 13.44 ounces. Page Ref: 677 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn. 36) At birth a newborn measured 20 inches. What length should the nurse instruct the mother to expect the baby to be at 4 months? (Calculate the anticipated length in cm and round to the nearest whole number.) Answer: 61 cm Explanation: The conversion 2.54 cm = 1 inch will be used. If the initial length was 20 inches, convert this to cm by multiplying 20 x 2.54 = 50.8 cm. If the average growth is approximately one inch per month for the first 6 months, then multiply 2.54 x 4 = 10.16 cm and add this amount to the birth length of 50.8 cm or 10.16 cm + 50.8 cm = 60.96. With rounding, the mother can expect the infant to be 61 cm in length. Page Ref: 669 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn. 36 Copyright © 2020 Pearson Education, Inc.

37) At birth a newborn's head circumference is 13 inches. What should the nurse expect the chest circumference to be in cm? (Round to the nearest whole number.) Answer: 31 cm Explanation: The circumference of the newborn's head is approximately 2 cm greater than the circumference of the newborn's chest at birth. First determine the infant's head circumference in cm by multiplying 13 inches by 2.54 cm or 13 x 2.54 = 33.02 or 33 cm. If the chest circumference is 2 cm smaller than the head circumference, the nurse should expect the infant's chest to measure 31 cm. Page Ref: 669 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn. 38) At birth a newborn weighed 7 pounds 10 ounces. If the average weight gain is 7 ounces every week for the first 6 months, what weight should the nurse expect when assessing an infant that is 20 weeks old? (Calculate the weight in ounces.) Answer: 260 ounces Explanation: Multiply 7 ounces x 20 = 140 ounces. Divide the amount in ounces by 16 or 140/16 = 8.75. Convert 8.75 to pounds and ounces by using the equation 75/100 = x/16; 1200 = 100x; x= 12 ounces. Convert the birth weight to ounces: 7 x 16 = 112 + 10 = 122. Convert the weight gained over 20 weeks: 8 x 16 = 128 + 12 = 140. Add the two weights: 122 + 140 = 260. The baby should weigh 260 ounces by 20 weeks. Page Ref: 669 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

39) While conducting a home visit, the nurse observes the father of a newborn hold the infant so that the following is observed. What should the nurse explain to the parents about this behavior?

A) This is abnormal and should be reported. B) This will disappear between 4 and 8 weeks of age. C) It means the child will begin walking at an early age. D) The infant should be given more formula when this occurs. Answer: B Explanation: B) This is the stepping reflex. When held upright with one foot touching a flat surface, the newborn puts one foot in front of the other and "walks." This reflex is more pronounced at birth and is lost in 4 to 8 weeks. This is not abnormal behavior. It does not mean that the infant will begin walking at an early age. This is not an indication that the infant needs to be fed. Page Ref: 667 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Identify the newborn reflexes that are present at birth. MNL LO: Demonstrate ability to perform assessment and interpret data for the newborn.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 28 The Normal Newborn: Needs and Care 1) The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? A) "Circumcision should be undertaken to prevent problems in the future." B) "Circumcision might decrease the child's risk of developing a urinary tract infection." C) "Circumcision can sometimes cause complications. What questions do you have?" D) "Circumcision is painful, and should be avoided unless you are Jewish." Answer: C Explanation: A) Although this is a common reason parents give for requesting circumcision, it is still an opinion not based in medical fact. B) Although circumcision permits exposure of the glans for easier cleaning, getting more information from the parents about their questions or concerns would be better. C) Asking this question allows the nurse to determine what the parents' concerns are, then address them specifically. D) Although circumcision can be painful, most providers administer a penile nerve root block to prevent or minimize procedural pain. Circumcision is practiced in many religions and traditions. Page Ref: 707 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

2) The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Providing a pacifier B) Stroking the head C) Restraining both arms and legs D) Talking to the infant E) Giving the infant a sedative before the procedure Answer: A, B, D Explanation: A) Providing a pacifier is an accepted method of soothing during the circumcision. B) Stroking the head is an accepted method of soothing during the circumcision. C) Only the legs are restrained during circumcision. D) Talking to the infant is an accepted method of soothing during the circumcision. E) The infant is never given a sedative. Page Ref: 708 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

3) The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? A) The infant's mother has group B streptococcal (GBS) disease. B) The infant's mother had an IV of lactated Ringer's solution. C) The infant's mother had a labor that lasted 12 hours. D) The infant's mother had a cesarean birth with her last child. Answer: A Explanation: A) A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis. B) An IV of lactated Ringer's solution will not affect the newborn's blood sugar. C) A 12-hour labor is normal. D) Having had a cesarean with her last child poses risk factors for the mother during labor, but does not affect this newborn. Page Ref: 704 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Summarize the essential areas of information to be obtained about a newborn's birth experience and immediate postnatal period. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

4) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Respiratory rate B) Skin texture C) Airway clearance D) Ability to feed E) Head weight Answer: A, C, D Explanation: A) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing vital signs (body temperature, heart rate, respiratory rate). B) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing skin color, not skin texture. C) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing airway clearance. D) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing ability to feed. E) The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing circumference and body weight, not head weight. Page Ref: 699 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Summarize the essential areas of information to be obtained about a newborn's birth experience and immediate postnatal period. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

5) The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? A) Heart rate 120 B) Temperature 96.8°F C) Respiratory rate 50 D) Temperature 99.6°F Answer: B Explanation: A) The heart rate is within normal limits for a newborn 2 hours old. B) The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the baby's axillary temperature is below 36.5°C (97.7°F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia. C) The respiratory rate is within normal limits for a newborn 2 hours old. D) This temperature (99.6°F) does not warrant placing the infant back in the radiant warmer. Page Ref: 701 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

6) In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? A) Eye prophylaxis medication B) Drying the newborn C) Vital signs D) Vitamin K injection Answer: A Explanation: A) Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding. B) Drying the newborn after birth is an essential nursing intervention, and should not be withheld. C) Taking vital signs is an essential nursing intervention, and should not be withheld. D) Vitamin K usually is given within 1 hour following birth, but does not interfere with eye contact and bonding between parent and newborn. Page Ref: 704 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

7) The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? A) Neonatal jaundice B) Neonatal hypothermia C) Neonatal hyperthermia D) Respiratory distress Answer: D Explanation: A) A high bilirubin level would be an indication of jaundice. B) Temperature instability would indicate either hyperthermia or hypothermia. C) A high temperature would indicate hyperthermia. D) Nasal flaring and facial grimacing are signs of respiratory distress. Page Ref: 704 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

8) A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Gently massage the site after injection. B) Use a 22-gauge, 1-inch needle. C) Inject in the vastus lateralis muscle. D) Cleanse the site with alcohol prior to injection. E) Inject at a 45-degree angle. Answer: A, C, D Explanation: A) The nurse would remove the needle and massage the site with an alcohol swab. B) Vitamin K is given IM using a 25-gauge, 5/8-inch needle. C) Vitamin K is given intramuscularly in the vastus lateralis muscle. D) Before injecting, the nurse must thoroughly clean the newborn's skin site for the injection with a small alcohol swab. E) Vitamin K is given IM at a 90-degree angle. Page Ref: 703 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Summarize the essential areas of information to be obtained about a newborn's birth experience and immediate postnatal period. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

9) To maintain a healthy temperature in the newborn, which of the following actions should be taken? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Keep the newborn's clothing and bedding dry. B) Reduce the newborn's exposure to drafts. C) Do not use the radiant warmer during procedures. D) Do not wrap the newborn. E) Encourage the mother to snuggle with the newborn under blankets. Answer: A, B, E Explanation: A) To maintain a healthy temperature in the newborn, keep the newborn's clothing and bedding dry. B) To maintain a healthy temperature in the newborn, reduce the newborn's exposure to drafts. C) To maintain a healthy temperature in the newborn, use the radiant warmer during procedures. D) To maintain a healthy temperature in the newborn, double-wrap the newborn. E) To maintain a healthy temperature in the newborn, encourage the mother to snuggle with the newborn under blankets. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

10) The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? A) 37-week male, respiratory rate 45 B) 8 pound 1 ounce female, pulse 150 C) Term male, nasal flaring D) 4-hour-old female who has not voided Answer: C Explanation: A) A normal respiratory rate is 30 to 60 breaths/min. This infant has no unexpected findings. B) A normal pulse is 110 to 160 beats/min. This infant has no unexpected findings. C) Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress. D) The first voiding should occur within 24 hours and first passage of stool within 48 hours. This is not a life-threatening condition. Page Ref: 704 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

11) The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? A) Temperature 97.9°F B) Respirations 68 breaths/minute C) Stable vital signs 45 minutes ago D) Heart rate 156 beats/min Answer: B Explanation: A) 97.9°F is within the normal temperature range of 97.5-99°F. B) The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-thanideal transition. C) The vital signs for a healthy term newborn should be monitored at least every 30 minutes until the newborn's condition has remained stable for 2 hours. D) This heart rate is within the normal range of 110-160 beats/min. Page Ref: 700 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

12) A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? A) "A quick cool bath will help wake up my son for feedings." B) "I can check my son's temperature under his arm." C) "My baby should be dressed warmly, with a hat." D) "Cuddling my son will help to keep him warm." Answer: A Explanation: A) Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal. B) The axilla is the preferred site for checking a newborn's temperature. C) Adequate clothing is needed to keep an infant warm. A snug cap placed on the infant's head reduces heat loss further. D) Encourage the mother to snuggle with the newborn under blankets to keep him or her warm. Page Ref: 701 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

13) The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The medication should be instilled in the lower conjunctival sac of each eye. B) The eyelids should be massaged gently to distribute the ointment. C) The medication must be given immediately after delivery. D) The medication does not cause any discomfort to the infant. E) The medication can interfere with the baby's ability to focus. Answer: A, B, E Explanation: A) Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. B) After administration, the nurse massages the eyelid gently to distribute the ointment. C) Instillation may be delayed up to 1 hour after birth to allow eye contact during parentnewborn bonding. D) Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and may interfere with the baby's ability to focus on the parents' faces and can result in edema, inflammation, and discharge. E) Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces. Page Ref: 703 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Stay current in professional healthcare knowledge. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

14) The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? A) Keep the infant NPO for 4 hours following the procedure. B) Observe for urine output. C) Wrap dry gauze tightly around the penis. D) Clean with cool water with each diaper change. Answer: B Explanation: A) The newborn does not need to be NPO. B) It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema. C) Gauze should not be wrapped tightly around the penis. Only if bleeding occurs should the nurse apply light pressure with a sterile gauze pad to stop the bleeding within a short time. D) The newborn should be cleaned with warm water with each diaper change. Page Ref: 708 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Stay current in professional healthcare knowledge. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

15) A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? A) "I will call your pediatrician immediately." B) "Passage of the first stool within 48 hours is normal." C) "Your newborn might not have a stool until the third day." D) "Your newborn must be dehydrated." Answer: B Explanation: A) This is not an emergency situation. B) The first voiding should occur within 24 hours and first passage of stool within 48 hours. C) The passage of the first stool should occur sooner. D) Decreased urinary output and depressed fontanelles indicate dehydration. Page Ref: 705 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

16) At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? A) Excessive B) Within normal limits C) Less than expected D) Unusual Answer: B Explanation: A) This is not an excessive weight loss. B) This newborn's weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life. C) This is not a less-than-expected amount of weight loss. D) This weight loss is not unusual. Page Ref: 705 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

17) The nurse teaches the parents of an infant who was recently circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? A) Wrap the diaper tightly. B) Clean with warm water with each diaper change. C) Apply gentle pressure to the site with gauze. D) Apply a new petroleum ointment gauze dressing. Answer: C Explanation: A) When diapering, ensure that the diaper is neither too loose, which can cause rubbing with movement, nor too tight, which can cause pain. B) Cleaning the newborn with warm water with each diaper change is part of the care plan, but it does not prevent bleeding. C) If bleeding does occur, apply light pressure with a sterile gauze pad to stop the bleeding within a short time. If this is not effective, contact the physician immediately or take the newborn to the healthcare provider. D) Continued application of a petroleum ointment can help protect the granulation tissue that forms as the glans heals, but does not stop any bleeding. Page Ref: 709 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

18) To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? A) Keep the baby in the room at all times. B) Check the identification of all personnel who transport the newborn. C) Place a "No Visitors" sign on the door. D) Keep the baby in the nursery at all times. Answer: B Explanation: A) Newborns need to return to the nursery at times. B) Parents should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance. C) A "No Visitors" sign would not ensure safety. D) Newborns will need to return to the nursery at times, but the newborn is not required to be there at all times. Page Ref: 706 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Promote communication and open reporting as a priority in healthcare. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

19) The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? A) Hold the newborn in an upright position. B) Massage the hands and feet. C) Swaddle the newborn in a blanket. D) Make eye contact while talking to the newborn. Answer: C Explanation: A) Holding the newborn upright is a waking activity. B) Increasing skin contact and gently rubbing hands and feet is a waking activity. C) Swaddling or bundling the baby increases the sense of security and is a quieting activity. D) Talking to the newborn while making eye contact is a waking activity. Page Ref: 710 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

20) Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? A) Preeclampsia screening B) Congenital kidney disease screening C) Visual screening D) Hearing screening Answer: D Explanation: A) Preeclampsia is a maternal condition, and not part of the newborn screening tests. B) Congenital heart disease screening, not kidney disease screening, is part of the newborn screening tests. C) Visual screening is not part of newborn screening tests. D) Newborn screening tests include hearing screening tests. Page Ref: 713 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

21) Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? A) 6 to 12 hours after birth B) Within 1 hour of birth C) 24 hours after birth D) 48 hours after birth Answer: B Explanation: A) Breastfeeding should be initiated within the first hour of life, not 6 to 12 hours after birth. B) Breastfeeding should be initiated within the first hour of life unless medically contraindicated. C) Breastfeeding should be initiated within the first hour of life, not 24 hours after birth. D) Breastfeeding should be initiated within the first hour of life, not 48 hours after birth. Page Ref: 704 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 6. Describe strategies to empower patients or families in all aspects of the healthcare process. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Stay current in professional healthcare knowledge. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain how the physiologic and behavioral responses of a newborn during the first 4 hours after birth (admission and transitional period) determine the newborn's nursing care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

22) The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? A) Large amounts of uric acid crystals in the first days of life B) At least 6 to 10 wet diapers a day after the first few days of life C) 1 to 2 stools a day for a formula-fed baby D) Urine that is straw to amber color without foul smell Answer: A Explanation: A) Small, not large, amounts of uric acid crystals are normal in the first days of life. B) 6 to 10 wet diapers a day after the first few days of life is normal. C) 1 to 2 stools a day for a formula-fed baby is normal. D) Urine that is straw to amber color without foul smell is normal. Page Ref: 715 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

23) The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Continual rise in temperature B) Decreased frequency of stools C) Absence of breathing longer than 20 seconds D) Lethargy E) Refusal of two feedings in a row Answer: A, C, D, E Explanation: A) Parents should call their healthcare provider due to a continual rise in temperature. B) Parents should call their healthcare provider when there are two consecutive green watery or black stools or increased frequency of stools. C) Parents should call their healthcare provider in the absence of breathing longer than 20 seconds. D) Parents should call their healthcare provider if the newborn exhibits lethargy and listlessness. E) Parents should call their healthcare provider if the newborn has refused two feedings in a row. Page Ref: 716 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

24) The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? A) 2 days B) 10 days C) 8 days D) 14 days Answer: C Explanation: A) The Plastibell does not fall off in 2 days. B) The Plastibell should fall off before 10 days. C) The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborn's physician. D) The Plastibell should fall off before 14 days. Page Ref: 716 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

25) New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? A) The foreskin will be retractable at 2 months. B) Retract the foreskin and clean thoroughly. C) Avoid retracting the foreskin. D) Use soap and Betadine to cleanse the penis daily. Answer: C Explanation: A) The foreskin is not fully retractable at 2 months. B) The foreskin is not fully retractable in a newborn, and should not be forced back over the penis. C) The foreskin will retract normally over time, and may take 3 to 5 years. D) If retraction has occurred, daily gentle washing of the glans with soap and water is sufficient to maintain adequate cleanliness. Page Ref: 716 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

26) A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "Cover the cord stump with gauze." C) "Apply Betadine around the cord stump." D) "This is normal during healing." Answer: A Explanation: A) Parents should check each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to the healthcare provider any signs of infection. B) Parents should fold diapers below the umbilical cord to air-dry the cord. Contact with wet or soiled diapers slows the drying process and increases the possibility of infection. C) Betadine is not used on the cord stump. D) These symptoms are not normal. Page Ref: 715 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Encourage patients and families to communicate their observations and concerns regarding safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

27) The nurse is analyzing various strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? A) Select videos on various topics of newborn care. B) Organize a class that includes first-time mothers only. C) Have mothers return in 1 week, when they feel more rested. D) Schedule time for one-to-one teaching in the mother's room. Answer: D Explanation: A) Selecting videos on various topics of newborn care would not ensure one-toone teaching. B) Organizing a class that includes first-time mothers only would not ensure one-to-one teaching. C) It is not appropriate or realistic to expect new mothers to return in 1 week. D) One-to-one teaching while the nurse is in the mother's room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions. Page Ref: 711 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

28) The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? A) "I should avoid looking directly into the baby's eyes to prevent frightening the baby." B) "My baby will be very sleepy immediately after birth and should go to the nursery." C) "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." D) "Giving my baby his first bath can really give me a chance to get to know him." Answer: D Explanation: A) Eye-to-eye contact between parents and their newborn is extremely important during the early hours after birth, when the newborn is in the first period of reactivity. B) Newborns are usually alert and responsive in the first few hours after birth. Interacting with the newborn during this first period of reactivity facilitates parent-infant attachment. C) Newborns can have direct eye contact with human faces, with an optimal range for visual acuity of 7 to 8 inches. Eye contact is an important component of the emerging parent-baby bond. D) Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their baby's behavior and the nurse can observe and point out behaviors. Page Ref: 705 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

29) The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? A) "You appear to be Muslim. Do you want your son circumcised?" B) "Let me explain newborn care here in the United States." C) "Your baby is a United States citizen. You must be very happy about that." D) "Could you explain your preferences regarding childrearing?" Answer: D Explanation: A) The nurse should avoid making assumptions about clients based on appearance. B) The nurse should not assume the family doesn't understand the United States healthcare system. C) The nurse should avoid making assumptions regarding family beliefs and values. D) The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care. Page Ref: 710 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. C. 6. Willingly support patient-centered care for individuals and groups whose values differ from own. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe the influence of cultural values on newborn care. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

30) The nurse is working with an adolescent mother who tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? A) "You are very young, and parenting will be a challenge for you." B) "Your mother was probably right. Be very careful with your baby." C) "Mothers have instincts that kick in when they get their babies home." D) "We can give the baby a bath together. I'll help you learn how to do it." Answer: D Explanation: A) Although this statement is true, it does not teach the client anything, or increase her confidence in being able to care for her infant. B) This statement is very judgmental, and does not teach the client anything, or increase her confidence in being able to care for her infant. C) Maternal instincts might indeed exist, but this client has expressed a specific fear about being a safe mother. It is best to work with her to teach her skills and increase her confidence. D) This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby. Page Ref: 701 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Discuss safety needs of the newborn that would ensure integration into the family unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

31) The nurse is planning visits to the homes of new parents and their newborns. Which client should the nurse see first? A) 3-day-old male who received hepatitis B vaccine prior to discharge B) 4-day-old female whose parents are both hearing-impaired C) 5-day-old male with light, sticky, yellow drainage on the circumcision site D) 6-day-old female with greenish discharge from the umbilical cord site Answer: D Explanation: A) This infant has no indications of unexpected findings. Immunization programs against the hepatitis B virus during the newborn period and infancy are in place in many states. B) This infant is not at risk, but the appointment should be scheduled when the sign language interpreter is available. C) This is normal healing and a light, sticky, yellow drainage may form over the head of the penis. D) Oozing greenish yellow material or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication. Page Ref: 715 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

32) The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? A) "The baby should be in the back seat." B) "Newborns must be in rear-facing car seats." C) "We need instruction on how to use the car seat before installing it." D) "We can bring the baby home from the hospital without a car seat, as it is only a short drive." Answer: D Explanation: A) The safest spot in any car is the middle of the back seat. The car seat should be positioned to face the rear of the car. B) The safest spot in any car is the middle of the back seat. The car seat should be positioned to face the rear of the car. C) Nurses need to ensure that all parents are knowledgeable about the benefits of child safety seat use and proper installation. Nurses can encourage parents to have their infant safety seats checked by local groups trained specifically for that purpose. D) Newborns must go home from the birthing unit in a car seat adapted to fit newborns. Page Ref: 713 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

33) The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? A) "Call your pediatrician if the baby's temperature is below 98.6°F axillary." B) "Your baby's stools will change to a greenish color when your milk comes in." C) "You can wipe away any eye drainage that might form." D) "Your infant should wet a diaper at least 6 times per day." Answer: D Explanation: A) The pediatrician should be called if the temperature is lower than 97.8°F axillary. B) Stool color for a breastfed infant is a yellow gold, soft or mushy stools. C) Eye drainage is abnormal, and should be reported to the baby's provider. D) A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake. Page Ref: 716 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

34) The nurse is preparing to provide a newborn with an injection of vitamin K. In which order should the nurse complete the following steps? 1. Cleanse skin with alcohol and allow to dry 2. Aspirate and then inject the medication slowly 3. Insert a 25-gauge 5/8 inch needle at a 90 degree angle 4. Remove the needle and massage with an alcohol swab 5. Bunch skin over mid-anterior lateral aspect of the thigh Answer: 1, 5, 3, 2, 4 Explanation: Procedure for vitamin K injection. Cleanse area thoroughly with alcohol swab and allow skin to dry. Bunch the tissue of the mid-anterior lateral aspect of the thigh (vastus lateralis muscle) and quickly insert a 25-gauge 5/8-inch needle at a 90-degree angle to the thigh. Aspirate, and then slowly inject the solution to distribute the medication evenly and minimize the baby's discomfort. Remove the needle and massage the site with an alcohol swab. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Nursing Process. Learning Outcome: 1 Summarize the essential areas of information to be obtained about a newborn's birth experience and immediate postnatal period. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

35) The nurse is preparing to provide a newborn with a prescribed intramuscular injection. Which area should the nurse use for this injection?

A) A B) B C) C D) D Answer: C Explanation: C) The middle third of the vastus lateralis muscle is the preferred site for intramuscular injection in the newborn. The middle third of the rectus femoris is an alternative site, but its proximity to major vessels and the sciatic nerve necessitates caution in using this site for injection. Page Ref: 703 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 1 Summarize the essential areas of information to be obtained about a newborn's birth experience and immediate postnatal period. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

36) The nurse obtains the following device to be used on a newborn. For which procedure is the nurse preparing this infant?

A) Hearing test B) Circumcision C) Neurological exam D) Assess for umbilical hernia Answer: B Explanation: B) This is a Plastibell, which is used for circumcision. This device is not used to assess hearing, conduct a neurological exam, or to assess for an umbilical hernia. Page Ref: 708 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 4 Discuss the common concerns of families regarding their newborns. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

37) The nurse is preparing to instruct the parents of a newborn on the care of the umbilical cord. In which order should the nurse provide these instructions? 1. Check the cord for color 2. Wash hands with soap and water 3. Fold diaper below umbilical cord 4. Clean cord and base of cord with cotton swab 5. Check the cord for odor or oozing of green material Answer: 2, 4, 1, 5, 3 Explanation: Wash hands with clean water and soap before and after care. Clean cord and skin around base with a cotton swab or cotton ball. Clean 2 to 3 times a day, or with each diaper change. Cord should look dark and dry up before falling off. Check cord each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. Fold diapers below umbilical cord to air-dry the cord. Page Ref: 715 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

38) The mother of a newly circumcised infant is concerned about caring for the infant at home. What should the nurse instruct the mother about the infant's care? Place the following actions in the order that should be instructed to the mother. 1. Pat dry 2. Rinse area with warm water 3. Fasten diaper snuggly over the penis 4. Apply small amount of petroleum jelly 5. Squeeze water over the circumcision site Answer: 5, 2, 1, 4, 3 Explanation: Squeeze water over circumcision site once a day. Rinse area off with warm water and pat dry. Apply small amount of petroleum jelly. Fasten diaper over penis snugly enough so that it does not move and rub the tender glans. Page Ref: 715 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 6 Identify opportunities to individualize parent teaching and enhance parent's abilities and confidence while providing newborn care in the birthing unit. MNL LO: Demonstrate use of the nursing process in the care of the normal newborn.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 29 Newborn Nutrition 1) A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? A) Orange juice B) Milk C) Decaffeinated tea D) Water Answer: B Explanation: A) Orange juice does not usually pose a problem for the infant. B) Often fussy breastfeeding or cow's milk-based formula-fed infants are switched to a lactosefree formula because of concerns about lactose intolerance. C) Decaffeinated tea does not usually present a problem for the infant. D) Water should not be a problem at any time. Page Ref: 723 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

2) The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? A) 4 hours B) 8 hours C) 12 hours D) 24 hours Answer: D Explanation: A) Thawed breast milk can stay refrigerated longer than 4 hours before it should be discarded. B) Thawed breast milk can stay refrigerated longer than 8 hours before it should be discarded. C) Thawed breast milk can stay refrigerated longer than 12 hours before it should be discarded. D) Previously frozen thawed breast milk is good in the refrigerator for 24 hours only. Page Ref: 740 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

3) The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? A) "In the first 3 to 4 months breastfed babies tend to gain weight faster." B) "In the first 3 to 4 months there is no difference in weight gain." C) "In the first 3 to 4 months bottle-fed babies grow faster." D) "In the first 3 to 4 months growth isn't as important as your comfort with the method." Answer: A Explanation: A) Exclusively breastfed infants have the same or slightly higher weight gain than their formula-fed and combination-fed peers in the first 3 to 4 months. B) Once feedings are established, growth rates for breastfed and formula-fed infants vary. C) Bottle-fed babies do not gain weight faster. D) Although comfort with the feeding method is important, the question is specifically about growth and weight gain; it is not therapeutic to change the topic and not answer the question. Page Ref: 720 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

4) The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? A) "I should use only soy-based formula for the first year." B) "I should follow the instructions for mixing the powdered formula exactly." C) "It is okay to add more water to the formula to make it last longer." D) "The mixed formula can be left on the counter for a day." Answer: B Explanation: A) Soy protein-based formula is not intended as a first-choice formula except for infants with primary lactase deficiency or galactosemia, for term infants of formula-feeding vegan parents, and for infants who develop secondary (transient) lactase deficiency following an acute bout with diarrhea. B) Powdered formula is the least expensive type of formula. Parents will need to be briefed on safety precautions during formula preparation, and they should be instructed to follow the directions on the formula package label precisely as written. C) Parents should know that adding too much water during preparation dilutes the nutrients and caloric density and may contribute to undernourishment, insufficient weight gain, and possibly water intoxication leading to hyponatremia and seizures. Not adding enough water concentrates nutrients and calories and can damage an infant's immature kidneys and digestive system, as well as cause dehydration. D) Allow freshly prepared (unused) formula to sit out at room temperature for no longer than 2 hours. Milk left over in the bottle after a feeding should be discarded. Page Ref: 744 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

5) What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? A) Colostrum B) Lactose C) Lactoferrin D) Secretory IgA Answer: B Explanation: A) Another term for human milk is colostrum. B) Lactose is the primary carbohydrate in mammalian milk. C) Lactoferrin is an iron-binding protein found only in breast milk. D) Secretory IgA is an immunoglobulin present in colostrum and mature breast milk. Page Ref: 726 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Compare the nutritional value and composition of human milk and formula preparations in relation to the nutritional needs of the newborn. MNL LO: Demonstrate understanding of newborn nutrition. 6) The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? A) A mother with a poorly balanced diet B) A mother who is overweight C) A mother who is HIV positive D) A mother who has twins Answer: C Explanation: A) A newborn whose mother has a poor diet might need to receive supplements. B) Mothers who are overweight can be encouraged to breastfeed. C) Women with HIV or AIDS are counseled against breastfeeding. D) Mothers who have twins can be encouraged to breastfeed. Page Ref: 730 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

7) Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Breastfed infants get more skin-to-skin contact and sleep better." B) "Breastfeeding raises the level of a hormone that makes me feel good." C) "Breastfeeding is complex and difficult, and I probably won't succeed." D) "Breastfeeding is worthwhile, even if it costs more overall." E) "Breastfed infants have fewer digestive and respiratory illnesses." Answer: A, B, E Explanation: A) Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding. B) Hormones of lactation promote maternal feelings and sense of well-being. C) Breastfeeding is a natural process but requires a certain knowledge base. Breastfeeding with proper technique should not hurt and these mothers should be encouraged to seek assistance from a knowledgeable person skilled in lactation. D) Breastfeeding actually costs less than formula-feeding. E) This is a true statement. The immunologic advantages of human milk include varying degrees of protection from respiratory tract and gastrointestinal tract infections. Page Ref: 740 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

8) A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? A) "Formula-feeding gives the baby protection from infections." B) "Breast milk cannot be stored; it has to be thrown away after pumping." C) "Breastfeeding is more expensive than formula-feeding." D) "My baby will have a lower risk of food allergies if I breastfeed." Answer: D Explanation: A) Formula does not provide the baby with protection from infections; breast milk does. B) Breast milk can be refrigerated or frozen after pumping. C) Formula must be purchased, and therefore is more expensive. D) Secretory IgA, an immunoglobulin present in colostrum and mature breast milk, has antiviral, antibacterial, and antigenic-inhibiting properties and plays a role in decreasing the permeability of the small intestine to help prevent large protein molecules from triggering an allergic response. Page Ref: 726 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

9) Which of the following are potential disadvantages to breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Pain with breastfeeding B) Leaking milk C) Equal feeding responsibilities with fathers D) Vaginal wetness E) Embarrassment Answer: A, B, E Explanation: A) Nipple tenderness is the most common source of discomfort and is usually related to improper positioning and/or not obtaining a proper attachment of the infant on the breast. Pain can also be related to engorgement or infection. B) Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience let-down. Mothers should be given reassurance that this problem diminishes over time. C) There are unequal feeding responsibilities and fathers are left out in the first 3 to 4 weeks. The parents should be informed that it is advisable for the father to wait to bottle feed the baby with expressed breast milk until after the milk supply and breastfeeding are established. D) Vaginal dryness is associated with breastfeeding. Some mothers experience vaginal dryness related to a low level of estrogen while lactating. This is only a temporary side effect. E) Some mothers feel uncomfortable about breastfeeding because they are modest or may feel embarrassed because our society views breasts as sexual objects and/or an unfriendly social environment makes it difficult to breastfeed in public. This is not an easy issue to overcome. Page Ref: 728 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

10) What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Drug's potential effect on hormone production B) Amount of drug excreted into the mother's blood C) Drug's potential adverse effects to the infant D) Infant's age and health E) Mother's need for the medication Answer: C, D, E Explanation: A) The healthcare provider should consider the drug's potential effect on milk production. B) The healthcare provider should consider the amount of drug excreted into the milk. C) The healthcare provider should consider the drug's potential adverse effects to the infant. D) The healthcare provider should consider the infant's age and health. E) The healthcare provider should consider the mother's need for the medication. Page Ref: 730 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

11) The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? A) Providing skin-to-skin contact B) Swaddling the newborn in a blanket C) Unwrapping the newborn D) Allowing the newborn to feel and smell the mother's breast Answer: B Explanation: A) Activities that encourage a sleepy newborn to breastfeed include providing skin-to-skin contact, which enhances bonding. B) Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. Swaddling the newborn has the opposite effect. C) Remove the baby's blanket and clothing so that the infant is wearing only a diaper and T-shirt. Babies feed better when they are not bundled, and they can achieve better attachment without the bulk of extra clothing and blankets. D) If the newborn falls asleep after the first few suckles, encourage the mother to use tactile stimulation while the newborn is still attached to the breast. The mother can also be encouraged to use breast compression or breast massage while the infant is breastfeeding. Page Ref: 742 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

12) A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? A) Pain with breastfeeding B) Number of hours passed since last feeding C) The newborn's cry D) Maternal fluid intake Answer: C Explanation: A) Pain with breastfeeding is associated with improper positioning, and does not stimulate the letdown reflex. B) Allowing too many hours between feedings can affect the milk supply. It does not stimulate the letdown reflex. C) Some women will leak milk when their breasts are full and it is nearly time to breastfeed again or whenever they experience letdown, which can be triggered by hearing, seeing, or even thinking of their baby. D) Maternal fluid intake can affect milk supply. It does not stimulate the letdown reflex. Page Ref: 728 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

13) When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? A) Decrease the number of minutes the newborn is at the breast per feeding. B) Decrease the mother's fluid intake. C) Place absorbent pads in the bra. D) Administer oxytocin. Answer: C Explanation: A) Decreasing the number of minutes the newborn is at the breast would be contraindicated for a breastfeeding client. B) The mother should consume a nutritionally balanced diet with appropriate caloric and fluid intake to support breastfeeding. Decreasing the mother's fluid intake would be contraindicated for a breastfeeding client. C) The mother can wear nursing pads inside her bra with instructions to change wet pads frequently. D) Early breastfeeding can enhance maternal-infant bonding and facilitate release of oxytocin. Administering oxytocin would be contraindicated for a breastfeeding client. Page Ref: 728 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IV. 9. Apply patient-care technologies as appropriate to address the needs of a diverse patient population. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

14) When is breastfeeding contraindicated? A) Infant has hypertension B) Mother has a history of treated tuberculosis C) Mother is HIV positive or has AIDS D) Mother has a history of treated herpes Answer: C Explanation: A) Breastfeeding is contraindicated when the infant has galactosemia. B) Breastfeeding is contraindicated when the mother has active, untreated tuberculosis. C) Breastfeeding is contraindicated when the mother is HIV positive or has AIDS and is counseled against breastfeeding. D) Breastfeeding is contraindicated when the mother has active herpes on her breast–the infant may still feed on the unaffected side only, until the lesion has healed. Page Ref: 730 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

15) Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? A) ABM B) WIC C) ILCA D) LLLI Answer: B Explanation: A) The Academy of Breastfeeding Medicine (ABM) provides many researchbased breastfeeding protocols. B) The Supplemental Nutrition Program for Women, Infants, and Children (WIC) functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs. C) International Lactation Consultant Association (ILCA) has listings of lactation consultants in specific geographic areas. D) La Leche League International (LLLI) is the first (not-for-profit international educational and service organization) mother-to-mother breastfeeding support group formally recognized in the United States. Page Ref: 747 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

16) The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? A) Otoscopic exam of the eardrum B) Bowel sounds C) Vital signs D) Skin assessment Answer: A Explanation: A) Infants who bottle feed in a supine position have an increased risk of otitis media and dental caries in the older infant. B) Bowel sounds are not affected by the position of the feeding. C) Vital signs are not affected by the position of the feeding. D) The skin is not affected by the position of the feeding. Page Ref: 745 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

17) The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? A) She puts the infant to breast when he is asleep to help wake him up. B) She takes off her gown to achieve skin-to-skin contact. C) She leans toward the infant so that he turns his head to access the nipple. D) The infant is crying when he is brought to the breast. Answer: B Explanation: A) Parents can be taught techniques to wake their sleepy baby, as breastfeeding is more successful if the infant is awake. With a little help, the baby may be gently roused to breastfeed. B) Skin-to-skin contact after birth helps the baby maintain his or her body temperature, helps with self-regulation, increases maternal oxytocin levels, helps the mother to notice subtle feeding cues, and promotes bonding. C) The mother should bring the baby to her breast, rather than leaning forward to the baby. D) Crying is a late cue of hunger. Newborns should be put to breast when they begin rooting, lipsmacking, or fussing behaviors. Page Ref: 740 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

18) A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? A) Stop breastfeeding and switch to formula. B) Eliminate dairy products from her diet. C) Supplement breastfeeding with a soy-based formula. D) Offer the baby water between feedings. Answer: B Explanation: A) At this point, there is no reason to stop breastfeeding. B) Breastfeeding babies may not be allergic to the mother's milk but rather to the cow's milk protein (an antigen) in the mother's milk. By eliminating the culprit (e.g., the bovine protein) from the mother's diet and therefore from the breast milk, the mother can continue to breastfeed, providing optimal nutrition and immune factors to her infant. C) Soy-protein-based formula is not the first choice for term infants unless they have special nutritional needs. D) Increased water can cause hyponatremia and, in excessive amounts, can cause seizures. Page Ref: 723 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

19) Which of the following is a sign of dehydration in the newborn? A) Slow, weak pulse B) Soft, loose stools C) Light colored, concentrated urine D) Depressed fontanelles Answer: D Explanation: A) A rapid, weak pulse is a sign of dehydration in the newborn. B) Dry, hard stools are a sign of dehydration in the newborn. C) Dark, concentrated urine is a sign of dehydration in the newborn. D) Depressed fontanelles are a sign of dehydration in the newborn. Page Ref: 721 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

20) The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? A) Offer a pacifier B) Burp the newborn C) Unwrap the newborn D) Stroke the newborn's spine and feet Answer: B Explanation: A) The newborn's cries are indicative of an issue; a pacifier would not solve the problem. B) Crying results in increased ingestion of air even before the infant has started feeding. Infants who are very hungry also gulp more air. For these situations, instruct the parents to burp their infant frequently. C) Unwrapping stimulates the newborn. D) Stroking the spine and feet stimulates the newborn. Page Ref: 745 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

21) The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? A) The vitamins and minerals in formula are more bioavailable to the infant. B) There is no cholesterol in breast milk. C) The only carbohydrate in breast milk is lactose. D) The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant. Answer: D Explanation: A) The vitamins and minerals in breast milk have a higher bioavailability. B) Approximately 98% of human milk fat is in the form of triglycerides, and a very small but clinically significant amount is from cholesterol. C) Lactose is the primary carbohydrate in breast milk. Human milk also contains trace amounts of other carbohydrates such as glucosamines and nitrogen-containing oligosaccharides. D) The ratio of whey to casein proteins in breast milk, unlike that in formula, is not static. It changes to meet the nutritional needs of the growing infant. Page Ref: 722 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Compare the nutritional value and composition of human milk and formula preparations in relation to the nutritional needs of the newborn. MNL LO: Demonstrate understanding of newborn nutrition.

22) The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? A) Day of birth B) First day after birth C) Second day after birth D) Third to fourth day after birth Answer: D Explanation: A) Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would not start breastfeeding the day of the birth. B) Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would not start breastfeeding the first day after the birth. C) Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would not start breastfeeding the second day after the birth. D) Among some traditional cultures around the world, it is believed that colostrum is "unclean" or even harmful to a newborn. Because of this ancient belief, mothers living the Middle East and parts of Asia even today discard their colostrum or wait 2 to 4 days to begin breastfeeding, when their "true milk" arrives. This mother would begin breastfeeding on the third or fourth day after the birth. Page Ref: 731 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: QSEN Competencies: I. C. 6. Willingly support patient-centered care for individuals and groups whose values differ from own. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the influence of cultural values on newborn/infant feeding practices. MNL LO: Demonstrate understanding of newborn nutrition.

23) The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? A) "What kind of formula would you like to use?" B) "That idea is folklore. Colostrum is good for the baby." C) "Now that you are here, you need to feed your baby the right way." D) "Let's give the baby formula after you breastfeed." Answer: D Explanation: A) This statement does not facilitate breastfeeding, and does not support the education provided to the client that colostrum is beneficial. B) Although colostrum is indeed good for newborns, this response is disrespectful. C) This answer is disrespectful and therefore not therapeutic. D) This response attempts to provide a compromise between acknowledging the client's desire to give formula and getting the baby to breast to get colostrum. Nurses should be aware that some immigrant mothers may have this misconception about their colostrum. Page Ref: 731 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Be open to others' ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Explain the influence of cultural values on newborn/infant feeding practices. MNL LO: Demonstrate understanding of newborn nutrition.

24) A client from Mexico has just delivered a son, and the nurse offers to assist in putting the baby to breast. Although the client indicated before the birth that she wanted to breastfeed, she is very hesitant, and says she would like to bottle-feed for the first few days. After talking to her, the nurse understands that her primary reason for wanting to delay breastfeeding is based on what cultural belief? A) Breast milk causes skin rashes. B) It is harmful to breastfeed immediately. C) Colostrum is bad for the baby. D) Thin milk causes diarrhea. Answer: C Explanation: A) Haitian mothers may believe that "strong emotions" spoil breast milk and that thick breast milk causes skin rashes. B) Believing it is harmful to breastfeed immediately is not a cultural belief of Hispanics. C) Some Hispanics may delay breastfeeding because they believe colostrum is "bad." D) Haitian mothers may believe that "strong emotions" spoil breast milk and that thin milk results in diarrhea. Page Ref: 731 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Be open to others' ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the influence of cultural values on newborn/infant feeding practices. MNL LO: Demonstrate understanding of newborn nutrition.

25) The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? A) "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." B) "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." C) "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." D) "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families." Answer: A Explanation: A) Although it is true that some cultures believe colostrum to be unhealthy, colostrum helps to protect the infant from disease and illness. B) It is not therapeutic to downplay a woman's concern by stating, "It's no big deal"; this type of statement should be avoided. C) Muslim women generally breastfeed until their children are 2 years of age. This is encouraged in the Koran. D) For Muslim women, it is culturally unacceptable for them to speak about intimate matters in front of their families. The nurse should be aware that it would be inappropriate to ask the new mother's husband or her children to be her interpreter. Page Ref: 731 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the influence of cultural values on newborn/infant feeding practices. MNL LO: Demonstrate understanding of newborn nutrition.

26) The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? A) "Newborns should regain their birth weight by 1 week of age." B) "Breastfed and formula-fed babies have different growth rates." C) "Formula-fed infants regain their birth weight earlier than breastfed infants." D) "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition." Answer: A Explanation: A) Newborns should gain at least 10 g/kg/day and be back to birth weight no later than day 14 of life. B) Breastfed and formula-fed babies have different growth rates because the compositions of human milk and formula are different. C) Formula-fed infants tend to regain their birth weight earlier than breastfed infants because of consistent fluid intake in the first few days of life, whereas the breastfed infant's fluid intake depends on the mother's milk supply and breastfeeding efficiency. D) Most healthcare providers (as well as representatives of formula companies) consider breastfeeding to be the "gold standard" for neonatal nutrition, and the outcomes associated with its use are the norm to which other forms of nutrition should be compared. Page Ref: 749 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe ways to educate parents about their newborn's nutritional needs and normal growth patterns. MNL LO: Demonstrate understanding of newborn nutrition.

27) A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? A) Stop breastfeeding B) Provide newborn supplements to the newborn C) Offer whole milk D) Supplement with skim milk Answer: B Explanation: A) The mother may continue to breastfeed. B) The mother may continue to breastfeed, but the caregiver may choose to prescribe additional vitamins for the newborn. Vitamins in human milk are influenced by the mother's vitamin intake, general nutritional status, and genetic differences. C) Cow's milk should not be given to infants before 1 year of age. The use of skim milk or lowfat cow's milk is not recommended for children under 2 years old. D) Cow's milk should not be given to infants before 1 year of age. The use of skim milk or lowfat cow's milk is not recommended for children under 2 years old. Page Ref: 722 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. C. 14. Appreciate shared decision-making with empowered patients and families, even when conflicts occur. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe ways to educate parents about their newborn's nutritional needs and normal growth patterns. MNL LO: Demonstrate understanding of newborn nutrition.

28) The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Early feedings stimulate peristalsis. B) Colostrum is thinner than mature milk. C) Early feedings enhance maternal-infant bonding. D) Early feedings promote the passage of meconium. E) Colostrum contains a high number of calories. Answer: A, C, D Explanation: A) Early breastfeeding stimulates the newborn's peristalsis. B) Colostrum is a thick, creamy, yellowish fluid with concentrated amounts of protein, fatsoluble vitamins, and minerals. C) Early breastfeeding enhances maternal-infant bonding. D) Early breastfeeding promotes the passage of meconium. E) Colostrum contains fewer calories than mature milk does. Page Ref: 740 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Explain the advantages and disadvantages of breastfeeding and formulafeeding in determining the nursing care of both mother/family and newborn. MNL LO: Demonstrate understanding of newborn nutrition.

29) The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? A) "I will put my baby to bed with his bottle so he doesn't get hungry during the night." B) "My baby will probably have a bowel movement each breastfeeding, and will wet often." C) "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." D) "I will drink fenugreek tea from my grandmother to prevent my milk from coming in." Answer: A Explanation: A) Putting a baby to bed with a propped bottle is a choking hazard, and should never be done. B) Breastfed infants have more frequent bowel movements than do bottle-fed infants. The infant will have 4 wet diapers, 3 to 4 bowel movements on day 4; 5 wet diapers, 3 to 4 bowel movements on day 5; and 6 to 8 wet diapers, 3 to 4 bowel movements every day thereafter during the first month of life. C) Breast milk is easier to digest than formula, therefore infants eat more frequently. Infants will arouse to feed at least every 3 hours and will stay awake until the end of each feeding. The infant will breastfeed 8 to 12 times per day. D) Herbal galactogogues can be consumed as a tea or can be taken as capsules or as a tincture added to liquid to drink. Fenugreek is probably the most well-known herbal galactogogue among lactation consultants in the United States. Page Ref: 745 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

30) A newborn weighs 7 lbs. 10 ounces at birth. What is the maximum number of calories that the nurse should instruct the mother that the baby needs to consume each day? (Calculate to the nearest whole number.) Answer: 400 calories Explanation: Caloric intake for a newborn is 45.5 to 52.5 kcal/lb/day or 100 to 115 kcal/kg/day. The nurse needs to convert the baby's weight in ounces to pounds by dividing 10 ounces/16 ounces or 10/16 or 0.625. Since the baby weighs 7.625 lbs., the nurse should multiply 52.5 x 7.625 = 400.3125 calories. When rounded to a whole number the infant needs a maximum of 400 calories per day. Page Ref: 720 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Explain the nutritional needs and normal growth patterns of newborns. MNL LO: Demonstrate understanding of newborn nutrition.

31) During an educational session the nurse learns that legislation was written to support breastfeeding mothers. In which order did the titles of this legislation occur? 1. Establish standards for safe and effective breast pumps 2. Include breastfeeding equipment as medical care for taxes 3. Require businesses with 50 or more employees to give lactating women breaks 4. Give tax incentives to businesses that establish a private place for breastfeeding 5. Protect lactating women from being fired or discriminated against in the workplace Answer: 5, 4, 1, 2, 3 Explanation: The Breastfeeding Promotion Act of 2009 was enacted into law on March 23, 2010 and acts to protect breastfeeding in the workplace through five provisions. These include the following: Title I: Amending the Civil Rights Act of 1964 to protect lactating women from being fired or discriminated against in the workplace. Title II: Giving tax incentives to businesses that establish a private space in the workplace for their employees to breastfeed or express their milk. Employers can also receive tax credits for supplying breastfeeding equipment and providing lactation consultation services for their employees. Title III: Establishing set standards for breast pumps to ensure that they are safe and effective. Title IV: Expanding the Internal Revenue Code definition of "medical care" to include breastfeeding equipment and lactation services as taxdeductible for families. Title V: Requiring employers with 50 or more employees to provide lactating employees break time and a private area to express their milk. Page Ref: 729 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 7. Explore ethical and legal implications of patientcentered care. | AACN Essentials Competencies: V. 4. Examine legislative and regulatory processes relevant to the provision of healthcare. | NLN Competencies: Context and Environment: Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families. | Nursing/Integrated Concepts: Assessment: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

32) A new mother asks the nurse about the football hold to use when breastfeeding. Which picture should the nurse use to explain this position to the new mother? A)

Answer: C Explanation: C) For the football hold position, place the baby on the side of the breast that will be used for feeding. The baby should be in a feet first position with the baby's bottom resting on the pillow near mother's elbow. Turn baby slightly on her side so that she faces the breast. The mother should clutch the baby's body close to her own. Baby's body should feel securely tucked in under the mother's arm. Choice 1: For the modified cradle position, place baby on mother's lap and turn baby's entire body toward mother (baby is in side-lying position). Position the baby's body so that the baby's nose lines up to the nipple. Maintain baby's body in a horizontal alignment. Choice 2: For the cradle position place the baby on the mother's lap and turn baby's entire body toward the mother (baby is in side-lying position). Position the baby's body so that the baby's nose lines up to the nipple. Maintain baby's body in a horizontal alignment. Choice 4: For the side-lying position, place baby in side-lying position next to mother's body. Baby's body should face mother's body. Baby's nose should line up to mother's nipple. Place a roll behind baby's back, if desired. Page Ref: 733 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

33) The nurse is instructing a new mother on the type of stool to expect a breast-fed newborn to produce. In which order should the nurse explain the stool changes? 1.

Answer: 3, 5, 2, 1, 4 Explanation: Choice 3: On day 1, the infant should produce at least one wet diaper and one meconium stool by 24 hours of age. Choice 5: On day 2, the infant should produce at least two wet diapers and two early transitional stools in a 24-hour period by 48 hours of age. Choice 2: On day 3, the infant should produce at least three wet diapers and three transitional stools in a 24-hour period by 72 hours of age. Choice 1: On day 4, the infant should produce at least four wet diapers and three to four yellow-green transitional stools or yellow milk stools in a 24-hour period by 96 hours of age. Choice 4: On day 5, the infant should produce at least five wet diapers and three to four yellow milk stools per day; the stools are typically explosive and have a curdy or seedy appearance. Page Ref: 738 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

34) The nurse is reviewing the process of pumping the breasts with a new mother. In which order should the nurse provide this information? 1. Fill glass or bottles 3/4 full 2. Massage the breasts and relax 3. Sit up straight or lean forward 4. Wash hands with soap and water 5. Pump each breast for 10 to 20 minutes Answer: 4, 2, 3, 5, 1 Explanation: Wash hands well with soap and water before preparing to pump. Take a few minutes to massage the breasts and relax. Sit up straight or lean slightly forward. Pump each breast for 10 to 20 minutes. Pump the expressed milk preferably into glass or plastic bottles. Do not fill milk storage containers more than 3/4 full, because milk expands during freezing. Page Ref: 739 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

35) The nurse is reviewing the contents of breastmilk with a new mother. What amount of water should the nurse explain is in 8 ounces of breastmilk? Record your answer rounding to the nearest whole number. Answer: 7 ounces Explanation: Breastmilk contains 87% water. The nurse should multiply 8 ounces by 87% to determine that 6.96 ounces out of 8 ounces of breast milk is water. With rounding, the volume of water in 8 ounces of breastmilk is 7 ounces. Page Ref: 725 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition. 36) The nurse is demonstrating to a patient the proper steps for breastfeeding a newborn. Put these steps in the logical order that would assist the patient in placing the newborn to her breast. 1. Tickle the newborn's lips with the nipple. 2. Allow the newborn to latch on to the nipple. 3. The newborn opens her mouth wide. 4. Have the newborn face the mother tummy to tummy. 5. Position the newborn so the nose is at the level of the nipple. Answer: 5, 4, 1, 3, 2 Explanation: Positioning the baby's nose at nipple level enhances latching on. The baby needs to face the mother. Tickling the newborn's lips provides stimulation, and the baby can smell the milk. If hungry, the newborn opens her mouth. The mother holds the baby to the breast for feeding. Page Ref: 736 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

37) A premature newborn is unable to suck at the breast. The nurse plans care for the mother, who is going to hand-express milk. Arrange the steps for milk expression in the correct order. 1. Roll the thumb and fingers simultaneously forward. 2. Position the thumb at 12:00 and the forefinger and middle finger at 6:00 around the areola. 3. Repeat the sequence multiple times to completely drain the breasts. 4. Stretch the areola back toward the chest wall without lifting the fingers off the breast. Answer: 2, 4, 1, 3 Explanation: Positioning the thumb at 12:00 and the forefinger and middle finger at 6:00 around the areola is the beginning position for manually expressing milk. Next the mother should stretch the areola back as far as possible. Then roll the thumb and fingers forward to stimulate the breast to empty. The sequence is repeated as necessary until the desired amount of milk has been expressed. Page Ref: 739 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Formulate guidelines for helping both breastfeeding and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings. MNL LO: Demonstrate understanding of newborn nutrition.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 30 The Newborn at Risk: Conditions Present at Birth 1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? A) Offer early feedings with formula or breast milk. B) Provide glucose water exclusively. C) Evaluate blood glucose levels at 12 hours after birth. D) Assess for hyperthermia. Answer: A Explanation: A) IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum). B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) Blood glucose determinations should be performed by heel stick hourly during the first 4 hours after birth and at 4-hour intervals until the risk period (about 48 hours) has passed. D) Hypothermia is a potential problem for the SGA newborn due to decreased brown fat stores and minimal subcutaneous tissues. Page Ref: 758 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory B) 23-year-old of low socioeconomic status, unmarried C) 16-year-old who began prenatal care at 30 weeks D) 28-year-old with a history of gestational diabetes Answer: A Explanation: A) This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. B) The main risk factor for this client is her low socioeconomic status. C) This client has two risk factors: young age and late onset of prenatal care. D) This client's only risk factor is the history of gestational diabetes. Page Ref: 754 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Explain the factors present at birth that indicate an at-risk newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? A) Preterm appropriate for gestational age, symmetrical IUGR B) Term small for gestational age, symmetrical IUGR C) Preterm small for gestational age, asymmetrical IUGR D) Preterm appropriate for gestational age, asymmetrical IUGR Answer: C Explanation: A) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. B) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is considered small for gestational age. Page Ref: 755 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe processes of care. | AACN Essentials Competencies: IV. 6. Evaluate data from all relevant sources, including technology, to inform the delivery of care. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? A) Monitor for feeding difficulties. B) Assess for facial paralysis. C) Monitor for signs of hyperglycemia. D) Maintain a warm environment. Answer: D Explanation: A) LGA, not SGA, newborns are more difficult to arouse to a quiet alert state, and can have feeding difficulties. B) LGA, not SGA, newborns often are prone to birth trauma such as facial paralysis, due to cephalopelvic disproportion. C) SGA newborns are more prone to hypoglycemia. D) Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss. Page Ref: 756 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the potential complications for large-for-gestational-age (LGA) newborns. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

5) The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? A) Obtain a blood calcium level. B) Take the newborn's temperature. C) Obtain a bilirubin level. D) Place a pulse oximeter on the newborn. Answer: A Explanation: A) Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. B) Body temperature might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. C) Bilirubin level might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. D) Oxygen saturation might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

6) A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? A) To recheck the blood sugar in 6 hours B) To begin an IV of 10% dextrose C) To feed the baby 1 ounce of formula D) To document the findings in the chart Answer: D Explanation: A) Blood glucose determinations should be performed on blood by heel stick hourly during the first 4 hours after birth, and subsequently at 4-hour intervals. B) A blood sugar reading of 47 mg/dL is considered normal for a neonate. No IV is needed. C) Feeding would be appropriate if the infant's blood sugar was below 45 mg/dL, but this infant's reading is 47. D) A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action. Page Ref: 762 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

7) The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? A) Offer early feedings. B) Administer an intravenous infusion of glucose. C) Assess for hypercalcemia. D) Assess for hyperbilirubinemia immediately after birth. Answer: A Explanation: A) Newborns of diabetic mothers may benefit from early feedings, as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia. B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) The newborn should be assessed for hypocalcemia. D) Hyperbilirubinemia can occur 48 to 72 hours after birth. Page Ref: 764 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

8) The nurse caring for a postterm newborn would not perform what intervention? A) Providing warmth B) Frequently monitoring blood glucose C) Observing respiratory status D) Restricting breastfeeding Answer: D Explanation: A) Provision of warmth is an important intervention for postterm newborns. B) Frequent monitoring of blood glucose is an important intervention for postterm newborns. C) Observation of respiratory status is an important intervention for postterm newborns. D) Breastfeeding is an appropriate means of feeding for the postterm newborn. Page Ref: 764 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the characteristics and potential complications that influence nursing management of the postterm newborn and the newborn with postmaturity syndrome. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

9) The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy." B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." C) "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." D) "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger." Answer: A Explanation: A) The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome. B) Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. C) Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. D) Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue. Page Ref: 764 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the characteristics and potential complications that influence nursing management of the postterm newborn and the newborn with postmaturity syndrome. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

10) The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? A) "Most newborns are nose breathers." B) "The tube will elicit the sucking reflex." C) "A smaller catheter is preferred for feedings." D) "Most newborns are mouth breathers." Answer: A Explanation: A) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. B) The tube or gavage feeding method is used with preterm infants who lack or have a poorly coordinated suck-swallow-breathing pattern. C) A small catheter is used for a nasogastric tube to minimize airway obstruction. D) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. Page Ref: 772 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

11) A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, their infant is at a greater risk for which of the following? A) Visual impairment B) Hyperthermia C) Central cyanosis D) Sensitive gag reflex Answer: A Explanation: A) Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina, causing characteristic retinal changes known as retinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has become the norm. B) Hypothermia is more common in premature infants. C) Central cyanosis can be caused by decreased oxygen. D) An absent or decreased gag reflex is more common in premature infants. Page Ref: 774 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

12) A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Schedule care throughout the day. B) Silence alarms quickly. C) Place a blanket over the top portion of the incubator. D) Do not offer a pacifier. E) Dim the lights. Answer: B, C, E Explanation: A) Nursing care should be planned to decrease the number of times the baby is disturbed. B) Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. C) Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. D) Pacifiers can be offered because they provide opportunities for nonnutritive sucking. E) Dimming the lights may encourage infants to open their eyes and be more responsive to their parents. Page Ref: 779 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

13) The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? A) Cry is weak and feeble B) Clitoris and labia minora are prominent C) Strong sucking reflex D) Lanugo is plentiful Answer: C Explanation: A) Findings that indicate prematurity include a weak cry. B) Findings that indicate prematurity include a prominent clitoris and labia minora. C) Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn. D) Findings that indicate prematurity include lanugo that is plentiful and widely distributed. Page Ref: 766 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

14) The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statement(s) by the parents indicate that additional teaching is needed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Our baby will be in an incubator to keep him warm." B) "Breathing might be harder for our baby because he is early." C) "The growth of our baby will be faster than if he were term." D) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days." Answer: C, D, E Explanation: A) Preterm infants have little subcutaneous fat, and have difficulty maintaining their body temperature. An incubator or warmer is used to keep the baby warm. B) Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. The infant may become hypoxic, pulmonary blood flow may be inefficient, and the preterm newborn's available energy is depleted. C) Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity. D) Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to the infant's poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex. E) Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine. Preterm infants usually have some urine output during the first 24 hours of life. Page Ref: 766 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

15) The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? A) The new nurse holds the infant after giving a gavage feeding. B) The new nurse provides skin-to-skin care. C) The new nurse provides care when the baby is awake. D) The new nurse gives the feeding with room-temperature formula. Answer: D Explanation: A) If the infant cannot be held during a feeding, she should be held after feedings for comfort. B) Skin-to-skin (kangaroo) care has become the norm in NICUs across the United States and is defined as the practice of holding infants skin to skin next to their parents. C) Preterm babies spend more time in sleep cycles; it is best to not interrupt sleep when possible. D) Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature. Page Ref: 766 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

16) Benefits of skin-to-skin care as a developmental intervention include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Routine discharge B) Stabilization of vital signs C) Increased periods of awake-alert state D) Decline in episodes of apnea and bradycardia E) Increased growth parameters Answer: B, D, E Explanation: A) Early discharge is a benefit of skin-to-skin care as a developmental intervention. B) Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. C) Increased periods of quiet sleep is a benefit of skin-to-skin care as a developmental intervention. D) A decline in episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention. E) Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention. Page Ref: 780 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

17) In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Volume of urine output B) Weight C) Blood pH D) Head circumference E) Bowel sounds Answer: A, B Explanation: A) In order to assess hydration status, volume of urine output must be evaluated. B) In order to assess hydration status, the infant's weight must be evaluated. C) Blood pH is not an indicator of hydration. D) Head circumference is not an indicator of hydration. E) Bowel sounds are not an indicator of hydration. Page Ref: 777 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

18) The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? A) Tissue Integrity, Impaired B) Infection, Risk for C) Gas Exchange, Impaired D) Family Processes, Dysfunctional Answer: C Explanation: A) Tissue Integrity, Impaired is related to fragile capillary network in the germinal matrix, but is not the highest priority. B) Infection, Risk for is related to lack of passive immunity and immature immune defenses due to preterm birth, but is not the highest priority. C) Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production, and has the highest priority. D) Family Processes, Dysfunctional is related to anger or guilt at having given birth to a premature baby and is a psychosocial need, and is therefore a lower priority than are physiologic needs. Page Ref: 756 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

19) The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? A) Specially prepared formulas B) Cataract problems C) Low glucose concentrations D) Administration of thyroid medication Answer: A Explanation: A) An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Phenyl-Free 1 and Phenex-1, are available. B) Cataracts are associated with infants who have galactosemia. C) Low glucose concentrations are not an indication an inborn error of metabolism. D) Thyroid medication is given to infants with congenital hypothyroidism. Page Ref: 801 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Explain the special care needed by a newborn diagnosed with an inborn error of metabolism. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

20) The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? A) Omphalocele B) Gastroschisis C) Diaphragmatic hernia D) Myelomeningocele Answer: D Explanation: A) Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Hydrocephalus is not associated with an omphalocele. B) Gastroschisis is a full-thickness defect of the abdominal wall that results in the abdominal organs being located on the outside of the body. Hydrocephalus is not associated with a gastroschisis. C) Diaphragmatic hernia is a portion of the intestines in the thoracic cavity due to an abnormal opening in diaphragm, occurring commonly on the left side. Hydrocephalus is not associated with a diaphragmatic hernia. D) Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in the thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on his or her abdomen or side and restrained to prevent pressure and trauma to the sac. Hydrocephalus is often present with this condition. Page Ref: 786 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

21) During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? A) Place the newborn in a prone position. B) Limit feedings to three a day to decrease diarrhea. C) Place the infant supine and operate a home apnea-monitoring system. D) Wean the newborn off the pacifier. Answer: C Explanation: A) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. B) Small, frequent feedings are recommended. C) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. D) A pacifier may be offered to provide nonnutritive sucking. Page Ref: 795 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

22) The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? A) Occasional watery stools B) Spitting up after feeding C) Jitteriness and irritability D) Nasal stuffiness Answer: C Explanation: A) An occasional watery stool can be associated with the normal newborn. B) Spitting up after some feedings can be associated with the normal newborn. C) Jitteriness and irritability can be an indicator of drug withdrawal. D) Nasal stuffiness can be associated with the normal newborn. Page Ref: 795 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

23) Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? A) "Our baby's heart murmur is from this syndrome." B) "He might be a fussy baby because of this." C) "His face looks like it does due to this problem." D) "Cuddling and rocking will help him stay calm." Answer: D Explanation: A) Valvular and septal defects are common in babies with FAS. B) FAS babies can be irritable and hyperactive in childhood. C) Facial characteristics of the FAS child include short palpebral fissures, epicanthal folds, broad nasal bridge, flattened midface, short upturned or beaklike nose, micrognathia (abnormally small lower jaw) or hypoplastic maxilla, thin upper lip or vermilion border, and smooth philtrum (groove on upper lip). D) The FASD baby is most comfortable in a quiet, minimally stimulating environment. Page Ref: 791 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

24) The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Hyperirritability B) Decreased muscle tone C) Exaggerated reflexes D) Low pitched cry E) Transient tachypnea Answer: A, C, E Explanation: A) Newborns born to drug-addicted mothers exhibit hyperirritability. B) Newborns born to drug-addicted mothers show increased, not decreased, muscle tone. C) Newborns born to drug-addicted mothers exhibit exaggerated reflexes. D) Newborns born to drug-addicted mothers exhibit a high-pitched, not a low-pitched, cry. E) Newborns born to drug-addicted mothers exhibit transient tachypnea. Page Ref: 793 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

25) In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? A) Allow extra time with feedings. B) Assign different personnel to the newborn each day. C) Place the newborn in a well-lit room. D) Monitor for hyperthermia. Answer: A Explanation: A) Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings. B) It is important to provide consistency in the staff working with the baby and parents and to keep personnel and visitors to a minimum at any one time. C) The FASD baby is most comfortable in a quiet, minimally stimulating environment. D) Nursing care of the FASD newborn is aimed at avoiding heat loss. Page Ref: 791 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

26) The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Use proper hand-washing technique. B) Provide three feedings per day. C) Place soiled diapers in a sealed plastic bag. D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. E) Take the temperature rectally. Answer: A, C, D Explanation: A) The nurse should instruct the parents on proper hand-washing technique. B) Small, frequent meals are recommended. C) The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed, and disposed of daily. D) The nurse should instruct parents that the diaper-changing areas should be cleaned with a 1:10 dilution of household bleach after each diaper change. E) Taking rectal temperatures is to be avoided because it could stimulate diarrhea. Page Ref: 799 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in the neonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

27) A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? A) Test with an HIV serologic test at 8 months. B) Begin prophylactic AZT (Zidovudine) administration. C) Provide 4 to 5 large feedings throughout the day. D) Encourage the mother to breastfeed the child. Answer: B Explanation: A) Currently available HIV serologic tests (enzyme-linked immunosorbent assay [ELISA] and Western blot test) cannot distinguish between maternal and infant antibodies; therefore, they are inappropriate for infants up to 18 months of age. B) For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon after birth as possible and continuing for 6 weeks. C) Nutrition is essential because failure to thrive and weight loss are common. Small, frequent feedings and food supplementation are helpful. D) Breastfeeding should be avoided with an HIV-positive mother, as transmission of the HIV virus to the newborn in breast milk is well documented. Page Ref: 799 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in the neonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

28) An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? A) Do not add food supplements to the baby's diet. B) Place soiled diapers in a sealed plastic bag. C) Wash soiled linens in cool water with bleach. D) Shield the baby's eyes from bright lights. Answer: B Explanation: A) Small, frequent feedings are recommended, as well as food supplementation as necessary to support weight gain. B) The nurse should instruct the parents about proper hand-washing techniques, proper disposal of soiled diapers, and the importance of wearing gloves when diapering. C) Soiled linens should be washed in hot, sudsy water with bleach. D) Shielding the baby's eyes from bright lights would be recommended for a preterm infant, not an infant with HIV. Page Ref: 800 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in the neonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

29) Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Swollen glands B) Hard stools C) Smaller than average spleen and liver D) Rhinorrhea E) Interstitial pneumonia Answer: A, D, E Explanation: A) Signs that may be seen in the early infancy period include swollen glands. B) Signs that may be seen in the early infancy period include recurrent gastrointestinal (GI) problems that include diarrhea. C) Signs that may be seen in the early infancy period include enlarged spleen and liver. D) Signs that may be seen in the early infancy period include rhinorrhea. E) Signs that may be seen in the early infancy period include interstitial pneumonia. Page Ref: 798 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in the neonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

30) The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? A) Apical heart rate of 140 beats per minute B) Respiratory rate of 40 C) Temperature of 36.5°C D) Visible, blue discoloration of the skin Answer: D Explanation: A) An apical heart rate of 140 is a normal assessment finding for newborns. B) A respiratory rate of 40 is a normal assessment finding for newborns. C) Temperature of 36.5°C is a normal assessment finding for newborns. D) Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect. Page Ref: 787 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify physical examination findings during the early newborn period that would make the nurse suspect a congenital cardiac defect or congestive heart failure. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

31) The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." B) "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." C) "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." D) "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal." Answer: A Explanation: A) Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. The severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. B) This describes coarctation of the aorta and is characterized by a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. C) This describes complete transposition of great vessels and is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery from the left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. D) This describes hypoplastic left heart syndrome which is the underdevelopment of the left side of the heart including aortic valve atresia, severe mitral valve stenosis, and small left ventricle. Page Ref: 787 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Identify physical examination findings during the early newborn period that would make the nurse suspect a congenital cardiac defect or congestive heart failure. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

32) The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? A) "This condition occurs more frequently among Japanese people." B) "We must be very careful to avoid most proteins to prevent brain damage." C) "Carbohydrates can cause our baby to develop cataracts and liver damage." D) "Our baby's thyroid gland isn't functioning properly." Answer: B Explanation: A) Japanese people have a very low rate of PKU disease; it is most common among northern Europeans. B) PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain tissue leads to progressive, irreversible intellectual disability. C) Galactosemia is a carbohydrate metabolism disease. D) Congenital hypothyroidism is the disorder of low thyroid function at birth. Page Ref: 801 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 11 Explain the special care needed by a newborn diagnosed with an inborn error of metabolism. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

33) The nurse is observed conducting the following measurement. For what will this measurement be used?

A) Determine fetal length B) Gauge stomach contents C) Placement of gavage tube D) Estimate chest circumference Answer: C Explanation: C) When measuring gavage tube length, measure the distance from the tip of the ear to the nose to the midpoint between the xiphoid process and the umbilicus, and mark the point with a small piece of paper tape to ensure there is enough tubing to enter the stomach. Page Ref: 771 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

34) The nurse is caring for a newborn with the following anomaly. What actions should the nurse take when caring for this infant?

Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Burp frequently 2. Assess patency of nares 3. Assist with parental coping 4. Clean the area with sterile water 5. Feed with a special nipple and bottle Answer: 1, 3, 4, 5 Explanation: The infant has a cleft lip. The nurse should feed with a special nipple and bottle, burp frequently, clean the cleft with sterile water to prevent crusting on cleft before repair, and support parental coping. Assessing patency of nares would be appropriate for choanal atresia. Page Ref: 782 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

35) The nurse is preparing teaching material for the parents of a newborn with tracheoesophageal fistula. Where on the diagram should the nurse identify the location of this disorder?

A) A B) B C) C D) D Answer: C Explanation: C) In a tracheoesophageal fistula, the lower esophageal segment connects to the lower trachea, with the upper esophageal segment ending blindly. Page Ref: 783 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

36) The nurse is preparing teaching material for the parents of a newborn. For which health problem should the nurse select the following diagram to be used for teaching?

A) Gastroschisis B) Omphalocele C) Diaphragmatic hernia D) Prune belly syndrome Answer: C Explanation: C) In a diaphragmatic hernia, a portion of the intestines enters the thoracic cavity through an abnormal opening in the diaphragm. This most commonly occurs on the left side. An omphalocele is the herniation of abdominal contents into the base of the umbilical cord. Gastroschisis is a full-thickness defect in the abdominal wall that allows viscera outside the body to the right of an intact umbilical cord. Prune belly syndrome is the congenital absence of one or more layers of abdominal muscles. Page Ref: 784 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

37) An infant is diagnosed with an atrial-septal defect. When teaching the parents of this infant about the disorder, which diagram should the nurse use? A)

Answer: A Explanation: A) Patent ductus arteriosus is a vascular connection that, during fetal life, bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. After birth, blood shunts through the ductus from the aorta to the pulmonary artery (left-to-right shunting). Coarctation of the aorta is characterized by a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. In tetralogy of Fallot, the severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. Complete transposition of great vessels is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery from the left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. Page Ref: 788 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize the nursing assessments and initial interventions for a newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

38) The nurse is preparing to gavage-feed a preterm infant. Put the steps in the order in which the nurse should provide this feeding. 1. Check pH of the gastric aspirate 2. Elevate the syringe 6-8 inches above the infant's head 3. Measure from the tip of the nose to the earlobe to the xiphoid process 4. Clear the tubing with 2-3 mL of air 5. Lubricate the tube by dipping it into sterile water Answer: 3, 5, 1, 2, 4 Explanation: Measurement occurs before inserting the tube into the infant. Lubricating the tube helps with passage into the infant. After passage, the pH of gastric contents is determined. The syringe is elevated above the infant's head for the feeding. At the end of the feeding the tube is cleared with 2-3 mL of air. Page Ref: 771 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 31 The Newborn at Risk: Birth-Related Stressors 1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? A) Initial resuscitation B) Vigorous stimulation at birth C) Phototherapy immediately D) An initial feeding of iron-enriched formula Answer: A Explanation: A) The presence of meconium in the amniotic fluid indicates that the fetus may be suffering from asphyxia. Meconium-stained newborns or newborns who have aspirated particulate meconium often have respiratory depression at birth and require resuscitation to establish adequate respiratory effort. B) Stimulation at birth should be avoided to minimize respiratory movements. C) Phototherapy is not required immediately. D) Mild or chronic anemia in an infant may be treated adequately with iron supplements alone or with iron-fortified formulas. Page Ref: 822 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and the nursing care required. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

2) A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? A) Begin chest compressions. B) Begin direct tracheal suctioning. C) Begin bag-and-mask ventilation. D) Obtain a blood pressure reading. Answer: C Explanation: A) Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established. B) Direct tracheal suctioning would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid in the question. C) Most newborns can be effectively resuscitated by bag-and-mask ventilation. D) Blood pressure is insignificant during resuscitation efforts. This infant needs respirations established. Page Ref: 809 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Describe how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

3) During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? A) The rise and fall of the chest B) Sudden wakefulness C) Urinary output D) Adequate thermoregulation Answer: A Explanation: A) With proper resuscitation, chest movement is observed for proper ventilation. Pressure should be adequate to move the chest wall. B) Sudden wakefulness is not associated with effectiveness of bag-and-mask ventilations. C) Urinary output is not associated with effectiveness of bag-and-mask ventilations. D) Adequate thermoregulation is not associated with effectiveness of bag-and-mask ventilations. Page Ref: 808 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Describe how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

4) A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? A) Grunting respirations B) Nasal flaring C) Respiratory rate of 40 during sleep D) Chest retractions Answer: C Explanation: A) Grunting with respirations is a characteristic of RDS. B) Nasal flaring is a characteristic of RDS. C) A respiratory rate of 40 during sleep is normal. D) Significant chest retractions are characteristic of RDS. Page Ref: 815 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and the nursing care required. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

5) A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? A) Delivery of the neonate on its side with head up, to facilitate drainage of secretions. B) Direct tracheal suctioning by specially trained personnel. C) Preparation for the immediate use of positive pressure to expand the lungs. D) Suctioning of the oropharynx when the newborn's head is delivered. Answer: B Explanation: A) The newborn is not delivered on its side. B) If the infant has absent or depressed respirations, heart rate less than 100 beats/min, or poor muscle tone, direct tracheal suctioning by specially trained personnel is recommended. C) Positive pressure is not used to expand the lungs. D) Current evidence does not support intrapartum oropharyngeal and nasopharyngeal suctioning as they do not prevent or alter the course of MAS. Page Ref: 808 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and the nursing care required. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

6) The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? A) Meconium aspiration syndrome B) Transient tachypnea of the newborn C) Respiratory distress syndrome D) Prematurity of the neonate Answer: B Explanation: A) There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome. B) The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn. C) The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome. D) The infant is not premature. Page Ref: 816 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and the nursing care required. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

7) A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? A) Decreased urine output B) Pulmonary vascular resistance increases C) Increased PCO2 D) Increased urination Answer: D Explanation: A) Increased urination, not decreased urine output, could be an indication that the newborn's condition is improving. B) Pulmonary vascular resistance increases with hypoxia. C) Increased PCO2 results from alveolar hypoventilation. D) In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination/diuresis may be an early clue that the baby's condition is improving. Page Ref: 815 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and the nursing care required. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

8) Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? A) Jitteriness B) Sucking on fingers C) Lusty cry D) Axillary temperature of 98°F Answer: A Explanation: A) Jitteriness of the newborn is associated with hypoglycemia. Aggressive treatment is recommended after a single low blood glucose value if the infant shows this symptom. B) Sucking on the fingers is a normal finding. C) A lusty cry is a normal finding. D) An axillary temperature of 98°F is a normal finding. Page Ref: 828 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

9) A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. B) Use a previous puncture site. C) Cool the heel prior to obtaining blood. D) Use a sterile needle and aspirate. Answer: A Explanation: A) The site should be cleaned by rubbing vigorously with a 70% isopropyl alcohol swab. The friction produces local heat, which aids vasodilation. B) A microlancet is used to make the puncture in an unpunctured site. C) The heel should not be cooled. D) A microlancet, not a needle, is used to make the puncture. Page Ref: 829 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

10) The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? A) Increased skin temperature and respirations B) Blood glucose level of 45 C) Room-temperature IV running D) Positioned under radiant warmer Answer: C Explanation: A) Decreased skin temperature and decreased respirations are signs and symptoms of cold stress. B) A blood glucose level of 45 is an adequate blood sugar in a neonate. A level lower than 40 indicates the infant is hypoglycemic. C) IV fluids should be warmed prior to administration and the newborn can be wrapped in a chemically activated warming mattress immediately following birth to decrease the postnatal fall in temperature that normally occurs. D) Radiant warmers are used to gradually increase the neonate's temperature. Page Ref: 827 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

11) The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Lights can stay on all the time. B) The eyes do not need to be covered. C) The lights will need to be removed for feedings. D) Newborns do not get overheated. E) Weight loss is not a complication of this system. Answer: A, B, D, E Explanation: A) With the fiber-optic blanket, the light stays on at all times. B) The eyes do not have to be covered with a fiber optic blanket. C) With the fiber-optic blanket, the light stays on at all times, and the newborn is accessible for care, feeding, and diaper changes. D) With the fiber-optic blanket, greater surface area is exposed and there are no thermoregulation issues. E) Fluid and weight loss are not complications of fiber-optic blankets. Page Ref: 835 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

12) The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? A) Eyes are covered, no clothing on, diaper in place B) Axillary temperature 99.7°F C) Infant removed from the isolette for breastfeeding D) Loose bowel movement Answer: B Explanation: A) Eye coverings are used because it is not known if phototherapy injures delicate eye structures, particularly the retina. Because the tissue absorbs the light, best results are obtained when there is maximum skin surface exposure. B) Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7°F-98.6°F. Vital signs should be monitored every 4 hours with axillary temperatures. C) Breastfeeding should continue during phototherapy; removing the infant for feedings repositions the infant to prevent pressure areas. D) Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. Page Ref: 835 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

13) The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Physiologic jaundice occurs after 24 hours of age. B) Pathologic jaundice occurs after 24 hours of age. C) Phototherapy increases serum bilirubin levels. D) The need for phototherapy depends on the bilirubin level and age of the infant. E) Kernicterus causes irreversible neurological damage. Answer: A, E Explanation: A) Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life, and appears after 24 hours of life. B) Diagnosis of pathologic jaundice is given to newborns who exhibit jaundice within the first 24 hours of life. C) Phototherapy decreases serum bilirubin levels. D) The decision to start phototherapy is based on two factors: gestational age and age in hours. E) Kernicterus refers to the deposition of unconjugated bilirubin in the basal ganglia of the brain and to permanent neurologic sequelae of untreated hyperbilirubinemia. Page Ref: 831 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

14) The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? A) Continue to observe B) Begin phototherapy C) Begin blood exchange transfusion D) Stop breastfeeding Answer: B Explanation: A) Continued observation is only appropriate with normal findings. B) Neonatal hyperbilirubinemia must be considered pathologic if the serum bilirubin concentration is rising by more than 0.2 mg/dL per hour. If the newborn is over 24 hours old, which is past the time where an increase in bilirubin would result from pathologic causes, phototherapy may be the treatment of choice to prevent the possible complications of kernicterus. C) If a newborn has hemolysis with an unconjugated bilirubin level of 14 mg/dL, weighs less than 2500 g (birth weight), and is 24 hours old or less, an exchange transfusion may be the best management. This newborn is 36-hours-old. D) The newborn may continue to breastfeed. Page Ref: 832 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

15) The client with blood type O Rh-negative has given birth to an infant with blood type O Rhpositive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? A) "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells." C) "The red blood cells of your baby are breaking down because you both have type O blood." D) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed." Answer: B Explanation: A) Although this statement is true, the term "alloimmunization" is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology. B) This explanation is accurate and easy for the client to understand. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin. C) Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if mother is O and baby is A or B. D) The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice. Page Ref: 831 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Explain how Rh incompatibility or ABO incompatibility can lead to the development of hyperbilirubinemia. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

16) Which of the following are considered risk factors for development of severe hyperbilirubinemia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Northern European descent B) Previous sibling received phototherapy C) Gestational age 27 to 30 weeks D) Exclusive breastfeeding E) Infection Answer: B, D, E Explanation: A) East Asian or Mediterranean descent is considered a risk factor for development of severe hyperbilirubinemia. B) Previous sibling received phototherapy is considered a risk factor for development of severe hyperbilirubinemia. C) Gestational age 35 to 36 weeks (late preterm gestational age) is considered a risk factor for development of severe hyperbilirubinemia. D) Exclusive breastfeeding, particularly if nursing is not going well and excessive weight loss is experienced, is considered a risk factor for development of severe hyperbilirubinemia. E) Infection is considered a risk factor for development of severe hyperbilirubinemia. Page Ref: 832 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Explain how Rh incompatibility or ABO incompatibility can lead to the development of hyperbilirubinemia. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

17) A newborn is receiving phototherapy. Which intervention by the nurse would be most important? A) Measurement of head circumference B) Encouraging the mother to stop breastfeeding C) Stool blood testing D) Assessment of hydration status Answer: D Explanation: A) Phototherapy does not affect head circumference. B) Breastfeeding most likely can be continued. C) The stools do not need to be tested for blood. D) Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. This increases their risk of dehydration. Page Ref: 835 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

18) The nurse is observing a student nurse who is caring for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? A) Urine specific gravity is assessed at each voiding. B) Eye coverings are left off to help keep the baby calm. C) Temperature is checked every 6 hours. D) The infant is taken out of the isolette for diaper changes. Answer: A Explanation: A) This action is correct. Specific gravity provides one measure of urine concentration. Highly concentrated urine is associated with a dehydrated state. Weight loss is also a sign of developing dehydration in the newborn. B) Eyes should be covered at all times. C) Six hours is too long. Vital signs should be monitored every 4 hours with axillary temperatures. D) The isolette helps the infant maintain his or her temperature while undressed. The diaper should be changed while the infant is under the lights in the isolette, as care activities should be clustered. Page Ref: 846 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. C. 2. Appreciate the cognitive and physical limits of human performance. | AACN Essentials Competencies: IX. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver's knowledge of care requirements to promote safe care. | NLN Competencies: Quality and Safety: Stay current in professional healthcare knowledge. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

19) The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? A) The newborn maintains a normal temperature B) An increase of serum bilirubin levels C) Weight loss D) Skin blanching yellow Answer: A Explanation: A) Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy. The isolette helps the infant maintain his or her temperature while undressed. B) Phototherapy is a primary intervention that is used for the prevention of hyperbilirubinemia, to halt bilirubin levels from climbing dangerously high. C) Weight loss is a sign of developing dehydration in the newborn. The newborn should be weighed daily. D) Yellowing in the skin should disappear with effective phototherapy. Page Ref: 835 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

20) The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased pulse B) High blood pressure C) Tachycardia D) Bradycardia E) Capillary filling time greater than 3 seconds Answer: C, E Explanation: A) Decreased pulse would be a sign of shock. B) Low blood pressure would be a sign of shock. C) Tachycardia would be a sign of shock. D) Tachycardia, not bradycardia, would be a sign of shock. E) Capillary filling time greater than 3 seconds would be a sign of shock. Page Ref: 840 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Explain the etiology and the nursing care of newborns with anemia. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

21) Mild or chronic anemia in an infant may be treated adequately by which of the following? A) Transfusions with O-negative or typed and cross-matched packed red cells B) Iron supplements or iron-fortified formulas C) Steroid therapy D) Antibiotics or antivirals Answer: B Explanation: A) Severe cases of anemia are treated with transfusions with O-negative or typed and cross-matched packed red cells. B) Mild or chronic anemia in an infant may be treated adequately with iron supplements or ironfortified formulas. C) Management of anemia of prematurity includes treating the causative factor (e.g., antibiotics or antivirals used for infection or steroid therapy for disorders of erythrocyte production). D) Management of anemia of prematurity includes treating the causative factor (e.g., antibiotics or antivirals used for infection or steroid therapy for disorders of erythrocyte production). Page Ref: 840 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Explain the etiology and the nursing care of newborns with anemia. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

22) What indications would lead the nurse to suspect sepsis in a newborn? A) Respiratory distress syndrome developing 48 hours after birth B) Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming. C) Irritability and flushing of the skin at 8 hours of age D) Bradycardia and tachypnea developing when the infant is 36 hours old Answer: B Explanation: A) The infant may deteriorate rapidly in the first 12 to 24 hours after birth if βhemolytic streptococcal infection is present. B) Temperature instability is often seen with sepsis. Fever is rare in a newborn. C) Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, and the skin is cool and clammy. D) Tachycardia and periods of apnea are seen with sepsis. Page Ref: 845 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Describe the clinical manifestations that would lead the nurse to suspect newborn sepsis. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

23) Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Obtain skin cultures. B) Restrict parental visits. C) Evaluate bilirubin levels. D) Administer oxygen as ordered. E) Observe for signs of hypoglycemia. Answer: A, C, D, E Explanation: A) The nurse will assist in obtaining skin cultures. Skin cultures are taken of any lesions or drainage from lesions or reddened areas. B) Restricting parental visits has not been shown to have any effect on the rate of infection and may be harmful to the newborn's psychologic development. C) The nurse will observe for hyperbilirubinemia, anemia, and hemorrhagic symptoms. D) The nurse will administer oxygen as ordered. E) The nurse will observe for signs of hypoglycemia. Page Ref: 846 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Delineate the nursing care of the newborn with an infection. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

24) The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? A) "I'll bring you to your baby and then leave so you can have some privacy." B) "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." C) "I am so sorry this has all happened. I know how stressful this can be." D) "Your baby is working hard to breathe and lying quite still, and has an IV." Answer: D Explanation: A) When bringing parents to see their ill newborn for the first time, it is important to prepare them for what they will see. Bringing parents without preparation is inappropriate. B) Although this statement describes the treatment the baby is receiving, it is worded in medical jargon that will not be understood by most parents. The nurse should describe the equipment being used for the at-risk newborn and its purpose before entering the unit. C) This response focuses on the nurse. Avoid saying "I know how you feel," because it is impossible for the nurse to actually know how clients feel. D) This answer is best because it explains what the parents will see in terminology that they will understand. A trusting relationship is essential for collaborative efforts in caring for the infant. The nurse should respond therapeutically to relate to the parents on a one-to-one basis. Page Ref: 849 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

25) The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? A) A history of obsessive-compulsive disorder (OCD) B) Chlamydia C) Delivered six other children by cesarean section D) A urinary tract infection (UTI) Answer: B Explanation: A) Obsessive-compulsive disorder (OCD) is not a risk factor for the infant. B) Infants born to mothers with chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and require close observation of the respiratory status and eyes. C) Having multiple siblings, regardless of how they were delivered, is not a risk factor for the infant. D) An infant whose mother has an untreated urinary tract infection might have been exposed to pathogens, but it is not known whether the mother in this question is on antibiotics. Page Ref: 843 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (HSV or CMV), and chlamydia, to the management of the newborn in the neonatal period. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

26) One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? A) Meticulous hand washing and antibiotic eye ointment administration. B) Intravenous acyclovir (Zovirax) and contact precautions. C) Cultures of blood and CSF and serial chest x-rays every 12 hours. D) Parental rooming-in and four intramuscular injections of penicillin. Answer: B Explanation: A) Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or chlamydia. B) Administering intravenous acyclovir (Zovirax) and contact precautions are appropriate measures for an infant at risk for developing herpes simplex 2 infection. C) Cultures of blood and CSF cultures are appropriate, but chest X-rays are not indicated. Chest X-rays are obtained if the neonate is thought to have group B strep pneumonia. D) Parental rooming-in is encouraged, but penicillin does not treat viral illness. Page Ref: 842 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (HSV or CMV), and chlamydia, to the management of the newborn in the neonatal period. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

27) The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? A) "Your newborn likes to be touched." B) "Stroking the newborn will help with stimulation." C) "Visits must be scheduled between feedings." D) "Your baby loves her pink blanket." Answer: C Explanation: A) Statements that encourage the parents to touch the newborn will help them bond with their child. B) Statements that encourage the parents to stroke the newborn will help them bond with their child and provide stimulation. C) The nurse should always encourage parents to visit and get to know their newborn, even in the NICU. Nurses foster the development of a safe, trusting environment by viewing the parents as essential caregivers, not as visitors or nuisances in the unit. D) Comments that personalize the baby will tell the parents their baby is unique and special. Page Ref: 849 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

28) The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? A) "If I had taken better care of myself, this wouldn't have happened." B) "I've been sleeping very well since I had the baby." C) "This is probably the doctor's fault." D) "If I hadn't seen our baby's birth, I wouldn't believe she is ours." Answer: B Explanation: A) Some parents may feel guilty about their baby's condition and think they have caused the problem. B) A sick infant is a source of great anxiety for parents. This response is from the mother would be unexpected. C) Parents express grief as shock and disbelief, denial of reality, anger toward self and others, guilt, blame, and concern for the future. D) Parents express grief as shock and disbelief, denial of reality, anger toward self and others, guilt, blame, and concern for the future. Page Ref: 835 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Delineate the nursing care of the newborn with an infection. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

29) An infant with a pneumothorax has the following chest x-ray result. Which area should the nurse identify as being the pneumothorax?

A) A B) B C) C D) D Answer: B Explanation: B) In a pneumothorax, rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung. Air shows on X-ray as a dark area over the lung. Page Ref: 824 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and the nursing care required. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

30) The nurse is preparing to measure a newborn's blood glucose level. Which areas on the heel should be used to obtain a blood sample for this test?

1. A 2. B 3. C 4. D 5. E Answer: 1, 5 Explanation: The infant's lateral heel is the site of choice because it precludes damaging the posterior tibial nerve and artery, plantar artery, and the important longitudinally oriented fat pad of the heel, which in later years could impede walking. Page Ref: 829 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

31) The nurse sees the following patient in the neonatal intensive care unit and realizes that additional care will need to be provided for which health problem?

A) Hypotension B) Hypoglycemia C) Hyperglycemia D) Hyperbilirubinemia Answer: D Explanation: D) This infant is receiving phototherapy. The phototherapy light is positioned over the incubator. Bilateral eye patches are always used during phototherapy to protect the baby's eyes. Eye coverings are not needed for hypoglycemia, hyperglycemia, or hypotension. Page Ref: 835 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

32) A neonate weighing 5.5 lb is prescribed to receive intravenous cefotaxime (Claforan) 50 mg/kg/dose every 6 hours for treatment of sepsis. How many mg of the medication should the nurse anticipate the patient will need for 24 hours? (Calculate to the nearest whole number.) Answer: 500 mg Explanation: First convert the patient's weight in lb to kg by dividing by 2.2, or 5.5/2.2 = 2.5 kg. Then calculate the amount of medication needed for each dose by multiplying 50 mg x 2.5 kg = 125 mg. Then multiply the amount of medication for each dose by 4 (one dose every 6 hours) or 125 mg x 4 = 500 mg. The patient will receive 500 mg of the medication in a 24-hour period. Page Ref: 845 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 9 Delineate the nursing care of the newborn with an infection. MNL LO: Demonstrate understanding of birth-related stressors that place the newborn at risk.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 32 Postpartum Adaptation and Nursing Assessment 1) The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do? A) Document the findings. B) Catheterize the client. C) Massage the uterine fundus until it is firm. D) Call the physician immediately. Answer: C Explanation: A) Documenting the findings would come after massage, reassessment, and evaluation. B) Catheterizing the client might be indicated if assessment reveals a full bladder and inability to void, but not as an initial intervention. C) The nurse would massage the uterine fundus until it is firm by keeping one hand in position and stabilizing the lower portion of the uterus. With one hand used to massage the fundus, the nurse would put steady pressure on the top of the now-firm fundus to see if she was able to express any clots. D) Calling the physician immediately is not necessary until more data are obtained. Page Ref: 869 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

2) The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Offer a warm water bottle for her abdomen. B) Call the physician to report this finding. C) Inform her that this is not normal, and she will need an oxytocic agent. D) Administer a mild analgesic to help with breastfeeding. E) Administer a mild analgesic at bedtime to ensure rest. Answer: A, D, E Explanation: A) A warm water bottle placed against the low abdomen may reduce the discomfort of afterpains. B) It is not necessary to report this finding to the physician. C) Afterpains are not abnormal in multiparas. Oxytocic agents stimulate uterine contraction and increase the discomfort of the afterpains. D) The breastfeeding mother may find it helpful to take a mild analgesic agent approximately 1 hour before feeding her infant. E) An analgesic agent such as ibuprofen is also helpful at bedtime if the afterpains interfere with the mother's rest. Page Ref: 862 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

3) The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? A) Methylergonovine maleate (Methergine) B) Rh immune globulin (RhoGAM) C) Terbutaline (Brethine) D) Docusate (Colace) Answer: A Explanation: A) Methylergonovine maleate is the drug used for the prevention and control of postpartum hemorrhage. B) RhoGAM is a medicine given by intramuscular injection that is used to prevent the immunological condition known as Rh disease (or hemolytic disease of the newborn). C) Terbutaline (Brethine) is a β2-adrenergic receptor agonist used as a "reliever" inhaler in the management of asthma. D) Docusate is a stool softener. Page Ref: 870 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

4) A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate? A) Encourage sitz baths. B) Position the client in the supine position. C) Avoid stool softeners. D) Decrease fluid intake. Answer: A Explanation: A) Encouraging sitz baths is the correct approach because moist heat decreases inflammation and provides for comfort. B) Position the client in a side-lying position. C) Avoiding stool softeners would put the client at risk for constipation and increase the likelihood of inflammation. D) Decreasing fluid intake would put the client at risk for constipation and would be contraindicated for reducing inflammation. Page Ref: 872 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

5) The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate? A) Encourage the new mother, saying, "It will happen soon." B) Instruct the client to eat a low-fiber diet. C) Decrease fluid intake. D) Obtain an order for a stool softener. Answer: D Explanation: A) Saying "It will happen soon" does not address the client's needs and could increase the chance for constipation. B) Eating a low-fiber diet would not increase bulk or moisture in the stool. C) Decreasing fluid intake would decrease moisture in the fecal material, encouraging constipation. D) Obtaining an order for a stool softener is the correct intervention by the third day. In resisting or delaying the bowel movement, the woman may cause increased constipation and more pain when elimination finally occurs. Page Ref: 859 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

6) The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first? A) Woman who is 2nd day post-cesarean, moderate lochia serosa B) Woman day of delivery, fundus firm 2 cm above umbilicus C) Woman who had a cesarean section, 1st postpartum day, 4 cm diastasis recti abdominis D) Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants Answer: B Explanation: A) This client is not experiencing any unexpected findings. The uterus rids itself of the debris remaining after birth through a discharge called lochia, which is classified according to its appearance and contents. Lochia serosa is a pinkish color. B) This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. If the fundus is in the midline but higher than expected, it is usually associated with clots within the uterus. C) Diastasis recti abdominis is normal and is especially pronounced in women who have undergone a cesarean section. D) Bowel sounds are often decreased after delivery and it may take a few days for the bowel to regain its tone. The woman who has had a cesarean or a difficult birth may benefit from stool softeners. Page Ref: 868 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

7) The nurse expects an initial weight loss for the average postpartum client to be which of the following? A) 5 to 8 pounds B) 10 to 12 pounds C) 12 to 15 pounds D) 15 to 20 pounds Answer: B Explanation: A) An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid. B) An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid. C) An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid. D) An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid. Page Ref: 861 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

8) To assess the healing of the uterus at the placental site, what does the nurse assess? A) Lab values B) Blood pressure C) Uterine size D) Type, amount, and consistency of lochia Answer: D Explanation: A) Lab values is an incomplete response because it does not indicate which lab values are referred to. B) Blood pressure varies slightly in normal postpartal women, and would not affect the placental site. C) Uterine size alone is not enough to assess the placental site. D) The type, amount, and consistency of lochia determine the state of healing of the placental site, and a progressive color change from bright red at birth to dark red to pink to white or clear should be observed. Page Ref: 858 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

9) The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement? A) "I should expect a lighter flow next week." B) "The flow will increase if I am too active." C) "My bleeding will remain red for about a month." D) "I will be able to use a pantiliner in a day or two." Answer: C Explanation: A) The uterus rids itself of the debris remaining after birth through a discharge called lochia. Lochia serosa is a pinkish color. It follows from about the 3rd to the 10th day toward a lighter amount of flow and a lighter color of discharge. When the lochia stops, the cervix is considered closed. B) The amount of lochia may be increased by exertion or breastfeeding. C) Lochia rubra is dark red in color. It is present for the first 2 to 3 days postpartum. Lochia serosa is a pinkish color and it follows from about the 3rd to the 10th day. D) By day three, the lochia shed is a lighter amount of flow and a lighter color of discharge. A pantiliner would be appropriate for use at this point. Page Ref: 858 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Describe the common concerns of the mother that are considered in a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

10) Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take? A) Answer questions quickly and try to divert her attention to other subjects. B) Review the documentation of the birth experience and discuss it with her. C) Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. D) Submit a referral to Social Services because of possible obsessive behavior. Answer: B Explanation: A) Answering questions quickly and trying to divert the client's attention trivializes her questions and does not allow her to sort out the reality from her fantasized experience. B) The client may talk about her labor and birth experience. The nurse should provide opportunities to discuss the birth experience in a nonjudgmental atmosphere if the woman desires to do so. C) Asking questions about the birth experience is normal behavior. Contacting the physician is not warranted. D) Submitting a referral to Social Services is inappropriate, because this client's behavior is normal. Page Ref: 875 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Describe the common concerns of the mother that are considered in a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

11) Which statement by a new mother 1 week postpartum indicates maternal role attainment? A) "I don't think I'll ever know what I'm doing." B) "This baby feels like a real stranger to me." C) "It works better for me to undress the baby and to nurse in the chair rather than the bed." D) "My sister took to mothering in no time. Why can't I?" Answer: C Explanation: A) This statement indicates that the mother has not yet achieved a level of comfort or confidence in her new role as a mother. B) This statement indicates that "binding in" to the newborn has not yet occurred. C) This statement indicates a stage of maternal role attainment in which the new mother feels comfortable enough to make her own decisions about parenting. D) This statement indicates that the mother has not yet achieved a level of comfort or confidence in her new role. Page Ref: 862 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 2 Describe the psychologic adjustments that normally occur during the postpartum period. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

12) On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following? A) The taking-hold phase B) Postpartum hemorrhage C) The taking-in period D) Epidural anesthesia Answer: C Explanation: A) By the second or third day after birth, the new mother may be observed to be ready to resume control of her body, her mothering, and her life in general. This is called the taking-hold phase. B) Postpartum hemorrhage is a serious complication and needs medical intervention. A low or decreasing blood pressure may reflect hypovolemia secondary to hemorrhage. C) Soon after birth during the taking-in period, the woman tends to be passive and somewhat dependent. She follows suggestions, hesitates about making decisions, and is still rather preoccupied with her needs. D) Epidural anesthesia is a pharmacological approach to pain control. There may be an increased incidence of headache if the woman had spinal or epidural anesthesia. Page Ref: 862 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

13) The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction? A) "The en face position promotes bonding and attachment." B) "Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed." C) "In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous." D) "The needs of the mother and of her infant are balanced during the phase of mutual regulation." Answer: B Explanation: A) The mother has direct face-to-face and eye-to-eye contact in the en face position, which is crucial to attachment. B) Ideally, initial skin-to-skin contact is immediate. The benefits of this practice are supported by a preponderance of evidence. C) Reciprocity is an interactional cycle that occurs simultaneously between mother and infant. It involves mutual cuing behaviors, expectancy, rhythmicity, and synchrony. D) In the phase of mutual regulation, mother and infant seek to deal with the degree of control to be exerted by each in their relationship. Page Ref: 865 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

14) The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Make sure she gets a kosher diet. B) Expect that most visitors will be women. C) Uncover only the necessary skin when assessing. D) The father will take an active role in infant care. E) She will prefer a male physician. Answer: B, C Explanation: A) A kosher diet is appropriate for Jewish women, not Muslims. Although many of the dietary laws are similar, kosher laws are not appropriate for a Muslim client. B) In Muslim cultures, emphasis on childrearing and infant care activities is on the mother and female relatives. C) Women of the Islamic faith may have specific modesty requirements; the woman must be completely covered, with only her feet and hands exposed. D) In Muslim cultures, emphasis on childrearing and infant care activities is on the mother and female relatives, and there is little involvement of the father in newborn care. E) Women of the Islamic faith may have specific modesty requirements; the woman must be completely covered, with only her feet and hands exposed, and no man, other than the husband or a family member, may be alone with her. Because of the culture of modesty, many Muslim women highly prefer female care providers. Page Ref: 863 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Be open to others' ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

15) The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following? A) Help the new mother by allowing her to focus on resting and caring for the baby. B) Teach her son-in-law the right way to be a father because this is his first child. C) Make sure that her daughter does not become abusive towards the infant. D) Pass on cultural values and beliefs to the newborn grandchild. Answer: A Explanation: A) Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods. B) The new father might be taught some skills either directly or indirectly through observation, but this is not the most important role of the grandmother. C) The new grandmother does not assume that her daughter will be abusive toward the infant. D) An infant is too young to be taught values and beliefs. Page Ref: 875 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Be open to others' ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

16) How does the nurse assess for Homans' sign? A) Extending the foot and inquiring about calf pain. B) Extending the leg and inquiring about foot pain. C) Flexing the knee and inquiring about thigh pain. D) Dorsiflexing the foot and inquiring about calf pain. Answer: D Explanation: A) This is not the correct procedure for assessing for Homans' sign. B) This is not the correct procedure for assessing for Homans' sign. C) This is not the correct procedure for assessing for Homans' sign. D) To assess for thrombophlebitis, the nurse should have the woman stretch her legs out, with the knees slightly flexed and the legs relaxed. The nurse then grasps the foot and dorsiflexes it sharply. If pain is elicited, the nurse notifies the physician/CNM that the woman has a positive Homans' sign. The pain is caused by inflammation of a vessel. Page Ref: 874 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 16. Demonstrate the application of psychomotor skills for efficient, safe and compassionate delivery of patient care. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

17) Which of the following symptoms would be an indication of postpartum blues? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Overeating B) Anger C) Mood swings D) Constant sleepiness E) Crying Answer: B, C, E Explanation: A) Anorexia, not overeating, would be a symptom of postpartum blues. B) Anger would be a symptom of postpartum blues. C) Mood swings would be a symptom of postpartum blues. D) Difficulty sleeping would be a symptom of postpartum blues. E) Weepiness and crying would be a symptom of postpartum blues. Page Ref: 863 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 16. Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

18) Nursing interventions that foster the process of becoming a mother include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Encouraging detachment from the nurse-patient relationship B) Promoting maternal-infant attachment C) Building awareness of and responsiveness to infant interactive capabilities D) Instruct about promoting newborn independence E) Preparing the woman for the maternal social role Answer: B, C, E Explanation: A) Encouraging interactive therapeutic nurse-patient relationships is a nursing intervention that fosters the process of becoming a mother. B) Promoting maternal-infant attachment is a nursing intervention that fosters the process of becoming a mother. C) Building awareness of and responsiveness to infant interactive capabilities is a nursing intervention that fosters the process of becoming a mother. D) Instructing about infant caregiving is a nursing intervention that fosters the process of becoming a mother. E) Preparing the woman for the maternal social role is a nursing intervention that fosters the process of becoming a mother. Page Ref: 862 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

19) The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following? A) Increased blood pressure B) Hypoglycemia C) Postpartum hemorrhage D) Postpartum infection Answer: C Explanation: A) Increased blood pressure would cause vasoconstriction, and is not identified in this client. B) Hypoglycemia would not be a usual assessment for the mother unless she was diabetic, and this is not identified in this client. C) The nurse will assess for postpartum hemorrhage. Overstretching of uterine muscles with conditions such as multiple gestation, polyhydramnios, or a very large baby may set the stage for slower uterine involution. D) Postpartum infection would be assessed through lochia odor. The odor of the lochia is nonoffensive and never foul. If foul odor is present, so is an infection. Infection would not be expected this soon after delivery. Page Ref: 857 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

20) The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse? A) Asking the client to void and donning clean gloves B) Listening to bowel sounds and then asking when her last bowel movement occurred C) Offering the patient pre-medication 2 hours before the assessment D) Completing the assessment and explaining the results to the client Answer: C Explanation: A) Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids. B) It is appropriate to ask about a body part when assessing that part. C) The patient should be offered premedication 30-45 minutes before assessing the fundus, especially if the patient has had a cesarean section. D) The nurse should provide an explanation of the purposes of regular assessment to the woman. Page Ref: 869 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

21) The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action? A) To massage the fundus vigorously B) To assess the client's pain level C) To increase the rate of the IV D) To assist the client to the bathroom Answer: D Explanation: A) The location of the fundus and the time since delivery indicate that the bladder is distended. Emptying the bladder is the top priority. B) To assess the client's pain level is not important at this time. Emptying the bladder is the top priority. C) Emptying the bladder is the top priority. A distended bladder is an indication that hydration is adequate. D) Emptying the bladder is the top priority. Page Ref: 869 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

22) During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? A) Firm fundus B) Fundus at the umbilical level C) Moderate lochia rubra D) Steady trickle of blood Answer: D Explanation: A) A firm fundus is desirable, and considered normal. B) Six hours after birth, the fundus at the umbilicus would not be a concern. C) Lochia rubra would be considered normal. D) The continuous seepage of blood is more consistent with cervical or vaginal lacerations. Lacerations should be suspected if the uterus is firm and of expected size, and no clots can be expressed. This finding would indicate a follow-up. Page Ref: 858 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

23) Which of the following behaviors noted in the postpartum client would require the nurse to assess further? A) Responds hesitantly to infant cries. B) Expresses satisfaction about the sex of the baby. C) Friends and family visit the client and give advice. D) Talks to and cuddles with the infant frequently. Answer: A Explanation: A) The mother tends to respond verbally to any sounds emitted by the newborn, such as cries, coughs, sneezes, and grunts. Responding hesitantly to infant cries suggests further assessment is needed to determine what the mother is feeling. B) Expressing satisfaction about the sex of the baby is usually a positive sign. C) Birth centers are especially geared toward the inclusion of the family in the birth process. In the hospital setting, the advent of open visiting hours and rooming-in permits siblings and grandparents to participate in the attachment process. D) Talking to and cuddling with the infant frequently is a behavior that facilitates attachment. Page Ref: 864 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

24) The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response? A) "We see this from time to time. It's not a big deal." B) "The gush is an indication that your fundus isn't contracting." C) "Don't worry. I'll make sure everything is fine." D) "Blood pooled in the vagina while you were in bed." Answer: D Explanation: A) Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic, because it does not answer the client's question. B) The fundus might be contracting well. The gush is from pooled lochia in the vagina. C) This response is not therapeutic because it focuses on the nurse and has a "don't worry" aspect that most clients find demeaning. D) A gush of blood when a fundal massage is undertaken may occur because of normal pooling of blood in vagina when the woman lies down to rest or sleep. Page Ref: 868 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

25) Which of the following conditions would predispose a client for thrombophlebitis? A) Severe anemia B) Cesarean delivery C) Anorexia D) Hypocoagulability Answer: A Explanation: A) Severe anemia would predispose a client for thrombophlebitis. B) A traumatic delivery would predispose a client for thrombophlebitis. C) Obesity, not anorexia, would predispose a client for thrombophlebitis. D) Hypercoagulability would predispose a client for thrombophlebitis. Page Ref: 874 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

26) The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues? A) "I am so happy and blessed to have my new baby." B) "One minute I'm laughing and the next I'm crying." C) "My husband is helping out by changing the baby at night." D) "Breastfeeding is going quite well now that the engorgement is gone." Answer: B Explanation: A) Feeling happy is not a symptom of postpartum blues. B) The postpartum blues consist of a transient period of depression that occurs during the first few days of puerperium. Symptoms may include mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown. C) The husband's assistance does not relate to postpartum blues. D) Successful lactation is not a symptom of postpartum blues. Page Ref: 863 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. B. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Threats to the integrity of relationships, and the potential for conflict and abuse. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

27) The postpartum client is about to go home. The nurse includes which subject in the teaching plan? A) Replacement of fluids B) Striae C) Diastasis of the recti muscles D) REEDA scale Answer: C Explanation: A) Frequently, the woman is quite thirsty following birth and will drink large amounts of fluid. Drinking fluids helps replace fluid lost during labor, in the urine, and through perspiration. This is not something that is taught to the patient at discharge. B) Striae (stretch marks) are a normal skin change in the pregnant woman. C) Diastasis recti abdominis and abdominal muscle tone can be improved with exercise. These exercises can be taught during the postpartum period prior to discharge. D) To evaluate the state of healing, the nurse inspects the Cesarean wound for redness, edema, ecchymosis, discharge, and approximation (REEDA scale). This is not something that is taught to the patient at discharge. Page Ref: 859 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

28) During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Establish a therapeutic relationship with her physician B) Adapt to altered lifestyles and family structure resulting from the addition of a new member C) Restore her intellectual abilities D) Restore physical condition E) Develop competence in caring for and meeting the needs of her infant Answer: B, D, E Explanation: A) During the first several postpartum weeks, the new mother must establish a relationship with her new child, not her physician. B) During the first several postpartum weeks, the new mother must adapt to altered lifestyles and family structure resulting from the addition of a new member. C) During the first several postpartum weeks, the new mother must restore her physical condition, not her intellectual abilities. D) During the first several postpartum weeks, the new mother must restore her physical condition. E) During the first several postpartum weeks, the new mother must develop competence in caring for and meeting the needs of her infant. Page Ref: 875 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Examine the physical and developmental tasks that the mother must accomplish during the postpartum period. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

29) The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? A) Describe the likely reaction of siblings to the new baby. B) Discuss adaptation to grandparenthood by her parents. C) Determine whether father-infant attachment is taking place. D) Assist the mother in identifying the baby's behavior cues. Answer: D Explanation: A) This is not appropriate, because the baby has no siblings. B) Adaptation to grandparenthood is a task for her parents, and not a high priority for teaching to the new mother. C) Although father-infant attachment is important, the mother is the main client, and teaching her directly is a higher priority. D) Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment. Page Ref: 864 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

30) A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn? A) The client who is discussing how the baby looks like her father B) The client who is singing softly to her baby C) The client who continues to touch her baby with only her fingertips D) The client who picks her baby up when the baby cries Answer: C Explanation: A) Pointing out family traits or characteristics in the newborn is a positive sign of developing early attachment. B) Speaking or singing to the baby frequently and affectionately is a positive sign of developing early attachment. C) In a progression of touching activities, the mother proceeds from fingertip exploration of the newborn's extremities toward palmar contact with larger body areas and finally to enfolding the infant with the whole hand and arms. If the client continues to touch with only her fingertips, she might not be developing adequate early attachment. D) Being sensitive to the newborn's needs is a positive sign of developing early attachment. Page Ref: 864 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

31) The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior? A) The client is not attaching to her infant appropriately. B) The client is not going to be a good mother, and the baby is at risk. C) The client has no mother present to role-model behaviors. D) The client is exhibiting normal behavior for her culture. Answer: D Explanation: A) Resting since the birth is expected behavior in certain cultures. B) The mother-infant couplet is not at risk. Resting since birth is expected behavior in certain cultures. C) Even though her mother is not present, her sister is role-modeling behaviors. D) Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods. Page Ref: 875 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

32) The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make? A) "I have a lot more time to myself than I thought I would have." B) "My confidence level in my parenting is higher than I anticipated." C) "I am constantly tired. I feel like I could sleep for a week." D) "My baby likes everyone, and never fusses when she's held by a stranger." Answer: C Explanation: A) Most new mothers have difficulty finding time for themselves. B) Feelings of incompetence at parenting are also common. C) Physical fatigue often affects adjustments and functions of the new mother. The nurse can also provide information about the fatigue that a new mother experiences, strategies to promote rest and sleep at home, and the impact fatigue can have on a woman's emotions and sense of control. D) At 8 months, some infants develop stranger anxiety, and they will cry when held by anyone other than the parents. Page Ref: 875 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

33) The nurse is preparing a class for mothers who have just recently delivered and their partners. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "We should avoid holding the baby too much." B) "Looking directly into the baby's eyes might frighten him." C) "Talking to the baby is good because he'll recognize our voices." D) "Holding the baby so we have direct face-to-face contact is good." E) "We should only touch the baby with our fingertips for the first month." Answer: C, D Explanation: A) Attachment behaviors include holding the baby in the en face position. B) Attachment behaviors include making eye contact. C) Attachment behaviors include cuddling, soothing, and calling the baby by name. D) Attachment behaviors include holding the baby in the en face position. E) In a progression of touching activities, the mother proceeds from fingertip exploration of the newborn's extremities toward palmar contact with larger body areas and finally to enfolding the infant with the whole hand and arms. The time taken to accomplish these steps varies from minutes to days. Page Ref: 878 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

34) The home care nurse is assessing the level of a mother's fundus who delivered 3 days ago. Where should the fundus be located?

A) A B) B C) C D) D Answer: B Explanation: B) About 6 to 12 hours after birth, the fundus is at the level of (or one fingerbreadth below) the umbilicus. The height of the fundus then decreases about one fingerbreadth (approximately 1 cm) each day. Page Ref: 857 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

35) During a postpartum assessment, the nurse suspects the patient has a full bladder. Where is the fundus located for the nurse to make this clinical determination?

A) A B) B C) C D) D Answer: A Explanation: A) The uterus becomes displaced and deviated to the right when the bladder is full. Page Ref: 858 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

36) The nurse performs the following while assessing a postpartum patient. For what is the nurse assessing?

A) Fundal height B) Uterine bleeding C) Bladder distention D) Abdominal distention Answer: A Explanation: A) The nurse is determining the position of the fundus for the patient recovering from a vaginal birth. The bottom of the uterus should always be supported when assessing the fundus. This technique is not used to assess uterine bleeding, bladder distention, or abdominal distention. Page Ref: 869 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period.

37) The nurse is determining a postpartum patient's amount of lochia. For which observation should the nurse document a moderate amount? A)

Answer: B Explanation: B) A moderate amount has less than a 6-inch stain on a peripad. Choice 1 is a heavy amount, characterized by a saturated peripad within 1 hour. Choice 3 is a light amount with a less than 4-inch stain on a peripad. Choice 4 is a scant amount, with blood only on tissue when wiped or less than 1-inch stain on peripad. Page Ref: 870 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Communication and Documentation. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period. 38) Put the following components specific to a postpartum examination in the proper sequential order: 1. L-lochia 2. E-emotional 3. H-Homans'/hemorrhoids 4. B-breasts 5. E-episiotomy/lacerations Answer: 4, 1, 5, 3, 2 Explanation: If following BUBBLEHE (B: breast, U: uterus, B: bladder, B: bowel, L: lochia, E: episiotomy/laceration, H: Homans'/hemorrhoids, and E: emotion) the breasts should be assessed first followed by lochia, episiotomy, Homan's/hemorrhoids, and ending with emotion. Page Ref: 868 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment. MNL LO: Demonstrate ability to perform assessment and interpret data during the postpartum period. 38 Copyright © 2020 Pearson Education, Inc.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 33 The Postpartum Family: Needs and Care 1) The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate? A) Assess fundus and bladder status. B) Catheterize the client. C) Administer Methergine IM per order. D) Contact the physician immediately. Answer: A Explanation: A) The amount, consistency, color, and odor of the lochia are monitored on an ongoing basis. Increased bleeding is most often related to uterine atony and responds to fundal massage, expression of any clots, and emptying the bladder. B) Catheterizing the client might be an intervention if the bladder is full and the client is unable to void, but it is not the initial intervention. C) It is not necessary to administer Methergine IM per order; the situation does not warrant this intervention. D) It is not necessary to contact the physician immediately; the situation does not warrant this intervention. Page Ref: 888 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

2) The nurse is providing education to the new family. Which question by the nurse is best? A) "Do you know how to give the baby a bath?" B) "You have diapers and supplies at home, right?" C) "How have your breastfeedings been going?" D) "How much formal education do you have?" Answer: C Explanation: A) This is a closed question; closed questions should be avoided. Also, bathing is a lower-priority need than is feeding. B) This is a leading question. Leading questions should be avoided. C) This is an open-ended question about an important physiologic issue. A discussion that includes both partners can facilitate an open dialog between them and can provide an opportunity for questions and answers. D) Although the family members' level of educational attainment helps when choosing written materials and words, it is rude to ask outright what education they have had. Page Ref: 888 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care; Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum family wellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

3) The nurse is preparing to administer postpartum neuraxial morphine to a client who is morbidly obese. For which side effect related to morbid obesity should the nurse monitor? A) Respiratory depression B) Confusion C) Constipation D) Hypotension Answer: A Explanation: A) Women who are morbidly obese are at increased risk for respiratory depression, which is managed by administration of naloxone (Narcan), mask ventilation, and endotracheal intubation with mechanical ventilation, if necessary. B) The client is not at increased risk of confusion, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. C) The client is not at increased risk of constipation, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. D) The client is not at increased risk of hypotension, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. Page Ref: 905 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify critical physiologic, psychosocial, and safety needs related to the care of obese and morbidly obese postpartum women. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

4) A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following? A) "I will need another vaccination in 3 months." B) "I must avoid getting pregnant for 1 month." C) "This will prevent me from getting chickenpox." D) "This will protect my newborn from getting the measles." Answer: B Explanation: A) The client will not need another vaccination in 3 months. B) The client must avoid pregnancy for at least 1 month after receiving the rubella vaccine. C) The vaccination prevents measles, not chickenpox. D) The vaccination will only protect the client receiving it; therefore, the newborn will not be protected until the child receives his own vaccination. Page Ref: 895 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Delineate nursing responsibilities for patient teaching during the early postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

5) The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Pain B) Excess energy C) Urinary incontinence D) Changes in mental health status E) Sleep deprivation Answer: A, C, D, E Explanation: A) Pain can be a discomfort in the first year postpartum. B) Fatigue, not excess energy, can be a discomfort in the first year postpartum. C) Urinary incontinence can be a complication in the first year postpartum. D) Changes in mental health status can be a complication in the first year postpartum. E) Sleep deprivation can be a complication in the first year postpartum. Page Ref: 884 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

6) A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief? A) Nonsteroidal anti-inflammatory agents B) Proquad C) Methergine D) Intravenous oxytocin Answer: A Explanation: A) A variety of drugs are used alone or in combination to provide relief of postpartum pain. An option would include nonsteroidal anti-inflammatory agents such as ibuprofen and ketorolac. B) Proquad is a measles, mumps, rubella, and varicella live virus vaccine. C) Methergine is prescribed to promote uterine contractions. D) Intravenous oxytocin (Pitocin) remains the first-line drug for excessive bleeding related to postpartum uterine atony. Page Ref: 897 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

7) On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following? A) Remove her bra B) Apply heat to the breasts C) Apply cold packs to the breasts D) Use a breast pump to release the milk Answer: C Explanation: A) A support bra is recommended. B) Applying heat would stimulate milk production. C) Applying cold packs to the breasts relieves discomfort and helps suppress lactation. D) Using a breast pump would stimulate milk production and delay the suppression process. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

8) The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Administer analgesics as needed. B) Encourage the client to ambulate to the bathroom to void. C) Encourage leg exercises every 2 hours. D) Encourage the client to cough and deep-breathe every 2 to 4 hours. E) Encourage the use of breathing, relaxation, and distraction. Answer: A, C, D, E Explanation: A) The nurse continues to assess the woman's pain level and provide relief measures as needed. B) Ambulation should begin no later than 24 hours postoperatively and should be encouraged at least 2 to 3 times a day, but not in the first 4 hours. C) Within the first 12 hours postoperatively, unless medically contraindicated, the woman should be assisted to dangle her legs off the side of the bed. D) The woman is encouraged to cough and breathe deeply and to use incentive spirometry every 2 to 4 hours while awake for the first few days following cesarean birth. E) The nurse should encourage the use of breathing, relaxation, and distraction techniques. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

9) A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond? A) "Everyone is different, and both responses are normal." B) "Most mothers do feel euphoria; I don't know why you don't." C) "It's good for me to know that because it might indicate a problem." D) "Let me bring your baby to the nursery so that you can rest." Answer: A Explanation: A) Following birth, some women feel exhausted and in need of rest. Other women are euphoric and full of psychic energy, ready to retell their experience of birth repeatedly. B) The nurse should not imply that a mother's emotional response is not expected. C) Both euphoria and exhaustion are normal feelings after birth. Fatigue after birth is not indicative of a problem. D) The client might want to be with her newborn, and the nurse should not encourage unnecessary separation of mother and child. Page Ref: 898 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate nursing responsibilities for patient teaching during the early postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

10) The breastfeeding client asks the nurse about appropriate contraception. What is the nurse's best response? A) "Breastfeeding has many effects on sexual intercourse." B) "IUDs are easy to use and easy to insert prior to sexual intercourse." C) "It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception." D) "Breastfeeding hampers ovulation, so no contraception is needed." Answer: C Explanation: A) This answer does not address the client's question about contraception. B) IUDs can only be placed by a healthcare provider in a clinic situation. C) The nurse should discuss the importance of contraception during the early postpartum period and provide information on the advantages and disadvantages of different methods, including special considerations for breastfeeding mothers. The woman's body needs adequate time to heal and recover from the stress of pregnancy and childbirth. D) Breastfeeding hampers ovulation, but to be safe, breastfeeding women should use a contraceptive. The nurse should discuss the importance of contraception during the early postpartum period and provide information on the advantages and disadvantages of different methods, including special considerations for breastfeeding mothers. Page Ref: 902 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate nursing responsibilities for patient teaching during the early postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

11) The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement by the client indicates that teaching was effective? A) "I can start running in 2 weeks, and can breastfeed as soon as I am done." B) "I should see how my energy level is at home, and increase my activity slowly." C) "Running is not recommended for breastfeeding women." D) "If I am getting 8 hours of sleep per day, I can start running." Answer: B Explanation: A) Running should not be initiated until after 6 weeks postpartum or with medical approval. The nurse can provide the new mother with suggestions for resuming her normal level of activity. Breastfeeding should take place prior to running to minimize chest discomfort. B) Women should be encouraged to limit the number of activities to prevent excessive fatigue, increase in lochia, and negative psychologic reactions, such as feeling overwhelmed. A regular exercise program including vigorous activities such as running, weight lifting, or competitive sports can usually be initiated after the 6-week postpartum examination or when approved by the client's physician/CNM. C) This statement is not true. It is more comfortable to nurse prior to running, but running is not contraindicated and can usually be initiated after the 6-week postpartum examination or when approved by the client's physician/CNM. D) This response does not address a more important factor, which is encouraging the client to assess her own energy level and to gradually return to previous activity levels. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the nurse's role in promoting maternal rest and helping the mother to gradually resume an appropriate level of activity. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

12) The hospital is developing a new maternity unit. What aspects should be included in the planning of the new unit to best promote family wellness? A) Normal newborn nursery centrally located to all client rooms B) A kitchen with a refrigerator stocked with juice and sandwiches C) Small, cozy rooms with a client bed and rocking chair D) A nursing care model based on providing couplet care Answer: D Explanation: A) Rooming-in provides the childbearing family with opportunities to interact with their newborn during the first hours and days of life. B) Although having snacks can be good for postpartum clients, some cultures prohibit drinking cold liquids after birth. C) Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better. D) Couplet care, which is care of both the mother and her baby, is an important part of the family-centered care approach, in which the infant remains at the mother's bedside and both are cared for by the same nurse. Page Ref: 900 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Teamwork: Contributions of other individuals and groups in helping patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum family wellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

13) Which statement by a nursing student preparing to care for a postpartum lesbian mother would indicate that the student is prepared for the teaching? A) "I can't let the client know I've never worked with lesbian mothers." B) "I will have to adjust some of my discharge instruction for this mother." C) "I don't need to include the partner when I provide care and instruction." D) "Discharge teaching is exactly the same for lesbian mothers as for all others." Answer: B Explanation: A) The nurse should ask the patient for guidance regarding any special needs or requests that she or her partner may have. B) The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception, might need to be individualized and amended. C) Providing quality patient-centered care for any postpartum woman involves acknowledging, welcoming, and involving her intimate partner in care and decision making. D) The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception, might need to be individualized and amended. Page Ref: 908 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Describe possible approaches to sensitive, holistic nursing care for targeted populations of childbearing patients: Lesbian birth mothers and co-mothers, women with special needs, women who have experienced abuse, and women relinquishing their newborns. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

14) A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond? A) "Babies like to be with their mothers more than they like to be in the nursery." B) "Contact between parents and babies increases attachment." C) "Budget cuts have decreased the number of nurses in the nursery." D) "Why do you ask? Do you have concerns about your daughter's parenting?" Answer: B Explanation: A) Although most newborns cry less when held than when in their cribs, this is not the most important reason for encouraging mothers to spend time with their babies. B) In a mother-baby unit, the newborn's crib is placed near the mother's bed, where she can see her baby easily; this is conducive to an on-demand feeding schedule for both breastfeeding and formula-feeding infants. C) Budget cuts are not a reason for babies' being in the nursery less than in the past. D) It is not therapeutic to use the word "why." The grandmother has not indicated that she has any concerns about her daughter's parenting. Page Ref: 900 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

15) What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth? A) The client receives a bolus of the analgesia when pressing the button. B) The client experiences pain relief within 30 minutes. C) The client feels a greater sense of control, and is less dependent on the nursing staff. D) The client can deliver as many doses of the medication as needed. Answer: C Explanation: A) With this approach, the woman is given a bolus of analgesia, often morphine, at the beginning of therapy and is not repeated. B) IV pain medications provide rapid pain relief. C) Using a special intravenous (IV) pump system, the woman presses a button to self-administer small doses of the medication as needed. For safety, the pump is preset with a time lockout so that the pump cannot deliver another dose until a specified time has elapsed. Women using PCA feel less anxious and have a greater sense of control with less dependence on the nursing staff. D) For safety, the pump is preset with a time lockout so that the pump cannot deliver another dose until a specified time has elapsed. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. C. 9. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

16) The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best? A) "We'll take good care of you and your baby. You'll be home before you know it." B) "You'll be wearing a sequential compression device until you start walking." C) "You will have a lot of pain, but there are medications that we give when it gets really bad." D) "You won't be able to nurse until the baby is 12 hours old, because of your epidural." Answer: B Explanation: A) This response focuses on the nurse, and does not provide specific information to answer the client's question. B) The use of sequential compression devices (SCDs) and early ambulation are essential to the prevention of deep vein thrombosis, especially if the client had a cesarean birth. C) Focusing on the pain is a negative emphasis and pain can also be a factor in a vaginal birth. D) Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother's ability to breastfeed. Page Ref: 906 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

17) The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased intake of cold beverages B) Leg exercises every 2 hours C) Abdominal tightening D) Ambulation E) Using a straw when drinking fluids Answer: B, C, D Explanation: A) The woman should avoid carbonated or very hot or cold beverages, as they would increase the distention through the increase of gas and constipation. B) Immobility increases the risk of abdominal distention and discomfort. Leg exercises serve to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. C) Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. D) Early ambulation prevents abdominal distention that can occur with excess accumulation of gas in the intestines. E) The woman should avoid the use of straws to avoid increasing the distention through increase of gas and constipation. Page Ref: 903 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

18) A multiparous client delivered her first child vaginally 2 years ago, and delivered an infant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make? A) "I can't believe how much more tired I was with the first baby." B) "I'm having significantly more pain this time than with my last birth." C) "It is disappointing that I can't breastfeed because of the cesarean." D) "Getting in and out of bed feels more comfortable than last time." Answer: B Explanation: A) Mothers who have experienced cesareans, particularly unanticipated ones that follow lengthy labors, may be fatigued, sleep deprived, and under the influence of medications that alter their level of consciousness. B) Women with cesarean births have special needs: increased need for rest and sleep; incisional care; self-care; and relief of pain and discomfort. C) Breastfeeding is not contraindicated by cesarean birth. D) Getting in and out of bed is more painful after cesarean birth than after vaginal birth. The nurse can assist the woman in identifying interventions to relieve discomfort or pain. The woman should be encouraged to take pain medication regularly, engage in frequent rest periods, avoid prolonged activity, and observe for signs of "overdoing it." Page Ref: 904 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. A. 3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Compare the nursing needs of a woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

19) The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client? A) "This client will need less teaching, because she will have gotten the right information in school." B) "Because of her age, this client will require less frequent fundal checks to assess for postpartal hemorrhage." C) "Because of her age, this client will probably need extra teaching about the terminology for her anatomy." D) "This client will need to have her grandmother provide day care and help raise the baby." Answer: C Explanation: A) Public or private education likely does not cover the extent of the information that the adolescent needs to know about pregnancy and delivery. The nurse has many opportunities for teaching adolescent parents about their newborn in the postpartum unit and serves as a role model for new parents when responding to and caring for the newborn. B) Adolescent mothers have the same basic physical care needs as older mothers. C) Some adolescents may not have a working knowledge of their own anatomy and physiology or the related terminology, and they may require special assistance with postpartum hygiene and care. D) Although the client will require day care to continue with her education, the assistance does not have to come from her grandmother. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Summarize the nursing needs of the childbearing adolescent during the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

20) The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? A) The client's mother is included in all discussions and demonstrations. B) The father of the baby is encouraged to change a diaper and give a bottle. C) The nurse explains the characteristics and cues of the baby when assessing him. D) A discussion on contraceptive methods is the first topic of teaching. Answer: C Explanation: A) Although the grandmother or another family member may plan to assist with or provide much of the newborn care in some cases, the nurse should always ensure that the adolescent mother has the knowledge and demonstrates the skills to provide care for her newborn before discharge. B) The father, if he is involved, should be included as much as possible, but having the mother learn more about her new baby is a higher priority. C) A newborn physical examination performed at the bedside gives the parent(s) immediate feedback about the newborn's health and demonstrates methods of handling an infant. This action helps the client learn about her baby as an individual and facilitates maternal-infant attachment. This is the highest priority. D) The nurse should offer detailed teaching on contraception, as the young woman may have no prior experience with it and may not feel comfortable requesting this information, but establishing rapport and facilitating understanding of and attachment to the newborn is a higher priority. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the nursing needs of the childbearing adolescent during the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

21) The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care? A) The baby's father should be encouraged to participate when the nurse is providing instruction. B) A class for all the adolescents would decrease teaching effectiveness. C) The schools that the adolescents attend will provide teaching on bathing. D) Adolescents understand the danger signals in newborns. Answer: A Explanation: A) The father, if he is involved, should be included as much as possible. If classes are offered in the hospital during the postpartum stay, the adolescent mother and father should be strongly encouraged to attend and participate. B) If classes are offered in the hospital during the postpartum stay, the adolescent mother and father should be strongly encouraged to attend and participate. C) The nurse should never assume that basic newborn care education will be provided to a client elsewhere. D) Group classes for adolescent mothers should include infant care skills, information about growth and development, infant feeding, well-baby care, and danger signals in the ill newborn. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the nursing needs of the childbearing adolescent during the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

22) The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important? A) Assign the client a room on the GYN surgical floor instead of on the postpartum floor. B) Prepare to complete teaching in time for discharge at 24 hours post-delivery. C) Make an effort not to bring up the topic of the baby, and discuss the mother's health instead. D) Ask the client how much contact she would like with the baby, and whether she wants to feed it. Answer: D Explanation: A) Clients relinquishing their newborns should be given options concerning contact with the infant, including where they would feel most comfortable if they opt for contact at all. B) Not all clients who relinquish their infants want early discharge. C) It is up to the client to decide how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. D) Assessing the birth mother's preferences by respectfully asking questions and making no assumptions facilitates a more positive experience. Page Ref: 908 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Describe possible approaches to sensitive, holistic nursing care for targeted populations of childbearing patients: Lesbian birth mothers and co-mothers, women with special needs, women who have experienced abuse, and women relinquishing their newborns. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

23) The nurse is caring for a client who plans to relinquish her baby for adoption. The nurse would implement which approach to care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Encourage the client to see and hold her infant. B) Encourage the client to express her emotions. C) Respect any special requests for the birth. D) Acknowledge the grieving process in the client. E) Allow access to the infant, if the client requests it. Answer: B, C, D, E Explanation: A) Encouraging the client to see and hold her infant does not respect the client's right to refuse interaction. The amount of contact she chooses to have with her newborn should be respected. B) The mother who decides to relinquish her baby needs emotional support and validation of her loss. C) The woman should decide whether to see and hold her baby and should have any special requests regarding the birth honored. D) Perinatal nurses should be aware that relinquishing mothers are at risk for disenfranchised grief, in which they are unable to proceed through the grieving process and come to resolution with the loss. The nurse should acknowledge the woman's loss and support her decision. E) The amount of contact she chooses to have with her newborn should be respected. Page Ref: 908 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Describe possible approaches to sensitive, holistic nursing care for targeted populations of childbearing patients: Lesbian birth mothers and co-mothers, women with special needs, women who have experienced abuse, and women relinquishing their newborns. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

24) The nurse is planning discharge teaching for a postpartum woman. What recommendations should the woman receive before being discharged? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) To abstain from sexual intercourse for 6 months B) To avoid showers for 4 weeks C) To avoid overexertion D) To practice postpartum exercises E) To obtain adequate rest Answer: C, D, E Explanation: A) The client should abstain from sexual intercourse until lochia has ceased. B) The client may take a shower and may continue sitz baths at home if she desires. C) The client should avoid overexertion. D) The client should receive information and instruction on postpartum exercises. E) The client should receive information on the need for adequate rest. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum family wellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

25) The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population? A) Baby baths and birth certificates B) Hygiene practices C) When and how to contact their healthcare provider D) Pain-relief options in labor and after birth Answer: C Explanation: A) Baby baths and birth certificates are necessary information, but not critical. B) It is important to consider cultural practices and realize that some women may prefer not to shower in the first few days following birth. Some Hispanic women prefer to delay showering. Hygiene practices are important, but not critical. C) Knowing how to contact their healthcare provider at all times is critical so that clients receive appropriate advice and care in case of a problem or emergency. Knowing what to watch for and when to call the healthcare provider also facilitates safety. These are the highest priorities. D) Pain relief is important, but not critical. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Describe the nurse's role related to promoting safety for the postpartum patient and family. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

26) To actively involve the postpartal client during discharge teaching, the postpartum nurse applies which learning principle? A) Reprints of magazine articles B) Classroom lectures C) Audiotapes D) Interactive nurse-patient relationships Answer: D Explanation: A) Providing magazine articles does not actively involve the client in learning. B) Classroom lectures do not actively involve the client in learning. C) Listening to audiotapes does not actively involve the client in learning. D) Effective parent learning requires precise timing of teaching, as well as choice of a teaching method that is effective for the family, such as DVDs and return demonstration. Content on selfcare, infant care, and anticipatory guidance is important. Page Ref: 911 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum family wellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

27) The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful? A) "Taking baths will help my perineum feel less sore each day." B) "If I develop heavy bleeding, I should take my temperature." C) "My bowel movements should resume in a week." D) "I will go back to the doctor in 4 days for my RhoGAM shot." Answer: A Explanation: A) A sitz bath or tub bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth. B) If heavy bleeding begins, the client should call her healthcare provider immediately, not take her temperature. Postpartum hemorrhage can be life-threatening. C) Bowel movements should resume in 2 to 3 days after birth. A week is too long a time frame, and indicates constipation. D) When RhoGAM is needed, it is given within 72 hours of birth, while still at the hospital. Page Ref: 891 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum family wellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

28) The nurse is assessing clients after delivery. For which client is early discharge at 24 hours after delivery appropriate? A) Woman and baby who have had two successful breastfeedings B) Woman who is bottle-feeding her infant and has not voided since delivery C) Twins delivered at 35 weeks, bottle-feeding D) Cesarean birth performed for fetal distress Answer: A Explanation: A) Early discharge may be advantageous if mother and baby are doing well, help is available for the mother at home, and the family and physician/CNM agree that both clients are healthy and ready for discharge. Feeding successfully is one of the physiologic needs of the infant and both mother and infant appear to be doing well. B) Early discharge may be advantageous if mother and baby are doing well. Voiding is a physiologic need of the mother and has not yet been accomplished. C) Preterm infants are not appropriate for early discharge. D) Infants who experienced distress in labor are not appropriate for early discharge. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Delineate the nurse's responsibilities related to early postpartum discharge. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

29) The nurse is preparing teaching material for a new mother. What should the nurse include when instructing on areas to include when observing the infant? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Touch 2. Vision 3. Hearing 4. Diaper care 5. General appearance Answer: 1, 2, 3, 5 Explanation: When teaching on observing the baby, the nurse should include general appearance and the five senses - vision, hearing, touch, smell, and taste. Diaper care is included when teaching about the skin. Page Ref: 886 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum family wellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

30) The nurse is monitoring a postpartum patient receiving methylergonovine maleate (Methergine). Which assessment findings should the nurse identify as being expected adverse effects of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Nausea 2. Leg pain 3. Headache 4. Hypertension 5. Uterine cramping Answer: 1, 3, 4, 5 Explanation: Common adverse effects of methylergonovine maleate (Methergine) include nausea, headache, hypertension, and uterine cramping. Leg pain is not an identified adverse effect of this medication. Page Ref: 889 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice: conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

31) The nurse is preparing to administer a sitz bath to a postpartum patient. In which order should the nurse perform the steps of this procedure? 1. Open the clamp on the tubing 2. Anchor the infusion bag to the sitz bath basin, with the tube facing upward 3. Fill the drainage bag with warm or cool water up to the top line as indicated on the bag 4. Close the clamp on the tubing, dry perineum with a clean towel, and apply new peri-pad 5. Secure the drainage bag from a hook over the toilet or from the handle used to flush the toilet Answer: 2, 3, 5, 1, 4 Explanation: When providing a sitz bath the nurse should: insert the large infusion bag or tube into the back of the sitz bath basin, anchoring it to the bottom of the basin with the small opening at the end of the tubing facing upward, toward the ceiling; fill the drainage bag with warm or cool water up to the top line as indicated on the bag; secure the drainage bag from a hook over the toilet or from the handle used to flush the toilet if it is a few feet higher than the toilet; open the clamp on the tubing; once the sitz bath is complete, instruct the woman to close the clamp on the tubing, dry perineum with a clean towel, and apply new peri-pad. Page Ref: 892 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

32) A new mother is planning to bottle feed her infant and wants helps with suppressing lactation. What should the nurse suggest to help this new mother? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Wear a 24-hour support bra 2. Apply cabbage leaves to the breast tissue 3. Apply warm compresses every 4 to 6 hours 4. Massage lotion on the breasts 3 times a day 5. Avoid all nipple stimulation for 7 to 10 days Answer: 1, 2, 5 Explanation: Nurses should advise the non-breastfeeding mother to avoid any stimulation of her breasts and nipples by her baby, herself, breast pumps, or her sexual partner until the sensation of fullness has passed (usually in 7 to 10 days). Such stimulation will increase milk production and delay the suppression process. Heat is avoided for the same reason. The wearing of a 24-hour support bra and the use of cabbage leaves and/or cold compresses should be helpful during this period of time. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

33) A postpartum patient who received epidural morphine prior to a cesarean birth is concerned about a severe headache that has persisted for several days. What should the nurse suggest to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Ingest fluids with caffeine 2. Engage in moderate exercise 3. Increase the intake of all fluids 4. Lie in bed in a quiet dark room 5. Restrict the intake of warm fluids Answer: 1, 3, 4 Explanation: For a spinal headache the nurse should instruct the patient to engage in bed rest in a quiet dark room. Caffeine and hydration are also helpful. Moderate exercise could exacerbate the headache. There is no reason to restrict the intake of warm fluids. Page Ref: 905 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternal comfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 34 Home Care of the Postpartum Family 1) The nurse is speaking to a community group about the controversy regarding the length of the hospital stay for postpartum clients. Which statement indicates that a participant needs additional information? A) "As of 1998, there's a law that requires insurance to pay for a 48-hour stay after an uncomplicated birth." B) "The length of stay was shortened by insurance companies to decrease healthcare costs." C) "Early discharge became more popular in the 1980s as an alternative to having a home birth." D) "With current length-of-stay laws, newborns have no problems at home, and get recommended follow-up care." Answer: D Explanation: A) The Newborns' and Mothers' Health Protection Act, which took effect in January 1998, provides for a guaranteed minimum stay of up to 48 hours following an uncomplicated vaginal birth and 96 hours following an uncomplicated cesarean birth at the discretion of the new mother and her healthcare provider. B) The average LOS decreased during the early 1990s in an effort to contain healthcare costs, with third-party payers reimbursing only a 24-hour stay following an uncomplicated vaginal delivery. C) Early discharge became more popular in the 1980s as an alternative to home delivery. D) Even with the current length-of-stay laws, many newborns do not always receive the recommended follow-up care when they go home early. The health and stability of the mother and baby, the mother's ability and confidence regarding self and newborn care, support systems available, and access to follow-up care should form the basis of the decision. Page Ref: 915 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the main purposes of home visits during the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

2) A new mother is concerned about spoiling her newborn. The home care nurse teaches the mother which of the following? A) Newborns can be manipulative, so caution is advised. B) Meeting the infant's needs develops a trusting relationship. C) An infant who is rocked to sleep every night is being spoiled. D) Crying is good for babies, and letting them cry it out is advised. Answer: B Explanation: A) This would be inappropriate and incorrect advice. B) Picking babies up when they cry teaches them that adults are responsive to their needs. This helps build a sense of trust and security. C) This would be inappropriate and incorrect advice. D) This would be inappropriate and incorrect advice. Page Ref: 928 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

3) The home care nurse is visiting a newborn-and-mother couplet. Which nursing action has the highest priority? A) Establish rapport with the family members. B) Review the hospital medical records. C) Determine the newborn's sleeping arrangements. D) Examine the umbilical cord stump. Answer: A Explanation: A) It is critical to establish rapport with family members prior to beginning any assessments. The nurse can rely on the same characteristics of a caring relationship that have been integral to hospital-based practice–regard for patients, genuineness, empathy, and establishment of trust and rapport. B) Although this is important, record review should be done prior to arriving at the home, so that the nurse is prepared. C) Determining the newborn's sleeping arrangements is less important than establishing rapport with the family members. D) Examining the umbilical cord stump is less important than establishing rapport with the family members. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Delineate aspects of fostering a caring relationship in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

4) The nurse is meeting with a new mother for the first time during a home visit. The client delivered her first child 3 days ago. She had a normal pregnancy and a vaginal delivery. The infant is breastfeeding. Which statements by the mother indicate that she needs more information about the home visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "You are going to check my baby's weight." B) "You are going to watch me nurse the baby and give me tips." C) "You are going to teach my mother about the baby." D) "You are checking for safety issues when my son starts crawling." E) "You are going to take blood samples from me and my son." Answer: C, D, E Explanation: A) The components of a postpartum home visit typically include weighing the infant. B) The components of a postpartum home visit typically include assessing a feeding, if possible. C) Teaching of family members might occur, but the main purpose of the visit is to assess the infant's physiologic stability. D) Safety when the infant crawls should be assessed later. E) Not all home visits require blood samples. If there were no pregnancy or birth complications, there may not be the need to draw blood from either the mother or the child. Page Ref: 918 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

5) The nurse is at the home of a postpartum client for an initial assessment. The client gave birth by cesarean section 1 week earlier. Which statements should the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Because you had a cesarean, I'd like to assess your incision." B) "You aren't having any problems nursing, right?" C) "How rested do you feel since you came home?" D) "Because you are bottle-feeding, I won't assess your breasts." E) "You should remain at home for the first 3 weeks after delivery." Answer: A, C Explanation: A) The nurse should assess the cesarean incision. B) Therapeutic communication prohibits asking leading questions. C) The nurse should talk with the mother about her fatigue level and ability to rest and sleep. D) Breasts should be assessed for engorgement even for bottle-feeding mothers. E) The nurse should talk with the mother about her activity level and self-care abilities. Page Ref: 932 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

6) Late preterm infants have higher infant morbidity and mortality rates than term infants. Which of the following complications can they experience? A) Hyperglycemia B) Jaundice C) Motor difficulties D) Sensory complications Answer: B Explanation: A) Late preterm infants can experience hypoglycemia, not hyperglycemia. B) Late preterm infants can experience jaundice. C) Motor difficulties are not one of the complications that late preterm infants experience. D) Sensory complications are not one of the issues that late preterm infants experience. Page Ref: 919 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

7) The nurse is teaching experienced postpartum nurses about home care visits. Which statements indicate that teaching was effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "I should tell the family to put any guns or knives away." B) "It is best to blend in with the community and not bring attention to myself on visits." C) "If I encounter a crime in progress, I should leave the area." D) "Wearing jewelry is a good way to demonstrate my professionalism." E) "Ignoring my 'gut' feelings might lead to an unsafe situation." Answer: A, C, E Explanation: A) The nurse should leave the home immediately if a weapon is visible and the patient or a family member refuses requests to put it away. B) The nurse should wear a name tag and carry identification. C) Nurses should avoid entering areas where violence is in progress. In such cases, they should return to the car and contact the appropriate authorities by calling 911. D) The nurse should avoid wearing expensive jewelry. E) The nurse should terminate the visit if a situation arises that feels unsafe, or if the previous requests are not honored. Page Ref: 918 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

8) The nurse is planning a home care visit to a mother who just recently delivered. The neighborhood is known to have a significant crime rate. What should the nurse do when planning this visit to facilitate personal safety? A) Be friendly to all pets encountered on the visit to build client rapport. B) Wait to find the exact location until arrival in the neighborhood. C) Put personal possessions in the trunk when leaving the office. D) Wear flashy jewelry to garner respect. Answer: C Explanation: A) The nurse should ask clients to keep threatening pets secured in a different area of the home during the visit. B) The nurse should confirm the address, ask for directions during the previsit contact, and trace out the route to the client's home on a map or the Internet before leaving for the visit and take the map along; the nurse should use a GPS device if available. C) The nurse should lock personal belongings in the trunk of the car, out of sight, before starting out or before arriving at the home. D) The nurse should avoid wearing expensive or flashy jewelry. Page Ref: 918 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. C. 5. Value relationship between national safety campaigns and implementation in local practices and practice settings. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Commit to a generative safety culture. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

9) The postpartum home care client asks the nurse why the visit is taking place. Which response is best? A) "We make home care visits to reinforce any teaching that you didn't quite grasp in the hospital." B) "We make home care visits to verify that both you and the baby are safe and doing well." C) "We make home care visits to ensure you are breastfeeding correctly." D) "We make home care visits to thoroughly assess your baby to make sure he is growing." Answer: B Explanation: A) Postpartum home care provides opportunities for expanding information and reinforcing self- and infant-care techniques initially presented in the birth setting. However, this response is not therapeutically worded. B) Family well-being should be determined through a comprehensive assessment that includes physical, emotional, and social functioning. C) Although this statement is true if the mother is breastfeeding, it is only one component of the entire home healthcare postpartum visit. D) Assessing the baby is only part of the reason home care visits are performed after birth. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the main purposes of home visits during the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

10) During a postpartum home visit, which step should the nurse take to establish a caring relationship? A) Ask family members how they want to be addressed. B) Do a portion of what the nurse agrees to do for the family, to avoid overwhelming them. C) Speak directly to the father when asking questions. D) Present information to the family instead of asking questions. Answer: A Explanation: A) Establishing a caring relationship starts with introducing yourself to the family and by calling the family members by their surnames until you have been invited to use the given or a less formal name. B) Trust will be built only if the nurse follows through and does whatever is promised. C) It is important to allow the mother to be the spokesperson. D) It is important to ask questions instead of talking at the family. Be prepared for the visit, honestly answer questions, provide information, and be truthful. If you do not know the answer to a question, tell the patient you will find the information and report back. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Delineate aspects of fostering a caring relationship in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

11) The nurse is making a postpartum home visit in the summer. The new father asks about taking the baby to a family outing this weekend. The nurse should encourage the father to do which of the following? A) Cover the infant with dark blankets to block the sun. B) Keep the infant in the shade. C) Uncover the infant's head to prevent hyperthermia. D) Avoid taking the infant outdoors for 6 months. Answer: B Explanation: A) Covering the infant with dark blankets would cause overheating and is not necessary. The infant should wear a light layer of clothing. B) To prevent sunburn, the newborn should remain shaded, wear a light layer of clothing, or be protected with sunscreen specifically formulated for infants. C) Newborns should wear a head covering outdoors to protect their sensitive ears from drafts and to prevent heat loss. D) Avoiding taking the infant outdoors for 6 months is neither necessary nor practical. Page Ref: 923 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

12) The home care nurse is examining a newborn who is sleeping on a pillow in a basket, covered with a fluffy blanket. There is also a stuffed animal in the basket. The most important nursing action to do is which of the following? A) Remove the stuffed animal from the basket and place it on the floor. B) Teach the parents the risk of SIDS from soft items in the infant's bed. C) Make certain that the blanket is firmly tucked under the baby. D) Ask whether the color of the blanket has cultural significance. Answer: B Explanation: A) Although loose bedding and soft objects should be removed from the infant's crib during sleep, the highest priority is teaching the parents that these items are safety hazards and about the risk of SIDS. B) Teaching the parents about the risk of sudden infant death syndrome (SIDS) is the highest priority. C) Loose bedding and soft objects should be removed from the infant's crib during sleep. D) Cultural significance is important, but the newborn's physical safety is a higher priority. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

13) Babies should sleep in what position every time they are put down for sleep? A) On their backs B) On their stomachs C) On their left sides D) On their right sides Answer: A Explanation: A) Babies should sleep on their backs every time they are put down for sleep. B) Babies should sleep on their backs every time they are put down for sleep, not their stomachs. C) Babies should sleep on their backs every time they are put down for sleep; all caregivers should be informed that side positioning is unsafe. D) Babies should sleep on their backs every time they are put down for sleep; all caregivers should be informed that side positioning is unsafe. Page Ref: 926 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

14) The nurse is performing a postpartum home care visit. Which teaching has the highest priority? A) Teaching or reviewing how to bathe the baby B) Teaching how to thoroughly childproof the house C) How many wet diapers the baby should have daily D) Prevention of plagiocephaly Answer: C Explanation: A) Although knowing how to bathe a newborn is important, the number of wet diapers is the highest priority. B) Childproofing the home is not necessary until the baby begins to crawl. This is a low priority at this time. C) Assessment of intake, output, weight, and hydration status is imperative. The baby should have at least six diapers that are saturated with clear urine each day by 1 week of age. Wet diapers are an indication of hydration of the newborn. This is the highest priority. D) Preventing flat spots on the back or side of the infant's head is primarily a cosmetic issue. The number of wet diapers would be a higher priority. Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

15) To prevent sudden infant death syndrome (SIDS), the nurse encourages the parents of a term infant to place the infant in which position when the infant is sleeping? A) On the parents' waterbed B) Swaddled in the infant swing C) On the back D) On the sides Answer: C Explanation: A) Babies should sleep in the same room as their parent(s) or an adult care provider, but they should not share the bed with anyone. They should also sleep on a firm surface to help prevent SIDS. B) Babies should not sleep with commercial devices marketed to maintain position. Safety has not been established. C) Babies should sleep on their backs every time they are put down for sleep. D) Babies should sleep on their backs every time they are put down for sleep; all caregivers should be informed that side positioning is unsafe. Page Ref: 926 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

16) The postpartum home care nurse is assessing a new mother, and finds her temperature to be 101.6°F. What is the most important nursing action? A) Ask the mother how often and how well the baby is nursing. B) Determine the frequency of the mother's voiding and stooling. C) Verify how many hours of sleep she is getting per day. D) Assess the odor and color of the lochia and perineum. Answer: D Explanation: A) A fever might indicate mastitis. Palpation of the breasts for warm or hardened areas is much better than asking about feedings because mothers of good feeders can develop mastitis. B) If she is voiding frequently, she might have a urinary tract infection (UTI), but the frequency of bowel movements is not related to a UTI. C) Although it is common for new mothers to be fatigued, fatigue does not cause fever. D) If the lochia is malodorous, or if the perineum is reddened or malodorous, an infection is present that could be causing the fever. Page Ref: 931 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

17) The nurse should explain to new parents that their infant's position should be changed periodically during the early months of life to prevent which of the following? A) Muscle contractures B) Respiratory distress C) Permanently flattened areas of the skull D) Esophageal reflux Answer: C Explanation: A) Preventing muscle contractures is not the rationale for periodically changing the infant's position. B) Respiratory distress would indicate complications, and would not be affected by periodic position changes. C) The nurse can describe plagiocephaly as a flattened area on the head and can recommend that parents alternate their infant's head position between the right and the left side when placing the infant supine for sleep. Placing the infant's head at alternate ends of the crib every few days is helpful as well. D) Esophageal reflux would indicate complications, and would not be affected by periodic position changes. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

18) Nurses should educate parents about which of the following AAP recommendations to promote a safe sleep environment and decrease the risk of SIDS and SUID in infants less than 12 months of age? A) Babies should not be offered a pacifier while falling asleep. B) Babies should be bottle-fed unless contraindicated. C) Babies should be under many covers when sleeping to keep them warm. D) Babies should have "tummy time" when they are awake. Answer: D Explanation: A) Babies should be offered a pacifier while falling asleep. B) Babies should be breastfed unless contraindicated. Exclusive breastfeeding for at least 6 months is ideal, but any amount is better than none. C) Babies should not be overheated by the use of too many covers during sleep. D) Babies should have "tummy time" when they are awake and observed by an adult to prevent positional plagiocephaly and to promote motor development. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

19) The nurse is assessing a new mother 2 days after a normal vaginal delivery. The mother has chosen not to breastfeed. What would an abnormal finding be? A) Weight loss of 3 pounds B) Small amount of breast milk expressed C) Pink striae on the abdomen D) Lochia serosa Answer: A Explanation: A) Normal weight loss postpartum is in the range of 12 to 20-plus pounds. B) At 2 days after the birth, a non-breastfeeding mother might express a small amount of milk. C) Pink, obvious striae on the abdomen are normal. D) At 2 days postpartum, lochia rubra or lochia serosa in decreasing quantities is normal. Page Ref: 932 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Discuss maternal and family assessment and anticipated progress after birth. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

20) The home care nurse is seeing a client at 6 weeks postpartum. Which statement by the client indicates the need for immediate intervention? A) "The baby sleeps 7 hours each night now." B) "My flow is red, and I need to wear a pad." C) "My breasts no longer leak between feedings." D) "I started back on the pill 2 weeks ago." Answer: B Explanation: A) The baby sleeping 7 hours a night by this time is an expected finding, and does not require intervention. B) By 6 weeks postpartum, lochia should be absent or minimal in amount, requiring only a pantiliner. Red, heavy flow is not an expected finding, and requires intervention. C) The mother's breasts no longer leaking between feedings is an expected finding, and does not require intervention. D) Six week postpartum is an appropriate time frame for restarting birth control pills, and does not require intervention. Page Ref: 933 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Discuss maternal and family assessment and anticipated progress after birth. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

21) A new mother at 36 hours post-delivery has asked to be discharged to home. The nurse explains that criteria for discharge before the newborn is 48 hours old include which of the following? A) The newborn's respiratory rate is less than 60/min. B) Singleton birth at a minimum 35 weeks' gestation. C) The newborn has passed at least three spontaneous stools. D) The newborn has normal and stable vital signs for 24 hours before discharge. Answer: A Explanation: A) Minimal criteria include a respiratory rate in the newborn less than 60/min. B) Minimal criteria include a singleton birth at 37 to 41 weeks' gestation. C) Minimal criteria include the newborn's passing at least one spontaneous stool. D) Vital signs must be normal and stable for 12 hours prior to discharge. Page Ref: 916 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Discuss maternal and family assessment and anticipated progress after birth. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

22) The postpartum client has chosen to bottle-feed her infant. Nursing actions that aid in lactation suppression include which of the following? A) Warm showers B) Pumping milk C) Ice packs to each breast D) Avoiding wearing a bra for 5 to 7 days Answer: C Explanation: A) A nonbreastfeeding mother should avoid warm showers to decrease the flow of breast milk. B) A nonbreastfeeding mother should avoid pumping milk or any stimulation of breasts to decrease the flow of breast milk. C) A nonbreastfeeding mother should use cooling packs for comfort and to decrease the flow of breast milk. D) A nonbreastfeeding mother should wear a supportive, well-fitted bra to decrease the flow of breast milk. Page Ref: 932 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

23) The postpartum nurse is performing a home care visit to a first-time mother on her third day after delivery. She reports that her nipples are becoming sore. What statement indicates that further teaching is needed? A) "I can apply lanolin cream to help with the nipple pain." B) "Watching how much areola is visible will help me see whether my baby has a good mouthful of breast or not." C) "My nipples will heal if I switch to bottle feeding for about 3 days while I pump my breasts." D) "Rotating breastfeeding positions will allow the sore areas of my nipples to have less friction." Answer: C Explanation: A) The application of highly purified anhydrous (HPA) lanolin and/or breast milk accompanied by air-drying at the end of feedings has been shown to be safe and effective in treating nipple pain. B) When latched, the baby's lips should be flanged out, and the newborn should cover as much of the areola as possible. C) For severe cases in which the mother is unable to tolerate breastfeeding, the mother will need to pump or hand-express the breast milk until the nipple condition improves. Bottle-feeding may not be necessary. D) Encouraging the mother to rotate positions when feeding the infant may decrease nipple soreness. Changing positions alters the focus of greatest stress and promotes more complete breast emptying. Page Ref: 937 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

24) The postpartum home care nurse has performed home visits to four breastfeeding mothers. Which mother is experiencing an expected outcome? A) Breasts are engorged; placing fresh cabbage leaves inside her bra B) Sore and cracked nipples; using hydrogel dressings to facilitate healing C) Breast engorgement; accompanied by erythema D) Concerns about milk supply; supplementing with formula Answer: A Explanation: A) A compress of fresh green cabbage leaves helps reduce engorgement. B) The use of hydrogel dressings cannot be recommended at this time due to concerns about infection. C) For breast engorgement accompanied by erythema, the nurse should instruct the mother to keep the breast empty by frequent feeding, rest when possible with breasts elevated, take prescribed pain relief medication, and drink adequate fluids. D) Because milk production follows the principle of supply and demand, if breasts are not pumped, the milk supply will decrease. Supplementing with formula will decrease milk supply. Page Ref: 939 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

25) A breastfeeding postpartum client reports sore nipples to the nurse during a home visit. What intervention would be the highest priority? A) Infant positioning B) Use of the breast shield C) Use of breast pads D) Type of soap used Answer: A Explanation: A) Poor latch and/or suck are the primary causes of nipple soreness and the baby's position at the breast is a critical factor in nipple soreness. Encouraging the mother to rotate positions when feeding the infant may decrease nipple soreness. Changing positions alters the focus of greatest stress and promotes more complete breast emptying. B) Using a breast shield is not a critical factor in alleviating nipple soreness. C) Using breast pads is not a critical factor in alleviating nipple soreness. D) The type of soap used is not a critical factor in alleviating nipple soreness. Page Ref: 937 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

26) The nurse is making an initial visit to a postpartum family's home. The mother states that she is having difficulty with breastfeeding. Which resource should the nurse tell the family about? A) The lactation consultant at the hospital B) Free immunizations through the county public health department clinics C) Sources of free formula at a local food pantry D) A support group for mothers who are experiencing postpartum depression Answer: A Explanation: A) When the client specifies a problem with breastfeeding, the best resource for the nurse to inform the family about is the lactation consultant. B) Free immunizations do not help with breastfeeding. C) Providing a mother with formula undermines her breastfeeding efforts and sends a message that she will not be successful with breastfeeding. D) There is no evidence that the client is experiencing postpartum depression. Page Ref: 937 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and selfdetermination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Identify postpartum resources that are available to new families. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

27) Before a newborn and mother are discharged from the hospital, the nurse informs the parents about routine screening tests for newborns. What is a good reason for having the screening tests done? A) The tests prevent infants from developing phenylketonuria. B) The tests detect such disorders as hypertension and diabetes. C) The tests detect disorders that cause physical, intellectual, and developmental complications or death if left undiscovered. D) The tests prevent sickle-cell anemia, galactosemia, and homocystinuria. Answer: C Explanation: A) Screening tests do not prevent any disorders. B) Screening tests do not detect hypertension or diabetes. C) Newborn screening tests use a few drops of the newborn's blood to detect disorders that are often asymptomatic at birth but cause irreversible harm if not detected early. Profound physical, intellectual, and developmental complications and even death can result from many of the conditions for which newborns are screened prior to discharge. D) Screening tests do not prevent any disorders. Page Ref: 930 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: health promotion/disease prevention. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

28) The nurse is instructing a new mother on basic infant care. For which activities should the nurse suggest that the mother use the following infant hold?

A) Burping B) Bottle feeding C) Shampooing hair D) Changing a diaper Answer: C Explanation: C) The football hold frees one of the caregiver's hands and permits eye contact. This hold is ideal for shampooing, carrying, or breastfeeding. The cradle hold is frequently used during feeding. The upright position is ideal for burping. The baby should be supine for changing a diaper. Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

29) The nurse is reviewing the process of applying a pre-folded diaper with a new mother. In which order should the nurse provide these instructions? 1.

Answer: 4, 2, 1, 3 Explanation: The nurse should review the figure in Choice 4 first. Then the three folds of material should be explained to the mother as identified in Choice 2. How the diaper should be placed is identified in Choice 1. And lastly, the application of the diaper onto the baby as shown in Choice 3. Page Ref: 924 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

30) The nurse is preparing teaching material for a new mother. For which activity should the nurse provide the following diagram?

A) Preparing to feed B) Wrapping the baby C) Preparing for a bath D) Changing the diaper Answer: B Explanation: B) This diagram is used to instruct a new mother on the process of wrapping the baby. This diagram would not be appropriate to use when teaching feeding, bathing, or changing the diaper. Page Ref: 924 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

31) The nurse is preparing an educational program for new parents. In which order should the nurse provide the Purple Crying information? 1. Unexpected 2. Long lasting 3. Pain-like face 4. Peak of crying 5. Resists soothing 6. Evening and late afternoon Answer: 4, 1, 5, 3, 2, 6 Explanation: The acronym PURPLE is derived from the character of the crying that some healthy infants experience between 2 and 4 months of age: P: Peak of crying; U: Unexpected; R: Resists soothing; P: Pain-like face; L: Long lasting; and E: Evening and late afternoon. Page Ref: 929 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 35 The Postpartum Family at Risk 1) The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? A) The client who was overdue and delivered vaginally B) The client who delivered by scheduled cesarean delivery C) The client who had oxytocin augmentation of labor D) The client who delivered vaginally at 36 weeks Answer: C Explanation: A) The client who was overdue and delivered vaginally has a lower risk for postpartum hemorrhage than would another client. B) The client who delivered by scheduled cesarean delivery has a lower risk for postpartum hemorrhage than would another client. C) Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor. D) The client who delivered vaginally at 36 weeks has a lower risk for postpartum hemorrhage than would another client. Page Ref: 946 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

2) The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? A) Assist the client to empty her bladder B) Help the client back to bed to check the fundus C) Assess her blood pressure and pulse D) Begin an IV of lactated Ringer's solution Answer: B Explanation: A) Assisting the client to empty her bladder is not the first action the nurse would take. B) Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts. C) Blood pressure and pulse do not change until 1000 to 2000 mL of blood has been lost. D) An IV might need to be started if the client becomes symptomatic. Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

3) A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Methergine B) Coumadin C) Misoprostol D) Serotonin reuptake inhibitors (SSRIs) E) Nonsteroidal anti-inflammatory drugs Answer: A, C Explanation: A) Methergine is commonly used orally for postpartum hemorrhage. B) Coumadin (warfarin) is an anticoagulant and is not used for postpartum hemorrhage. C) Misoprostol is commonly used rectally for postpartum hemorrhage. D) Serotonin reuptake inhibitors (SSRIs) are antidepressants and would not be used for postpartum hemorrhage. E) Nonsteroidal anti-inflammatory drugs increase anticoagulant activity and would not be used for postpartum hemorrhage. Page Ref: 949 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

4) The client has experienced a hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond? A) "Sometimes the uterus relaxes and excessive bleeding occurs." B) "The blood collected in the vagina and poured out when your partner stood up." C) "Bottle-feeding prevents the uterus from getting enough stimulation to contract." D) "The placenta had embedded in the uterine tissue abnormally." Answer: A Explanation: A) Uterine atony (relaxation of the uterus) is the leading cause of early postpartum hemorrhage, accounting for over 50% of postpartum hemorrhage cases. B) Although blood can pool in the vagina and thus pour out when the client stands, this does not constitute a hemorrhage. C) Although breastfeeding stimulates the release of oxytocin, which causes the uterus to contract, bottle-feeding does not cause hemorrhage. D) Had the placenta embedded abnormally (as in placenta accreta), the hemorrhage would have occurred immediately after the placenta delivered. Page Ref: 946 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

5) A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? A) That the client would be encouraged to ambulate freely B) That the client would be given aspirin 650 mg by mouth C) That the client would be given Methergine IM D) That the client would be placed on bed rest Answer: D Explanation: A) Ambulation would increase the inflammation. B) Aspirin 650 mg by mouth has anticoagulant properties, but usually is not necessary unless complications occur. C) Methergine is given only for postpartum hemorrhage, and would only cause vasoconstriction of an already inflamed vessel. D) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose. Page Ref: 964 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

6) The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? A) Wearing a tight-fitting bra B) Limiting breastfeedings C) Frequent breastfeedings D) Restricting fluid intake Answer: C Explanation: A) Although wearing a supportive bra is recommended, a tight-fitting bra would tend to suppress lactation. B) The woman should continue to breastfeed; in fact, regular drainage of both breasts actually helps by preventing milk stasis and abscess formation. C) Treatment and prevention of mastitis includes frequent and complete emptying of the breasts. D) Supportive measures include increased fluid intake (at least 2 to 2.5 L/day). Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

7) A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect? A) Nipple soreness B) Engorgement C) Mastitis D) Letdown reflex Answer: C Explanation: A) These are not symptoms of nipple soreness. B) These are not symptoms of engorgement. C) Signs of mastitis include late-onset nipple pain, followed by shooting pain between feedings, often radiating to the chest wall. Eventually, the skin of the affected breast may become pink, flaking, and pruritic. D) These are not symptoms of the letdown reflex. Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

8) Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? A) Urge ambulation B) Apply ice to the leg C) Elevate the affected limb D) Massage her calf Answer: C Explanation: A) Ambulation would increase discomfort. B) Applying ice to the leg is contraindicated in thrombophlebitis treatment. Treatment includes application of local heat. C) Treatment for superficial thrombophlebitis involves application of local heat, elevation of the affected limb, and analgesic agents. D) Massaging the calf is contraindicated because it can cause a breakup of a clot and put the client at risk for a pulmonary embolus. Pulmonary embolism occurs when a thrombus from a lower extremity or the pelvis lodges in the pulmonary vascular bed and restricts circulation to the corresponding area of the lung vasculature. Page Ref: 963 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

9) Which of the following would be considered a clinical sign of hemorrhage? A) Increased blood pressure B) Increasing pulse C) Increased urinary output D) Hunger Answer: B Explanation: A) Decreased blood pressure would be considered a clinical sign of hemorrhage. B) Increasing pulse, widening pulse pressure would be considered a clinical sign of hemorrhage. C) Decreased urinary output would be considered a clinical sign of hemorrhage. D) Thirst, not hunger, would be considered a clinical sign of hemorrhage. Page Ref: 946 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

10) Which findings would indicate the presence of a perineal wound infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Redness B) Tender at the margins C) Vaginal bleeding D) Hardened tissue E) Purulent drainage Answer: A, B, D, E Explanation: A) Redness is a classic sign of a perineal wound infection. B) The wound is typically red, indurated, tender at the margins, and draining purulent exudate. C) Vaginal bleeding is nonspecific to identifying a perineal wound infection. D) The wound is typically red, indurated, tender at the margins, and draining purulent exudate. E) Purulent drainage is a classic sign of a perineal wound infection. Page Ref: 955 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

11) A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? A) Decreased bladder capacity B) Inhibited neural control of the bladder following the use of anesthetic agents C) Increased bladder sensitivity D) Abnormal postpartum diuresis Answer: B Explanation: A) A postpartum woman is at increased risk for developing urinary tract problems because of increased bladder capacity. B) A postpartum woman is at increased risk for developing urinary tract problems because of inhibited neural control of the bladder following the use of anesthetic agents. C) A postpartum woman is at increased risk for developing urinary tract problems because of decreased bladder sensitivity from stretching or trauma. D) A postpartum woman is at increased risk for developing urinary tract problems because of normal postpartum diuresis. Page Ref: 958 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

12) Which of the following is a risk factor for urinary retention after childbirth? A) Multiparity B) Precipitous labor C) Unassisted childbirth D) Not sufficiently recovering from the effects of anesthesia Answer: D Explanation: A) Nulliparity is a risk factor for urinary retention after childbirth. B) Prolonged labor is risk factor for urinary retention after childbirth. C) Instrumental childbirth is a risk factor for urinary retention after childbirth. D) Women who have not sufficiently recovered from the effects of anesthesia and cannot void spontaneously are at risk for urinary retention after childbirth. Page Ref: 958 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

13) The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately? A) The client who describes feeling sad all the time B) The client who reports hearing voices talking about the baby C) The client who states she has no appetite and wants to sleep all day D) The client who says she needs a refill on her sertraline (Zoloft) next week Answer: B Explanation: A) Feeling sad is an indication the client is experiencing postpartum blues, and is not the highest priority. B) Hearing voices is an indication the client is experiencing postpartum psychosis, and is the highest priority because the voices might tell her to harm her baby. C) Having no appetite and sleeping all day is an indication the client is experiencing postpartum depression, but is not the highest priority. D) A client on medications needs refills on time, but right now she has medication, and therefore is not a high priority. Page Ref: 970 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

14) To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following? A) Address pain early B) Change peri-pads frequently C) Avoid overhydration D) Report symptoms of uterine cramping Answer: B Explanation: A) Addressing pain early would not be a preventive action for infection. B) Changing peri-pads frequently decreases skin contact with a moist medium that favors bacteria growth. C) Avoiding overhydration actually would increase the risk for infection by not providing adequate fluids to flush the kidneys and bladder. D) Reporting symptoms of uterine cramping would not be a preventive action for infection. Page Ref: 956 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

15) A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Avoid crossing the legs. B) Avoid prolonged standing or sitting. C) Take frequent walks. D) Take a daily aspirin dose of 650 mg. E) Avoid long car trips. Answer: A, B, C Explanation: A) Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. B) Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. C) Women should be advised to avoid a sedentary lifestyle and to exercise as much as possible (walking is ideal). D) Taking a daily aspirin increases anticoagulant activity, and should be avoided if the client is being treated with other anticoagulants. E) Avoiding long car trips is not necessary. The client should be encouraged to take frequent breaks during long car trips and to walk around, thereby preventing prolonged venous stasis. Page Ref: 964 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify the woman's knowledge of self-care measures, signs of complications to be reported to the primary care provider, and measures that can be taken to prevent recurrence of complications. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

16) The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? A) "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple." B) "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." C) "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." D) "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe." Answer: A Explanation: A) If the mother finds that one area of her breast feels distended or lumpy, she can massage the lumpy area toward the nipple as the infant nurses. B) This statement is not accurate. Most first-time moms do not experience mastitis. C) Cabbage leaves are applied to suppress lactation, not prevent mastitis. D) The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for catching early onset of the infection. Page Ref: 961 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify the woman's knowledge of self-care measures, signs of complications to be reported to the primary care provider, and measures that can be taken to prevent recurrence of complications. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

17) The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about? A) Postpartum psychosis B) Postpartum infection C) Postpartum depression D) Postpartum blues Answer: C Explanation: A) Postpartum psychosis is more severe, and includes hallucinations and irrationality, which are not represented in this situation. B) Postpartum infection is not related to this situation. C) Postpartum depression can impair maternal-infant bonding and can cause developmental and cognitive delays in the child. D) Postpartum blues episodes occur frequently in the week after birth, are associated with hormonal fluctuations, and are typically transient. Page Ref: 970 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Crisis Intervention Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

18) The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? A) Purulent, foul-smelling lochia B) Decreased blood pressure C) Flank pain D) Breast is hot and swollen Answer: A Explanation: A) Assessment findings consistent with endometritis are foul-smelling lochia, fever, uterine tenderness on palpation, lower abdominal pain, tachycardia, and chills. B) Decreased blood pressure is a sign of hemorrhage. C) Flank pain is a symptom of a urinary tract infection. D) The breast being hot and swollen is a symptom of engorgement. Page Ref: 950 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

19) The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? A) "This condition is called parametritis." B) "Gonorrhea is the most common organism that causes this type of infection." C) "My positive Beta-strep culture might have contributed to this problem." D) "If I had walked more yesterday, this probably wouldn't have happened." Answer: C Explanation: A) Pelvic cellulitis (parametritis) is an infection that has ascended to involve the connective tissue of the broad ligament or, in more severe forms, the connective tissue of all the pelvic structures. B) Gonorrhea is not a common cause of endometritis. C) Clinical findings of endometritis in the initial 24 to 36 hours postpartum tend to be related to group B streptococcus (GBS). D) Walking would prevent deep vein thrombophlebitis, not endometritis. Page Ref: 954 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

20) The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? A) The client reports she had this condition after her last pregnancy. B) The client develops pain and swelling in her left lower leg. C) The client appears anxious, and describes pressure in her chest. D) The client becomes upset that she cannot go home yet. Answer: C Explanation: A) A risk factor includes recurrent thromboembolic disease, but this is neither a predictor nor an indication of complications. B) Development of thrombophlebitis is a complication, but not the top priority. C) The most common clinical findings of a pulmonary embolism include dyspnea, pleuritic chest pain, cough with or without hemoptysis, cyanosis, tachypnea and tachycardia, panic, syncope, or sudden hypotension and require immediate intervention. D) Becoming upset is a psychosocial issue and far less important than another finding. Page Ref: 965 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

21) A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Shooting pain between breastfeedings B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple D) Nipple soreness when the infant latches on E) Pain radiating to the underarm area from the breast Answer: A, B, C Explanation: A) Mastitis is characterized by shooting pain between feedings, often radiating to the chest wall. B) Mastitis is characterized by late-onset nipple pain. C) The skin of the affected breast becomes pink, flaking, and pruritic. D) Nipple soreness when the infant latches on is not a symptom of mastitis. E) The pain from mastitis does not radiate to the underarm area. Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

22) The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? A) "Cesarean birth after extended labor with ruptured membranes." B) "Unassisted childbirth and afterbirth." C) "External fetal monitoring used throughout labor." D) "The client has history of pregnancy-induced hypertension." Answer: A Explanation: A) Cesarean birth is the single most significant risk factor for postpartum endometritis, along with prolonged premature rupture of the amniotic membranes (PPROM). B) Instrument-assisted childbirth (vacuum or forceps) and manual removal of the placenta are risk factors for postpartum endometritis. C) Use of fetal scalp electrode or intrauterine pressure catheter for internal monitoring during labor are risk factors for postpartum endometritis. D) Pregnancy-induced hypertension is not a risk factor for postpartum endometritis. Page Ref: 955 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

23) The nurse suspects that a client has developed a perineal hematoma. What assessment findings would lead the nurse to this conclusion? A) Facial petechiae B) Large, soft hemorrhoids C) Tense tissues with severe pain D) Elevated temperature Answer: C Explanation: A) Facial petechiae do not indicate perineal hematoma. B) Large, soft hemorrhoids are not indicative of perineal hematoma. C) Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas. D) An elevated temperature is not a symptom of a perineal hematoma. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

24) The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) High fever B) Frequency C) Suprapubic pain D) Chills E) Nausea and vomiting Answer: B, C Explanation: A) High fever is not usually present in acute cystitis, although it can appear if the cystitis progresses to pyelonephritis. B) Frequency is characteristic of acute cystitis. C) Suprapubic pain is characteristic of acute cystitis. D) Chills are not usually present in acute cystitis, although they can appear if the cystitis progresses to pyelonephritis. E) Nausea and vomiting are not usually present in acute cystitis, although they can appear if the cystitis progresses to pyelonephritis. Page Ref: 959 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

25) The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? A) Assist the client to the bathroom in 2 hours to void. B) Place a Foley catheter now. C) Apply warm packs to the perineum three times a day. D) Allow the client to rest for the next 8 hours. Answer: A Explanation: A) This client is at risk for urinary retention and bladder overdistention. Overdistention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention. B) A Foley catheter is not indicated at this time. C) Cold packs will help decrease the perineal edema; warm packs would increase the edema. D) Waiting 8 hours to reassess the bladder is too long. Page Ref: 958 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

26) Risk factors associated with increased risk of thromboembolic disease include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Diabetes mellitus B) Varicose veins C) Hypertension D) Adolescent pregnancy E) Malignancy Answer: A, B, E Explanation: A) Diabetes mellitus is a risk factor for thromboembolic disease. B) Varicose veins are a risk factor for thromboembolic disease. C) Hypertension is not a risk factor for thromboembolic disease. D) Advanced maternal age, not adolescence, is a risk factor for thromboembolic disease. E) Malignancy is a risk factor for thromboembolic disease. Page Ref: 963 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Current best practices. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

27) A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include? A) The client can douche every other day. B) Sexual intercourse can be resumed when the client feels up to it. C) Light housework will provide needed exercise. D) The baby's mouth should be examined for thrush. Answer: D Explanation: A) Douching is contraindicated for this client. B) Pelvic rest is necessary for this client, and sexual activity should be resumed only when the physician says it is safe. C) The woman with a puerperal infection needs assistance when she is discharged from the hospital. If the family cannot provide this home assistance, a referral to home care services is needed. D) A breastfeeding mother on antibiotics should check her baby's mouth for signs of thrush, which should be reported to the physician. Page Ref: 958 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 2 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

28) The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? A) "If your incision becomes increasingly painful, call the doctor." B) "It is normal for the incision to ooze greenish discharge in a few days." C) "Increasing redness around the incision is a part of the healing process." D) "A fever is to be expected because you had a surgical delivery." Answer: A Explanation: A) The client should call the doctor if the incision becomes increasingly painful. After cesarean delivery, wound infection is most often associated with concurrent endometritis. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. Some women have cellulitis without actual purulent drainage. B) Green drainage is not an acceptable symptom. C) The client should call the doctor if the incision becomes increasingly painful. Cesarean wound infections are characterized by increasing redness and tenderness at the margins. D) A fever could be a symptom of infection and this client should call the doctor Page Ref: 955 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

29) The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue? A) "If I start to have burning with urination, I need to call the doctor." B) "Drinking 8 glasses of water each day will help prevent another UTI." C) "I will remember to wipe from front to back after I move my bowels." D) "Voiding 2 or 3 times per day will help prevent a recurrence." Answer: D Explanation: A) Burning with urination is a common symptom of a UTI. B) Drinking 8 to 10 8-oz glasses of water daily will help to prevent the development of a UTI. C) Wiping from front to back after bowel movements will help to prevent the development of a UTI. D) Voiding only 2 or 3 times per day is not sufficient to prevent recurrence of a urinary tract infection (UTI). The woman needs to empty her bladder whenever she feels the urge to void, or at least every 2 to 4 hours while awake. Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

30) The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client? A) One visit from a home care nurse, to take place in 2 days B) Two visits from a public health nurse over the next month C) An appointment with a mental health counselor D) Follow-up with the obstetrician in 6 weeks Answer: D Explanation: A) A home visit in 2 days will be helpful to assess feeding, but is too early to detect signs of postpartum depression. B) Two home visits in a month are too sporadic to accurately detect postpartum depression. C) Postpartum depression has a high recurrence rate. Women with a history of postpartum psychosis or depression, or other risk factors, may benefit from a referral to a mental health professional for counseling during pregnancy or postpartum. D) Following up with the obstetrician in 6 weeks is too long a wait. Page Ref: 972 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Crisis Intervention Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

31) Clinical features of posttraumatic stress disorder (PTSD) include which of the following? A) Difficulty sleeping B) Acute awareness C) Flashbacks D) The need to be constantly around others E) Irritability Answer: A, C, E Explanation: A) A clinical feature of PTSD is difficulty sleeping. B) Numbness, not acute awareness, is a clinical feature of PTSD. C) A clinical feature of PTSD is intrusive thoughts and flashbacks to the threatening event. D) Avoidance of others is a clinical feature of PTSD. E) A clinical feature of PTSD is irritability. Page Ref: 972 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

32) A patient who is hemorrhaging after a vaginal delivery is being considered for a uterine tamponade. What should the nurse instruct the patient about this process? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A balloon is inserted into the uterus 2. The balloon is kept in place for 12 hours 3. The balloon is inflated with 300 to 500 mL of saline 4. After removal, the uterus is packed with sterile gauze 5. The tube has an open tip to permit bleeding to be visualized Answer: 1, 3, 5 Explanation: If utero-tonic agents are unsuccessful at correcting uterine atony, the physician may use uterine tamponade. One technique of uterine tamponade is the use of the Bakri balloon, which is inserted into the uterine cavity and inflated with 300-500 mL of isotonic saline to provide pressure against the uterine walls. The tube has an open tip, which permits any continuous bleeding from the uterus to be visualized. If bleeding is controlled, the tamponade is removed after 24 hours and not 12 hours. Packing the uterus with sterile gauze is no longer favored as a method of tamponade. Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

33) The nurse provides a postpartum patient with the following diagram. For which procedure is the nurse preparing this patient?

A) Uterine tamponade B) Manual removal of the placenta C) B-Lynch compression procedure D) Manual compression of the uterus Answer: D Explanation: D) Bimanual massage compresses the body of the uterus from below while the abdominal hand massages the fundus from above. Uterine tamponade is the insertion of a balloon into the uterus to apply pressure to the uterine walls. The B-Lynch compression procedure is conducted through a laparotomy. Manual removal of the placenta may be done immediately after the placenta is delivered. Page Ref: 948 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

34) A patient experiencing postpartum hemorrhage is prescribed to receive 741 mL of a crystalloid solution. How many mL of blood did this patient lose from the hemorrhage? (Calculate to the nearest whole number.) Answer: 247 mL Explanation: Lost intravascular volume is replaced initially with rapid administration of warmed crystalloid solutions, in a 3 mL solution per 1 mL of estimated blood lost ratio. To determine blood loss, divide the volume of fluid by 3 or 741/3 = 247 mL. Page Ref: 951 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late hemorrhage during the postpartum period. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

35) The nurse selects the following diagram to take when making a home visit to a postpartum patient. For which health problem is the nurse preparing educational material?

A) Cystitis B) Metritis C) Mastitis D) Parametritis Answer: C Explanation: C) For mastitis, erythema and swelling are present in the upper outer quadrant of the breast. Axillary lymph nodes are often enlarged and tender. Cystitis is a urinary tract infection. Pelvic cellulitis (parametritis) is an infection that has ascended to involve the connective tissue of the broad ligament or, in more severe forms, the connective tissue of all the pelvic structures. Postpartum endometritis (metritis) is an inflammation of the endometrium portion of the uterine lining. Page Ref: 960 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Teaching/Learning. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

36) A postpartum patient weighing 165 lb is prescribed a subcutaneous injection of Enoxaparin 1 mg/kg twice daily. The medication available is 50 mg/mL. How many mL of medication should the nurse provide for each injection? (Calculate to the nearest tenth decimal point.) Answer: 1.5 mL Explanation: First determine the patient's weight in kg by dividing 165 lb by 2.2 or 165/2.2 = 75 kg. Next determine the prescribed dose by multiplying the amount of 1 mg by kg of body weight or 1 mg x 75 kg = 75 mg. Next calculate the amount of medication to provide by using the equation Dosage Required/Dosage Available x mL; 75 mg/50 mg x 1 mL = 75/50 x 1 = 1.5 mL. The nurse should provide 1.5 mL for each injection. Page Ref: 965 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder. MNL LO: Demonstrate understanding of factors that may pose risks for the postpartum family.

Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 36 Grief and Loss in the Child-Bearing Family 1) The nurse is planning an in-service presentation about perinatal loss. Which statements should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Perinatal loss refers to third-trimester fetal death in utero." B) "Perinatal loss occurs more frequently in assisted reproduction." C) "Perinatal loss rates have declined in the United States over the past few years." D) "Perinatal loss includes 25% of stillbirths occurring before the onset of labor." E) "Perinatal loss rarely causes an emotional problem for the family." Answer: B, C Explanation: A) Perinatal loss is the death of a fetus or infant from the time of conception through the end of the newborn period 28 days after birth. B) Pregnancies conceived by in vitro fertilization have higher rates of pregnancy loss and pregnancy complications. C) Perinatal loss in industrialized countries has declined in recent years as early diagnosis of congenital anomalies and advances in genetic testing techniques have increased the use of elective termination. D) It is estimated that 50% of stillbirths occur before the onset of labor, with more than 24.4% occurring between 20 and 28 weeks' gestation. E) Perinatal losses are grieved by most couples and families like any other death. Like other grief, the grief over perinatal loss can become overwhelming. Page Ref: 977 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

2) The nurse has returned from working as a maternal-child nurse volunteer for a nongovernmental organization. After completing a community presentation about this experience, the nurse knows that learning has occurred when a participant states which of the following? A) "Malaria is a chronic disease, and rarely causes fetal loss." B) "Escherichia coli bacteria can cause diarrhea, but not stillbirth." C) "Group B streptococci can cause infection and the death of the fetus." D) "Viral infections don't cause fetal death in developing nations." Answer: C Explanation: A) Malaria is associated with a high stillbirth rate when contracted for the first time by the mother during the pregnancy, and it carries a much higher morbidity and mortality rate in developing countries. B) E. coli can cause ascending infections prior to or after rupture of membranes. C) Group B streptococci can cause ascending infections prior to or after rupture of membranes. D) Viral infections play a significant role in fetal death in developing countries. Page Ref: 977 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

3) The community nurse has identified that the mother who gave birth to a stillborn baby last week is an intuitive griever. Which behavior has the nurse encountered that would lead to this assessment? A) The mother verbalized that her problem-solving skills have been helpful during this process. B) The mother repeatedly talks about her thoughts, feelings, and emotions about losing her child. C) The mother talks little about her experience, and appears detached and unaffected by the loss of her child. D) The mother has asked close friends, co-workers, and relatives not to call or visit. Answer: B Explanation: A) Instrumental grievers tend to use problem-solving skills in the grief process. B) Intuitive grievers tend to feel their way through the loss and seek emotional and psychosocial support. C) Instrumental grievers can appear detached and unaffected by the experience. D) Intuitive grievers seek emotional and psychosocial support from friends and family. Page Ref: 982 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

4) The nurse is anticipating the arrival of a couple in the labor unit. It has been determined that the 37-week fetus has died in utero from unknown causes. What should the nurse include in the plan of care for this couple? A) Allow the couple to adjust to the labor unit in the waiting area. B) Place the couple in a labor room at the end of the hall with an empty room next door. C) Encourage the father to go home and rest for a few hours. D) Contact the mother's emergency contact person and explain the situation. Answer: B Explanation: A) Care should be taken not to leave the couple in the waiting room with other expectant parents or visitors waiting for news from other women in labor. B) Upon arrival at the facility, the couple with a known or suspected fetal demise should immediately be placed in a private room. When possible, the woman should be in the room that is farthest away from other laboring women. C) The couple should be allowed to remain together as much as they wish. Provide privacy as needed and maintain a supportive environment. D) Some couples may want outside support, such as family members or friends, to be present during the labor. The nurse needs to facilitate the couple's wishes, including not contacting anyone if that wish is expressed. Page Ref: 990 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

5) A couple requests to see their stillborn infant. How should the nurse prepare the infant? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Wrapping the infant in a blanket B) Removing all blankets from the infant C) Placing a hat on the infant D) Removing any identification from the infant E) Placing a diaper on the infant is not necessary. Answer: A, C Explanation: A) After bathing, the infant should be placed in a suitable-sized gown and then wrapped in a blanket. Many parents will eventually remove the covering to inspect the infant; however, applying a covering allows them time to adjust to the appearance at their own pace. B) Removing blankets from the infant would not be appropriate. C) A hat can be applied to cover birth defects. This allows the parents an opportunity to view the infant before seeing the birth defect. D) Removing any identification from the infant would not be appropriate. Page Ref: 994 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

6) Which of the following may lead to the development of disseminated intravascular coagulation (DIC), also called consumption coagulopathy, in the mother? A) Hypertensive disorders B) Abruptio placentae C) Prolonged retention of the dead fetus D) Heritable thrombophilias Answer: C Explanation: A) Hypertensive disorders may contribute to the incidence of stillbirth. B) Abruptio placentae contributes to the incidence of stillbirth. C) Prolonged retention of the dead fetus may lead to the development of disseminated intravascular coagulation (DIC), also called consumption coagulopathy, in the mother. D) Heritable thrombophilias may contribute to the incidence of stillbirth. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: RelationshipCentered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

7) The client at 37 weeks' gestation calls the clinic nurse to report that neither she nor her partner has felt fetal movement for the past 48 hours. The nurse anticipates that the physician will order which test to assess fetal viability? A) Ultrasound B) Serum progesterone levels C) Computed tomography (CT) scan D) Contraction stress test Answer: A Explanation: A) Diagnosis of intrauterine fetal death (IUFD) is confirmed by visualization of the fetal heart with absence of heart action on ultrasound. B) Serum estriol levels drop during fetal demise, but progesterone levels are not measured. C) A computed tomography (CT) scan is not indicated. D) Contraction stress tests are used to determine whether a fetus will tolerate the stresses of labor. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

8) The postpartum unit nurse is caring for a client who delivered a term stillborn infant yesterday. The mother is heard screaming at the nutrition services worker, "This food is horrible! You people are incompetent and can't cook a simple edible meal!" The nurse understands this as which of the following? A) An indication that the mother is in the anger phase of grief. B) An abnormal response to the loss of the child. C) Reactive stress management techniques in use. D) Denial of the death of the child she delivered yesterday. Answer: A Explanation: A) Anger, resulting from feelings of loss, loneliness, and, perhaps, guilt, is a common reaction. Anger may be projected at significant others and/or healthcare team members. B) Anger is a common and normal response to the grief of perinatal loss. C) Reactive stress management techniques do not exist. D) Denial of the loss would manifest as believing that she still has a live fetus in utero. Page Ref: 980 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 9. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

9) The nurse is caring for a client who experienced the birth of a stillborn son earlier in the day. The client is from a culture where a woman's status is dominated by themes of motherhood and childrearing. What behavior would the nurse expect in this client? A) Crying inconsolably B) Expressing feelings of failure as a woman C) Requesting family members to be present D) Showing little emotion Answer: B Explanation: A) Inconsolable crying is not a sign of a maternalistic culture, but is a universal sign of deep grief. B) Mothers will often blame themselves, whether by commission or omission, particularly in cultures where a woman's status is dominated by themes of motherhood and childrearing. C) Inconsolable crying is not a sign of a maternalistic culture, nor is the presence of multiple family members. D) Showing little emotion indicates a stoic culture, which might not be maternalistic. Page Ref: 987 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

10) As the couple and their families begin to confront the pain of their loss, many normal manifestations of grief may be present. Which of the following would indicate an emotional response to the loss? A) Lack of meaning or direction B) Preoccupation C) Flat affect D) Dreams of the deceased Answer: C Explanation: A) Lack of meaning or direction would be a spiritual response to loss. B) Preoccupation would be a cognitive response to loss. C) Flat affect would be an emotional response to loss. D) Dreams of the deceased would be a behavioral response to loss. Page Ref: 981 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

11) The nurse is working with a family who experienced the stillbirth of a son 2 months ago. Which statement by the mother would be expected? A) "I seem to keep crying for no reason." B) "The death of my son hasn't changed my life." C) "I have not visited my son's gravesite." D) "I feel happy all the time." Answer: A Explanation: A) Mourning may be manifested by certain behaviors and rituals, such as weeping, which help the person experience, accept, and adjust to the loss. B) A fetal loss is devastating to parents, and results in significant life changes. C) Mourning may be manifested by certain behaviors and rituals, such as visiting a gravesite, which can help the person experience, accept, and adjust to the loss. D) Happiness is not an expected part of mourning. Page Ref: 979 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

12) A 15-year-old client has delivered a 22-week stillborn fetus. What does the nurse understand? A) Grieving a fetal loss manifests with very similar behaviors regardless of the age of the client. B) Teens tend to withhold emotions and need older adults with the same type of loss to help process the experience. C) Most teens have had a great deal of contact with death and loss and have an established method of coping. D) Assisting the client might be difficult because of her mistrust of authority figures. Answer: D Explanation: A) Grieving behaviors are very different in adolescents than in older clients. Adolescents rely heavily on peer support. B) Adolescents rely more heavily on peer support than on adults for emotional support. C) For many adolescents, a pregnancy loss may be the first time they are experiencing the psychologic impact of grief. D) Adolescents rely heavily on peer support and have a natural mistrust of authority figures, which can make assisting them more difficult. Page Ref: 982 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

13) The nurse is present when a mother and her partner are told that their 35-week fetus has died. Which nursing intervention should the nurse perform first? A) Encourage open communication with the family and the healthcare team. B) Ask the family to withhold questions until the next day. C) Request that another nurse come and care for this family. D) Contact a local funeral home to help the family with funeral plans. Answer: A Explanation: A) The top priority for the nurse is to encourage open communication. The nurse functions as an advocate for the family in organizing interdisciplinary involvement, maintaining continuity of care, offering the opportunity for open communication, and ensuring that the family's wishes regarding their loss experience are honored. B) Requesting that the couple not ask questions does not facilitate communication. The nurse should provide ongoing opportunities for the couple to ask questions. C) Requesting that another nurse care for the family does not facilitate communication. When possible, the same nurse should provide care for the couple so that a therapeutic relationship can be established. D) Funeral plans can be made later and are usually made by the family. Page Ref: 991 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

14) The labor and delivery nurse is caring for a client whose labor is being induced due to fetal death in utero at 35 weeks' gestation. In planning intrapartum care for this client, which nursing diagnosis is most likely to be applied? A) Powerlessness B) Urinary Elimination, Impaired C) Coping: Family, Readiness for Enhanced D) Skin Integrity, Impaired Answer: A Explanation: A) Powerlessness is commonly experienced by families who face fetal loss. Powerlessness is related to a sense of lack of control in the current situational crisis. B) Impaired urinary elimination is not related to fetal loss. C) Ineffective family coping is more likely to occur at this point than readiness for enhanced family coping. D) Impaired skin integrity is not related to fetal loss. Page Ref: 989 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

15) The nurse is supervising care by a new graduate nurse who is working with a couple who have experienced a stillbirth. Which statement made by the new nurse indicates that further instruction is necessary? A) "I should stay out of their room as much as possible." B) "The parents might express their grief differently from each other." C) "My role is to help the family communicate and cope." D) "Hopelessness might be expressed by this family." Answer: A Explanation: A) Families experiencing perinatal loss need support. The nurse should stay with the couple so they do not feel alone and isolated; however, cues that the couple wants to be alone should be assessed continuously. B) Partners often express grief very differently. C) Families need to communicate to cope effectively. D) Hopelessness is commonly experienced by families after perinatal loss. Page Ref: 992 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

16) The nurse is working with a laboring woman who has a known intrauterine fetal demise. To facilitate the family's acceptance of the fetal loss, after delivery the nurse should do which of the following? A) Encourage the parents to look at the infant from across the room. B) Offer the parents the choice of holding the infant in their arms. C) Take the infant to the morgue immediately. D) Call family members and inform them of the birth. Answer: B Explanation: A) Looking at the infant from a distance would not be helpful. B) The nurse should offer the couple the opportunity to see and hold the infant and reassure the couple that any decision they make for themselves is the right one. C) Taking the infant to the morgue before the parents have a chance to see and hold it would not be appropriate. D) Calling family members would not be helpful or appropriate for the nurse to do. Page Ref: 994 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

17) The mother of a client who has experienced a term stillbirth arrives at the hospital and goes to the nurses' desk. The mother asks what she should say to her daughter in this difficult time. What is the nurse's best response? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "Use clichés; your daughter will find the repetition comforting." B) "Remind her that she is young and can have more children." C) "Keep talking about other things to keep her mind off the loss." D) "Express your sadness, and sit silently with her if she doesn't respond." E) "Encourage her to talk about the baby whenever she wants to." Answer: D, E Explanation: A) Although grieving people often say that it is easier to forgive less-than-helpful remarks than to forgive those who do not reach out to them at all, the use of clichés can be harmful. B) Reminding the mother that she is young enough to have other children downplays the importance of this baby. C) Nonstop talking does not allow the client to express her emotions and feelings. Sitting in silence with a grieving family is often the most helpful form of intervention available. D) Silence is commonly what is needed most, and simply saying "I'm sorry for your loss" might help to facilitate communication. E) Talking is a way for the client experiencing grief and begin to come to terms with what has happened, and is important for resolution of grief. Intuitive grievers will need to talk about the event. Page Ref: 982, 1000 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Differentiate between helpful and nonhelpful responses in caring for families experiencing perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

18) The community nurse is planning care for a family that experienced the loss of twins at 20 weeks. Which of these steps should be part of the nurse's care of this family? A) Base care on the reactions of previous clients who experienced stillbirth. B) Express the belief that the family will be able to get through this experience. C) Encourage the couple to keep their feelings to themselves. D) Honor the birth by reminding the couple that their babies are happy in heaven. Answer: B Explanation: A) Care for a family experiencing perinatal loss must be individualized; no two families will respond in the same way. B) Maintaining belief is defined as believing in the parents' capacity to get through the event and face a future with meaning, and it is one of the attributes of caring theory. C) Communication should be encouraged. D) Clichés are to be avoided. Page Ref: 990 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

19) It is confirmed that a 14-week fetus has died. The patient has an unfavorable cervix. Which approaches to deliver the fetus should be reviewed with the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Oxytocin 2. Misoprostol 3. Prostaglandins 4. Laminaria tent 5. Cesarean section Answer: 1, 2, 3, 4 Explanation: Women with an unfavorable cervix may be given vaginal prostaglandin agents, misoprostol, or laminaria tents. Women whose gestations are less than 16 gestational weeks may have a laminaria tent inserted into the cervix before a dilatation and extraction procedure. Women less than 28 weeks' gestation are typically given prostaglandin E2 vaginal suppositories (10-20 mg q 4-6 h), misoprostol 400 mcg vaginally or orally every 4 to 6 hours, and/or oxytocin until spontaneous labor occurs. Cesarean section is not a method identified to deliver the dead fetus. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

20) The nurse is a caring for a patient who is recovering from the loss of her 24-week fetus. Which observations should the nurse identify as being the patient's behavioral responses to this loss? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Crying 2. Disorientation 3. Time confusion 4. Fear of being alone 5. Absent-mindedness Answer: 1, 4, 5 Explanation: Behavioral responses to loss include fear of being alone, absent-minded behavior, and crying. Cognitive responses to loss include disorientation and time confusion. Page Ref: 981 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

21) The fetus of a pregnant Latino American patient has died. When assisting the family with the perinatal loss, what should the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The fetus will be baptized 2. Pictures will be taken of the fetus 3. Cremation will occur within a day 4. The fetus will have an open casket 5. The mother will be dressed in black Answer: 1, 2, 4, 5 Explanation: For a perinatal loss in many Latino American cultures, the fetus will be baptized. Pictures and other mementos are important, as they are utilized to honor the infant in the home. Open casket ceremonies are preferred. The mother may wear traditional dark funeral clothing for an undefined mourning period. Burial is preferred over cremation. Page Ref: 985 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

22) The nurse is preparing to care for a patient who has just learned that her fetus has died. In which order should the nurse adhere to the RESPONDING approach to grieving families? 1. Genuine caring 2. Open communication 3. Nonjudgmental attitude 4. Decision making assistance 5. Spiritual and cultural accommodation 6. Recognition and validation of the loss Answer: 6, 5, 2, 4, 3, 1 Explanation: The nurse should follow the essential elements of responding effectively to the needs of grieving families by following the steps in the acronym RESPONDING: recognition and validation of the loss; spiritual and cultural accommodation; open communication; decision making assistance; nonjudgmental attitude; and genuine caring. Page Ref: 990 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 5 Differentiate between helpful and nonhelpful responses in caring for families experiencing perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

23) The nurse is preparing to bathe and dress a fetus that has died. In which order should the nurse provide this postmortem care? 1. Pat dry 2. Apply gloves 3. Diaper and dress the fetus 4. Place in second basin of water to rinse 5. Place infant in lukewarm basin of water 6. Bathe according to skin integrity condition Answer: 2, 5, 6, 4, 1, 3 Explanation: When bathing and dressing a fetus as part of postmortem care, the nurse should apply gloves and then place the fetus in a lukewarm basin of water. Cleanse the skin according to the fetus's skin integrity. Place fetus in a second basin of lukewarm water to rinse. Gently pat dry. Diaper and dress fetus in clothing provided. Page Ref: 995 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

24) The nurse educator is teaching a group of students about maternal medical conditions that contribute to stillbirth. Which student statement indicates correct understanding of the material presented? A) "Maternal hypertensive disorders often contribute to stillbirth." B) "Maternal congenital anomalies contribute to stillbirth." C) "Maternal chromosomal abnormalities contribute to stillbirth." D) "Maternal malformations contribute to stillbirth." Answer: A Explanation: A) Maternal hypertensive disorders are a contributing factor to stillbirth. This statement indicates correct understanding by the student. B) Fetal, not maternal, congenital anomalies contribute to stillbirth. This statement indicates the need for additional education. C) Fetal, not maternal, chromosomal abnormalities contribute to stillbirth. This statement indicates the need for additional education. D) Fetal, not maternal, malformations contribute to stillbirth. This statement indicates the need for additional education. Page Ref: 978 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

25) Which is the criterion that practitioners use to diagnosis fetal demise in utero? A) Absence of fetal movement B) Absence of fetal heartbeat C) Increased serum estriol D) Increased serum testosterone Answer: B Explanation: A) While the absence of fetal movement often cues the pregnant client that there may be something wrong, this is not the criterion for the diagnosis of fetal demise in utero. B) Absence of a fetal heartbeat is the criterion that practitioners use to diagnose fetal demise in utero. C) A decreased, not increased, level of estriol that accompanies fetal demise will often initiate labor. However, this is not the criterion for diagnosis of fetal demise in utero. D) Testosterone levels do not cause, nor do they change, as a result of fetal demise; therefore, this is not a criterion used to diagnose fetal demise in utero. Page Ref: 978 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

26) The nurse is providing care to a pregnant client who experienced a fetal demise in utero. The client opted to wait more than 24 hours prior to scheduling the induction procedure. Which complication is the client at increased risk for based on this data? A) Anxiety B) Hemorrhage C) Hypertension D) Mania Answer: A Explanation: A) Clients who opt to wait more than 24 hours to schedule the induction procedure after a fetal demise are at an increased risk for anxiety. B) Hemorrhage is not a complication that the client is at increased risk for when waiting more than 24 hours to schedule the induction procedure. C) Hypertension is not a complication that the client is at increased risk for when waiting more than 24 hours to schedule the induction procedure. D) Mania is not a complication that the client is at increased risk for when waiting more than 24 hours to schedule the induction procedure. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

27) A couple who experienced a fetal demise would like to determine the specific cause. Which method of fetal testing will the nurse prepare for based on this request? A) Diabetes testing B) Urine toxicology testing C) Infectious disease studies D) Chromosomal studies Answer: D Explanation: A) Diabetes testing is a method of maternal testing, not fetal testing, to determine the cause of fetal demise. B) Urine toxicology testing is a method of maternal testing, not fetal testing, to determine the cause of fetal demise. C) Infectious disease studies are a method of maternal testing, not fetal testing, to determine the cause of fetal demise. D) Chromosomal studies are a method of fetal testing that is used to determine the cause of fetal demise. Page Ref: 979 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

28) The nurse is providing care to a couple who have experienced a perinatal loss. Which is an expected early physical response to the loss? A) Confusion B) Preoccupation C) Loss of appetite D) Poor concentration Answer: C Explanation: A) Confusion is an early cognitive, not physical, response to the loss. B) Preoccupation is an early cognitive, not physical, response to the loss. C) Loss of appetite is an early physical response to loss. D) Poor concentration is an early cognitive, not physical, response to loss. Page Ref: 981 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

29) The nurse is providing care to a Hispanic client who has experienced a stillbirth. Which action by the nurse is appropriate when providing culturally competent care to the client and family members? A) Asking the paternal grandfather if they will sit in shiva B) Asking the oldest male member of the family if he would like to participate in the cremation C) Asking the parents if they wish to have their baby baptized D) Asking the parents if they wish to participate in the ritual of painting the baby's body Answer: C Explanation: A) A Jewish, not Hispanic, family may sit in shiva after the loss of a baby. This action is not appropriate when providing culturally competent care to the client and family. B) A Hindu, not Hispanic, family, may want the oldest male member of the family to participate in the baby's cremation. This action is not appropriate when providing culturally competent care to the client and family. C) Many Hispanic families will want the baby to be baptized. This action is appropriate when providing culturally competent care to the client and family. D) A Native American, not Hispanic, family may want to participate in a ritual of painting the baby's body. This action is not appropriate when providing culturally competent care to the client and family. Page Ref: 984 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

30) The nurse is providing care to a couple who have experienced a stillbirth. Which is a therapeutic statement from the nurse when providing care to the client? A) "You are young; you can try again." B) "It's a blessing in disguise." C) "God needed another angel in heaven." D) "I am here to listen if you would like to talk about it." Answer: D Explanation: A) Telling the couple that they are young and can try again diminishes their current pain. B) Telling the couple that it was a blessing in disguise often unfortunately occurs when there are fetal deformities. There are no adequate explanations as to why the couple is experiencing this tragedy, and none should be offered. C) It is not appropriate for the nurse to impose his or her belief system on the family. D) This statement reassures the couple that the nurse cares and is a therapeutic statement from the nurse. Page Ref: 991 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Communication and Documentation. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

31) The nurse is preparing a stillborn newborn to be held by the parents. Which action by the nurse is appropriate? A) Using baby lotion so that the newborn smells like a baby B) Placing cotton in the newborn's nostrils if seepage is noted C) Using a washcloth when bathing the newborn's skin to decrease tissue sloughing D) Placing the newborn in the provided outfit and blanket Answer: D Explanation: A) Scented baby products should be avoided, as they will enhance skin maceration. B) Petroleum jelly, not cotton, should be placed in the newborn's nostrils if seepage is noted. C) A gloved hand, not a washcloth, should be used when bathing the newborn's skin to decrease tissue sloughing. D) The baby should be placed in the provided outfit and wrapped in a blanket in preparation for parents who wish to hold their baby after death. Page Ref: 995 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

32) Which nursing action is appropriate prior to presenting the stillborn newborn to the parents for holding? A) Staying with the family while they hold and say goodbye to their newborn B) Telling the family that they should not hold their baby because it will be too painful C) Preparing the family by telling them what they will see, feel, and smell D) Telling the family that they can have up to thirty minutes with their baby Answer: C Explanation: A) The nurse should offer the family time alone with the baby, but check back frequently within previously specified time frames. B) The nurse should not impose his or her beliefs on the couple when providing care. C) The nurse should prepare the family for holding the baby by telling them what they will see, feel, and smell. D) The nurse should allow the family to have as much time as they need to hold their baby and say goodbye. Page Ref: 995 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

33) Which items will the nurse include in a memory box for a couple who have experienced a stillbirth? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pictures 2. ID bracelet 3. Memory card 4. Bereavement clothing 5. Grief and loss pamphlets Answer: 1, 2, 3, 4 Explanation: When preparing a memory box for a couple who lost their newborn to stillbirth, the nurse will include pictures of the baby, ID bracelets, a memory card, and bereavement clothing. Grief and loss pamphlets should be provided to the couple, but not included in the memory box. Page Ref: 995 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

34) The nurse is providing care to a couple who have experienced a perinatal loss. Which nursing diagnosis is appropriate to include in the plan of care? A) Acute Pain B) Complicated Grieving C) Powerlessness D) Insomnia Answer: C Explanation: A) Acute pain is not an appropriate nursing diagnosis to include in the couple's plan of care. B) Complicated grieving is not an appropriate nursing diagnosis to include in the couple's plan of care. C) Powerlessness related to the sense of a lack of control in the current situational crisis is an appropriate nursing diagnosis to include in the couple's plan of care. D) Insomnia is not an appropriate nursing diagnosis to include in the couple's plan of care. Page Ref: 989 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

35) The nurse is assessing a client's risk for death during the postpartum period. Which finding would cause the nurse to increase surveillance for this client? A) Maternal age of 25 B) History of bipolar disorder C) Increased body mass index D) Decreased blood pressure Answer: C Explanation: A) Advanced maternal age is a risk factor for maternal death during the postpartum period. Advanced maternal age is defined as greater than 35 years of age. B) A history of bipolar disorder increases the risk of postpartum depression and psychosis, not maternal demise. C) An increased body mass index is often a risk factor for maternal demise during the postpartum period. D) An increased, not decreased, blood pressure is a risk factor for maternal demise during the postpartum period. Page Ref: 988 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: Demonstrate use of the nursing process in the care of the childbearing family experiencing grief and loss.

Solution Manual for Olds Maternal-Newborn Nursing & Women Health Across the Lifespan, 11 Edition

richard@qwconsultancy.com

1|Pa ge

Instructor’s Resource Manual for Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan, 11e

Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan Eleventh Edition

Michele Davidson Marcia London Patricia Ladewig

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 1 Contemporary Maternal-Newborn Nursing Contemporary Childbirth..................................................................................

The Self-Care Movement..................................................................................

The Healthcare Environment............................................................................

Culturally Competent Care................................................................................

Professional Options in Maternal-Newborn Nursing Practice.........................

Legal and Ethical Considerations......................................................................

Special Ethical Situations in Maternity Care.....................................................

Evidence-Based Practice in Maternal-Child Nursing........................................

Focus Your Study……………………………………………….............................................

Activities.............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Contemporary Childbirth

A. Scope of Practice of Maternal and Newborn Nurses Has Changed Dramatically 1. Broader responsibilities 2. Focus on goals of childbearing woman and her family, family-centered care a) Fathers, siblings, family members b) New definitions of family evolving 3. Characterized by increasing number of choices about childbirth a) Place b) Primary caregiver c) Birth-related experiences 4. Home follow-up nursing care a) Cost-effective b) Favorable long-term family outcomes 5. Internet access a) Families have wealth of information and advice 6. Complementary and alternative medicine (CAM) practices growing nationwide a) Impact care of childbearing families b) Nurses need to recognize families may not share this information with their healthcare provider 7. Choice of certified nurse-midwife (CNM) to manage pregnancy, birth a) CNM direct entry (1) As of 2010, graduate degree is required b) Certification agencies (1) American College of Nurse-Midwives (ACNM) (a) Certified nurse midwife (CNM) (2) North American Registry of Midwives (NARM) (a) Certified professional midwife (CPM) 8. Choice of home birth a) Healthcare professionals do not generally recommend

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

II.

The Self-Care Movement

A. Late 1960s 1. Consumers sought to understand technology, take interest in health, basic self-care skills 2. Requiring greater information and accountability from healthcare providers

B. Practicing Self-Care → Assuming Responsibility for One’s Own Health 1. Assertiveness 2. Active role in seeking information 3. Foster self-care by focusing on health promotion education a) Exercise, bike helmet b) Related to specific health concerns c) Promoting health decreases healthcare costs d) Health promotion education activities increased significantly 4. Maternal-newborn care essentially health focused 5. Health promotion education, self-care vital part of healthcare a) Nursing recognizing that people who are able should take an active role in their own health care

III.

The Healthcare Environment

B. Healthcare Issues: Cost, Access, Quality 1. Healthcare expenditures increasing 2. Almost all adults over age 65 are covered by Medicare 3. Vast majority of the uninsured are under age 65

C. Early Prenatal Care Reduces Adverse Pregnancy Outcomes 1. 77.1% of United States pregnant women began prenatal care in first trimester

D. Healthy People 2020 1. Goal: Increase proportion of women who receive early and adequate prenatal care a) Demographic changes b) Recognition of the need to improve access to care c) Public demand for more effective healthcare options d) New research findings e) Women’s preferences for healthcare

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Primary Healthcare Services the Base on Which Secondary and Tertiary Services Built 1. System currently focuses on high-tech care rather than prevention

IV.

Culturally Competent Care

A. U.S. Population Ever Increasing in Diversity 1. Culture develops from socially learned beliefs, lifestyles, values, patterns of behavior 2. By 2020, less than half of all children in the United States will be non-Hispanic White 3. Specific elements contribute to value system a) Religion and social beliefs b) Presence and influence of extended family c) Communication patterns d) Beliefs and understanding about concepts of health, illness e) Permissible physical contact with strangers f) Education 4. Specific differences in beliefs between families, providers a) Help-seeking behaviors b) Pregnancy and childbirth practices c) Causes of diseases or illnesses d) Death and dying e) Caretaking and care giving f) Childrearing practices 5. Influence of cultural beliefs, values → making group unique a) Misunderstandings when healthcare professional, family from different cultural groups b) Nurses must recognize, respect, respond to ethnic diversity c) Identify culturally relevant facts about patient 6. Developing cultural competence a) Values conflicts (1) Traditional rituals and practices versus current healthcare practices 7. Cultural values incorporated into care plan → family likely to accept and comply with needed care a) Avoid imposing personal cultural values

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Professional Options in Maternal-Newborn Nursing Practice A. Settings for Maternal-Newborn Nurses 1. Maternity department of acute care facilities 2. Physicians’ offices 3. Clinics 4. College health services 5. School-based programs 6. Community health services

B. Titles Include 1. Professional nurse, registered nurse (RN) 2. Certified registered nurse (RNC) 3. Nurse practitioner (NP) a) Doctor of Nursing Practice (DNP) or master’s degree b) Specialization areas c) Ambulatory care services d) Acute care 4. Clinical nurse specialist (CNS) 5. Certified nurse-midwife (CNM) 6. Advanced practice nurse → additional education, practice, function in expanded role 7. Nurse researcher

C. Interprofessional Cooperation and Collaborative Practice 1. Comprehensive model of health care using multidisciplinary team a) Cost-effective b) High-quality care 2. Maternal-newborn setting a) CNMs, NPs, in practice with physicians b) Autonomous but functions within clearly defined scope of practice

D. Community-Based Nursing Care 1. Increasing emphasis on primary care a) Health promotion b) Illness prevention c) Individual responsibility for one’s own health 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Third-party payer plans offer opportunities and challenges a) Model for coordinated, comprehensive care b) Challenge to integrate essential community providers (1) Essential element of health care for uninsured and underinsured c) Consumers requesting “seamless” system d) Shortened lengths of stays have resulted in need for coordination of services 3. Maternal-newborn nurse involved in changes a) Most health care provided to childbearing families takes place outside hospitals

E. Home Care 1. Important dimension of community-based nursing care 2. Nurses major providers of home care services a) Providing and supervising care 3. Postpartum and newborn home visits

F. Healthy People 2020 Goals 1. Maternal, infant, and child health 2. Adolescent health (new) 3. Family planning 4. Injury and violence prevention 5. Lesbian, gay, bisexual, and transgender health (new) 6. Sexually transmitted infections 7. Genomics

VI.

Legal and Ethical Considerations

A. Full Understanding of: 1. Practice standards 2. Institutional or agency policies 3. Local, state, and federal laws 4. Understanding of ethical implications

B. Scope of Practice 1. State nurse practice acts protect public by broadly defining legal scope of practice a) Most cover expanded practice roles

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nurse must function within scope of practice or risk being accused of practicing medicine without a license 3. Correct interpretation and understanding state practice acts a) Enables nurse to provide safe care within limits of nursing practice

C. Standards of Nursing Care 1. Establish minimum criteria a) Competent, proficient delivery of nursing care

D. Sources of Care Standards 1. American Nurses Association (ANA) 2. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) 3. National Association of Neonatal Nurses (NANN) 4. Association of Operating Room Nurses (AORN) 5. Agency policies, procedures, protocols 6. The Joint Commission 7. Clinical practice guidelines a) Comprehensive interdisciplinary care plans b) Reduce variation in care management c) Limit costs of care d) Evaluate the effectiveness of care

E. Patients’ Rights 1. Include patient safety, informed consent, privacy, confidentiality

F. Patient Safety 1. The Joint Commission identified patient safety as important responsibility of healthcare providers a) Patient safety goals 2. Quality and Safety Education for Nurses (QSEN) project, 2005 a) Patient-centered care b) Teamwork and collaboration c) Evidence-based practice d) Quality improvement e) Safety f) Informatics

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

G. Informed Consent 1. Allows patients to make intelligent decisions regarding own health care 2. Patient (legally designated decision) granted permission for treatment or procedure a) Based on full information b) Pertains to any nursing, medical, or surgical intervention 3. Several elements ensure informed consent a) Clearly and concisely presented b) Understandable to patient c) Include risks and benefits d) Probability of success e) Significant treatment alternatives f) Consequences of receiving no treatment or procedure g) Told of right to refuse specific treatment or procedure h) Told that refusing specified treatment or procedure does not result in withdrawal of all support or care 4. Individual ultimately responsible for treatment or procedure should provide information a) Nurse may witness signature b) May help by clarifying information physician provides c) Determine that patient understands information before making decision 5. Parents have authority and responsibility to give consent for minor children 6. Children younger than 18 or 21 can give legally informed consent when they are: a) Minor parents of the newborn, infant, or child patient b) Emancipated minors 7. Mature minors can give consent in some states 8. Problems in maternity nursing a) Minor might be able to give consent for infant but not for self 9. Refusal of treatment, medication, procedure a) Sign release form 10. Nurses responsible for educating patients about any nursing care

H. Right to Privacy 1. Right of person to keep person and property free from public scrutiny 2. Statutory or common law a) ANA, National League for Nursing (NLN), The Joint Commission b) HIPAA 3. Laws, standards, policies specify information can be shared a) Only by health professionals responsible for their care 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Authorization for release c) Legal versus ethical considerations

I. Confidentiality 1. Crucial for development of trust in relationship 2. Privileged communications 3. Federal Patient Self-Determination Act a) Advance directives

J. Professionalism in Practice 1. Confidentiality and the pregnant adolescent a) Openly discuss limits of confidentiality

VII.

Special Ethical Situations in Maternity Care

A. Maternal–Fetal Conflict 1. Fetus viewed as patient separate from mother 2. Divergent interests rather than shared interests

B. Most Women Strongly Motivated → Protect Health, Well-Being of Fetus 1. Forced intervention on behalf of fetus a) Cesarean birth, coercion to enter substance-abuse treatment, mandating experimental in utero therapy or surgery 2. Intervention infringes on autonomy of mother 3. Criminalize behaviors that are considered harmful 4. American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics a) Affirmed fundamental right of pregnant women (1) To make informed, uncoerced decisions about medical interventions (2) Direct stand against coercive and punitive approaches to maternal–fetal relationship, citing “overwhelming rationale” for avoiding such approaches (3) ACOG and American Academy of Pediatrics (AAP) recognize cases of maternal–fetal conflict that involve two patients, both of whom deserve respect and treatment

C. Abortion 1. 1973 Roe v. Wade, abortion legal in United States 2. Performed until period of viability a) After viability, abortion permissible only when the life or health of the mother is threatened b) Before viability, the mother’s rights are paramount; after viability, the rights of the fetus take precedence 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Personal beliefs, cultural norms, life experiences, religious convictions 4. Decisions about abortion made by woman and physician a) Nurses have right to refuse to assist → may be dismissed for refusing (1) Ensure that someone with similar qualifications is able to provide appropriate care for patient

D. Fetal Research 1. Fetal tissue research 2. Therapeutic research with living fetuses a) Aimed at treating fetal condition 3. Intrauterine fetal surgery a) Open uterus during second trimester → treat fetal lesion → replace fetus in uterus b) Experimental c) Risks of the surgery, commitment to cesarean birth, alternatives to treatment d) Caregivers must respect pregnant woman’s autonomy, she retains right to refuse any surgical procedure

E. Reproductive Assistance 1. Infertile couples have wide range of options a) Intrauterine insemination (IUI) (1) Husband, partner, or donor (2) Child is biologic child of mother → donor must sign form waiving parental rights (3) Donor → health information b) Assisted reproductive technology (ART) (1) Any treatment in which both egg and sperm are handled (2) In vitro fertilization and embryo transfer (IVF–ET) (a) Legislative effort to address consumer concerns about ART (b) Increases multifetal pregnancies (i) Increases risk of miscarriage, preterm birth, neonatal morbidity, and mortality (c) American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART) → guidelines to limit number of embryos transferred (i) Fetal reduction (ii) Ethical concerns (d) Prevention should be first approach to problem of multifetal pregnancy 2. Surrogate childbearing 3. Ethical questions a) Religious objections b) Financial and moral responsibility for child with congenital defect

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Candidate selections d) Threat of genetic engineering e) What should be done with surplus fertilized oocytes f) To whom do frozen embryos belong g) Who is liable if woman or offspring contracts HIV disease from donated sperm h) Should children be told the method of their conception

F. Embryonic Stem Cell Research 1. Human stem cells found in embryonic tissue 2. Stem cell tissue cultures → cells for blood, nerve, heart a) Used to treat problems 3. Positions vary dramatically a) Additional questions arise (1) Sources acceptable (2) Cloning (3) Use of embryos remaining after fertility treatments 4. How embryo should be viewed a) Person or property b) Includes issue of consent

G. Implications for Nursing Practice 1. Complex ethical issues facing maternal-newborn nurses a) Social, cultural, legal, professional ramifications

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Anticipate, clarify own positions and values

VIII.

Evidence-Based Practice in Maternal-Child Nursing

A. Evidence-Based Practice (EBP) → Interventions Supported by Current, Valid Research or Evidence 1. Useful approach to problem solving/decision making 2. Self-directed, patient-centered, lifelong learning

B. Clinical Nurses Must Meet Three Basic EBP Competencies 1. Recognize which clinical practices are supported by sound evidence, which practices have conflicting findings as to their effect on patient outcomes, which practices have no evidence to support their use 2. Use data in their clinical work to evaluate outcomes of care 3. Appraise and integrate scientific bases into practice

C. Need for More Responsible Clinical Practice 1. Need to know what data being tracked a) How care practices, outcomes improved as result of quality improvement initiatives 2. Impact of EBP → moves clinicians beyond practices of habit and opinion

D. Nursing Research 1. Vital to expanding science of nursing a) Fostering EBP b) Improving patient care c) Advancing profession of nursing 2. Gap between research and practice being narrow by publication of findings

E. Nursing Care Plans and Concept Maps 1. Nursing care plans a) Use nursing process as organizing framework 2. Concept maps

F. Statistical Data and Maternal-Infant Care 1. Health-related statistics provide objective basis a) Projecting patient needs b) Planning use of resources c) Determining effectiveness of treatment

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Descriptive statistics → describe, summarize a set of data 3. Inferential statistics → allow investigator to draw conclusions, inferences about what is happening a) Between two or more variables in a population b) Suggest or refute causal relationships between them 4. Descriptive statistics starting point for formation of research questions 5. Inferential statistics answer specific questions, generate theories

G. Birth Rate → Number of Live Births per 1000 People 1. 2016 → 12.2/1000 2. Fell for all 5-year age groups from 15 to 29 years of age 3. Increased for women 30 to 49 years of age 4. Remained unchanged for girls 10 to 14 years of age 5. Live births declined in 2016 by 1% to 3,945,875 6. Childbearing by unmarried women continued to decline in both actual number of births and birth rate 7. Caesarean birth rate in 2016 was 42.4% a) See Table 1–1: Births and Birth Rates by Race, 2016, p. 12 8. Research questions a) Association between birth rates and changing societal values? b) Differences in birth rates between various age groups reflect education or changed attitudes toward motherhood? c) Differences in birth rates among various countries reflect cultural differences? Represent availability of contraceptive information? Other factors at work? d) See Table 1–2: Live Birth Rates and Infant Mortality Rates for Selected Countries, p. 12

H. Infant Mortality 1. Number of deaths of infants younger than 1 year of age per 1000 live births in a given population a) Neonatal mortality → number of deaths of infants younger than 28 days of age per 1000 live births b) Postnatal mortality → number of deaths of infants between 28 days and 1 year of age c) Perinatal mortality → includes both neonatal deaths and fetal deaths per 1000 live births d) Fetal death → death in utero at 20 weeks’ or more gestation e) 2015: U.S. rate 5.90 f) Varied widely by race of mother

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. United States ranks significantly higher among industrialized nations a) High percentage of preterm births in United States main cause b) Stress need in United States for better prenatal care, coordination of health services, provision of comprehensive maternal-child services c) Range is dramatic d) Information prompts questions (1) Infant mortality correlated with specific maternal age? (2) Leading causes of infant mortality in each country? (3) Difference in mortality rates among racial groups? If so, is it associated with availability of prenatal care? With educational level of mother or father?

I. Maternal Mortality Rate → Number of Deaths from Any Cause Related to or Aggravated by Pregnancy or Its Management during the Pregnancy Cycle per 100,000 Live Births 1. 2015 → 17.3 per 100,000 live births 2. In general, maternal mortality rates significantly lower than 25 years ago a) Increased use of hospitals, specialized healthcare personnel b) Establishment of care centers for high-risk mothers and infants c) Prevention and control of infection d) Availability of blood, blood products e) Lowered rates of anesthesia-related deaths 3. Research questions a) Correlation between maternal mortality and age? b) Correlation with availability of healthcare? Socioeconomic status?

J. Implications for Nursing Practice 1. Healthy People 2020 a) Determine populations at risk b) Assess relationship between specific factors c) Help establish databases for specific patient populations d) Determine the levels of care needed by particular patient populations e) Evaluate success of specific nursing interventions f) Determine priorities in caseloads g) Estimate staffing and equipment needs of hospital units and clinics 2. Information available from many sources a) Professional literature b) State and city health departments c) Vital statistics sections of agencies d) Special programs or agencies e) Demographic profiles of specific geographic areas

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IX.

Focus Your Study

Activities 1. Individual Assign students to find research reports related to maternal-child nursing interventions and write a two- to three-page paper discussing how they influence evidence-based practice. 2. Small Group Divide the class into small groups of three to five students and have the groups share family values and practices related to maternal-child health and how they influence their values. 3. Large Group Invite maternal-child nurses with different clinical responsibilities to talk about their roles with your class.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 2 Families, Cultures, and Complementary Therapies The Family........................................................................................................

Cultural Influences Affecting the Family..........................................................

Culture and Nursing Care…………………………………………………………………………….

Complementary Health Approaches and the Family…….................................

Focus Your Study…………………………………………………………………………………………

Activities............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

The Family

A. Definitions of Family 1. U.S. Census Bureau: two or more individuals who are joined together by marriage, birth, or adoption and live together in the same household 2. Broad definition: families as individuals who have established bonds of emotional closeness, sharing, and support

B. Family Values 1. Guided by a common set of values or beliefs about the worth and importance of certain ideas and traditions 2. Bind family members together 3. Influenced by external factors

C. Types of Families 1. Nuclear family a) Children live in a household with both biological parents and no other relatives or persons b) Dual-career/dual-earner family now considered the norm 2. Child-free (childless) family 3. Extended family a) Couple shares household and childrearing responsibilities with parents, siblings, or other relatives 4. Extended kin network family a) Two nuclear families of primary or unmarried kin live in proximity to each other 5. Single-parent family 6. Single mother by choice family 7. Blended or reconstituted nuclear family a) Two parents with biological children from a previous marriage or relationship who marry or cohabitate 8. Binuclear family a) Postdivorce family in which the biological children are members of two nuclear households, with parenting by both the father and the mother b) Heterosexual couple who may or may not have children and who live together outside of marriage c) Gay and lesbian families

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

9. Heterosexual cohabitating family

D. Family Development Frameworks 1. Family’s progression over time according to specific, typical stages in family life 2. Multiple models 3. See Table 2–1: Eight-Stage Family Life Cycle, p. 19

E. Family Assessment 1. Definition: collection of data about the family’s: a) Type and structure b) Current level of functioning c) Support system d) Sociocultural background e) Environment f) Needs 2. Nurse needs to establish trusting relationship 3. Basic information a) Name, age, sex, family relationship of all people residing in the household b) Family type, structure, roles, values c) Cultural associations, including norms and customs related to childbearing, childrearing, newborn/infant feeding d) Religious affiliations e) Support network f) Communication patterns g) Disabilities

II.

Cultural Influences Affecting the Family

A. Culture Characterized by Certain Key Elements 1. Shared values and beliefs 2. Is learned and dynamic 3. Is integrated into life and uses symbols 4. Race (a) Group of people who share biologic similarities such as skin color, bone structure, and genetic traits 5. Ethnicity a) A cultural group’s sense of identification associated with the group’s common social and cultural heritage b) Stereotyping: assuming all members of a group have the same characteristics 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Acculturation a) Process of modifying one’s culture to fit within the new or dominant culture 7. Assimilation a) Related to acculturation; adopting and incorporating traits of the new culture within one’s practice b) Improved health status and health behaviors c) Health sometimes declines

B. Family Roles and Structure 1. Largely dependent on cultural influence 2. Family structure defines acceptable roles and behavior of family members 3. Culture defines gender roles, role of the elderly, and role of the extended family 4. Family goals determined by cultural values and practices, as are family member roles and childbearing and childrearing practices and beliefs

C. Health Beliefs, Approaches, and Practices 1. Incorporation of spirituality a) Health and illness determined by supernatural forces such as God, gods, magic, spirits, or fate b) Miscarriage or the illness of a pregnant woman may be perceived as a punishment for actions 2. Scientific or biomedical health paradigm d) Physiology explains all illness and life itself e) Biochemical reactions and genomic code explain all health states f) Approach often called “Western medicine” 3. Holistic health belief a) Illness results when the natural balance or harmony is disturbed b) Common in North American Indian and Asian cultures c) Hot and cold theory of disease d) See Table 2–2: Hot and Cold Conditions and Foods, p. 22

D. Healthcare Practitioners 1. Combination of spiritual, holistic, or biomedical healthcare providers 2. Folk healers vary according to the culture a) Hispanic Americans: curanderismo, sobador b) Latin America and the Caribbean: espiritistas describes a healer who communicates with spirits for the physical and emotional development of the patient c) Native Americans: shaman

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Impact of Religion and Spirituality 1. Diverse meanings of religion and spirituality 2. Religion → belief in or worshipping of a supernatural being or Supreme Being (such as God or Allah) 3. Spirituality → individual’s experience and own interpretation of his or her relationship with a Supreme Being 4. Religious beliefs, affiliations, practices → influence experiences, attitudes toward healthcare, childbearing, childrearing a) Belong to large institutionalized religious groups b) No formal affiliation c) Agnostic d) Atheist 5. Attempt to accommodate religious rituals, practices requested by family 6. Not unusual to encounter childbearing families with belief in conflict with own a) Nurse must respect family’s view and avoid being judgmental about their beliefs

F. Childbearing Practices 1. Families in the United States and Western countries commonly have only one or two children 2. In many cultures, it is common to have as many children as possible 3. In some cultures, a woman who gives birth attains a higher status, especially if child is male 4. Culture may influence attitudes and beliefs about contraception 5. Health values and beliefs important in understanding reactions and behavior 6. Individuals of many cultures take protective precautions based on their beliefs a) Taboo: behavior or thing that is to be avoided 7. In developing countries, mortality rates among infants and young children are extremely high a) Traditions focus on protecting baby from evil spirits

III.

Culture and Nursing Care

A. Without Cultural Awareness, Caregivers Tend to Project Their Own Cultural Responses 1. Ethnocentrism a) Conviction that the values and beliefs of one’s own cultural group are the best or only acceptable ones

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Inability to understand the beliefs and worldview of another culture 2. Culture shock a) Experience of attempting to understand or adapt to a culture fundamentally different from own culture 3. Cultural competence a) Ability to understand and effectively respond to the needs of individuals and families from different cultural backgrounds

B. Culturally Influenced Responses 1. Biologic differences a) Genetic and physical differences occur among cultural groups b) Can lead to disparity in needs and care c) Blood type, body build, skin color, drug metabolism, susceptibility to certain diseases d) Fundamental differences between genders, ages, and races 2. Communication patterns a) Members of cultural groups share information and preserve their beliefs, values, norms, and practices b) Essential families communicate with nurses and other healthcare providers c) Language can affect health literacy skills d) Translation services should be available in all healthcare settings e) Variations reflected in word meaning, voice inflection and quality, verbal styles f) Use of first names and surnames varies among cultural groups g) Address family members respectfully h) Nonverbal communication: body language such as posture, gestures, facial expressions, eye contact, and touch, use of silence (1) Eye contact has different meanings among different cultures (2) Silence considered sign of respect in some cultures (3) Appropriateness of touch varies with each culture (4) Sense of personal space differs by culture 3. Time orientation a) Cultures have specific values and meanings regarding time orientation b) Events of the past, events that occur in the present, events that will occur in the future c) Time refers to punctuality regarding schedules and appointments 4. Nutrition a) Nutritional habits and patterns vary among cultures; related to both religious practices and health beliefs b) Nutrition essential to culture’s practices for health promotion and care during illness

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Nursing Management for Providing Culturally Competent Care 1. Focus of nursing care is assessment of cultural influences on patient’s health a) Determining family’s cultural healthcare beliefs and practices b) See Table 2–3: Sample Cultural Assessment, p. 27 2. North American Nursing Diagnosis Association (NANDA) nursing diagnoses a) May be culturally biased b) Specific nursing diagnoses dependent on reason family seeks contact with healthcare professionals c) Apply culturally sensitive techniques when dispelling any cultural myths d) Collaborate with a multidisciplinary team

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Complementary Health Approaches and the Family A. Complementary Therapy 1. Procedure or product used as adjunct to conventional medical treatment 2. Acupuncture, acupressure, and massage therapy often used with conventional medical care 3. Many health insurance plans cover at least a portion of the cost

B. Integrative Health Approaches 1. Use of complementary and conventional medical techniques together in a coordinated manner 2. Used in the relief of pain, addressing side effects of drug therapies, cancer pain, health promotion

C. Alternative Therapy 1. Substance or procedure used in place of conventional medicine 2. Not usually available in conventional clinics and hospitals 3. Costs not typically covered under health insurance policies

D. Western Healthcare 1. Integration between conventional medicine and complementary therapies 2. National Center for Complementary and Integrative Health (NCCIH) 3. Complementary and alternative therapies must be assessed for safety, including positive and negative benefits, cost, efficacy, and clinical usefulness

E. Benefits and Risks 1. Many health benefits a) Health promotion, wellness, holistic healing vs. physical cure 2. Safety alert a) Complementary and alternative therapies must be assessed for safety. (1) Positive and negative benefits, cost, efficacy, clinical usefulness b) Use of herbs and natural products (1) Issues regarding misleading claims and safety (2) Especially important for pregnant women

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

F. Types of Complementary Health Approaches 1. Homeopathy: person treated with small doses of medicines that would cause illness when given to someone who is healthy 2. Naturopathy: utilizes healing forces of nature; referred to as natural medicine 3. Traditional Chinese medicine (TCM): seeks to ensure the balance of energy, called chi or qi a) Yin and yang, opposing internal and external forces that, together, represent the whole b) Acupuncture c) Acupressure (Chinese massage) d) Herbal therapy e) Qi gong f) T’ai chi g) Moxibustion 4. Mind-based therapies a) Biofeedback b) Hypnosis c) Visualization d) Guided imagery 5. Chiropractic a) Concepts of manipulation to address health problems thought to be result of abnormal nerve transmissions caused by misalignment of the spine 6. Massage therapy a) Manipulation of the soft tissues of the body to reduce stress and tension, increase circulation, diminish pain, and promote a sense of well-being b) Swedish massage, shiatsu massage, Rolfing, trigger point massage c) Techniques: pressing, kneading, gliding, circular motion, tapping, and vibrational strokes d) Most common recommended complementary therapy during the prenatal and intrapartum period 7. Herbal therapies a) Used since ancient times to treat illnesses and ailments b) Herbs categorized as dietary supplements and controlled by Dietary Supplement Health Education Act c) Do not require approval by Food and Drug Administration (FDA) d) Lists identifying common herbs women are advised to avoid or use with caution during pregnancy and lactation are available 8. Therapeutic touch a) Belief that people are a system of energy with a self-healing potential b) Healing promoted when the body’s energies are in balance c) Applied cautiously to pregnant women and newborns by trained providers

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

9. Other types of complementary health approaches a) Ayurveda b) Meditation c) Craniosacral therapy d) Reflexology e) Hydrotherapy f) Hatha yoga g) Regular physical exercise h) Aromatherapy i) Color and light therapy j) Music and sound therapies k) Magnetic therapy l) Reiki

G. Nursing Care of the Family Using Complementary Therapies 1. Complementary and alternative medicine (CAM) used by 33.2% of adults and 11.6% of children in United States 2. Use of CAM in pregnancy: desire for normal birth and rewarding emotional birth experience 3. Nurses should use a nonjudgmental approach in assessing pregnant women and families for use of CAM 4. Nurses should use complementary modalities in the scope of their nursing practice and nursing practice act in their state 5. Nurses should document their use of CAM within the context of nursing practice 6. Nurses have a role in conducting and supporting research on CAM

Focus Your Study

VI.

Activities 1. Individual Have students develop a family tree and identify the type of family to which they belong. 2. Small Group Divide the class into pairs. Have pairs of students interview each other and conduct a transcultural assessment. 3. Large Group Survey students about their families’ cultural and ethnic backgrounds. Discuss how the backgrounds may affect healthcare practices related to maternal–child nursing.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 3 Health Promotion Community-Based Nursing Care……………………………………………………………………..

The Nurse’s Role in Addressing Issues of Women’s Wellness and Sexuality …..

Menstruation.......................................................................................................

Health Promotion Education................................................................................

Menopause...........................................................................................................

Focus Your Study..................................................................................................

Activities................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Community-Based Nursing Care

A. Women’s Health 1. Holistic view of women and health-related needs 2. Within context of everyday lives 3. Health teaching and information a) In schools b) During routine examinations c) At senior centers d) At meetings of volunteer organizations e) Through classes offered by local health department, community college f) In the home 4. Vast majority of women’s healthcare provided outside of acute care settings

II.

The Nurse’s Role in Addressing Issues of Women’s Wellness and Sexuality

A. Expectation for Nurse to Be Knowledgeable About Gynecologic Health and Wide Variety of Health Topics 1. Most women experience concern, anxiety about some aspect a) Menstruation, contraception, or sexual activity b) Adolescents and young adults c) Older women 2. Nurse must be secure in own sexuality a) Structures, functions of reproductive systems b) Accurate, up-to-date information

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Taking a Sexual History 1. Open sexual history discussion with brief explanation of purpose of questions 2. Use direct eye contact, if culturally acceptable 3. Little writing during this part of interview 4. Open-ended questions 5. Be alert to body language, nonverbal cues 6. Do not assume woman is heterosexual 7. Assess information a) Concerns → refer to nurse practitioner, certified nurse-midwife, physician, counselor as necessary b) Develop nursing diagnosis → plan and implement appropriate intervention

III.

Menstruation

A. Education of Girls About Puberty, Menstruation at Young Age 1. Some education from peers, media → incomplete, inaccurate, sensationalized 2. Cultural, religious, personal attitudes part of menstrual experience

B. Counseling the Premenstrual Girl About Menarche 1. Average age is about 12.43 years for girls in United States a) Range between 9 and 15 years of age b) Genetics most important factor in determining age at which menarche starts c) Series of physical changes prior to menarche 2. Cycle length a) Determined from first day of one menses to first day of next b) May be irregular c) Usually about 28 to 30 days, normal varies from 21 to 35 days 3. Amount of flow a) Approximately 25 to 60 mL per period b) Often heavier at first, lighter at end 4. Length of menses a) Usually lasts from 4 to 6 days, may last up to 7 days

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Nurse should stress variations in age at menarche, length of cycle, and duration of menses are normal, acknowledge negative aspects and stress positive role as symbol of maturity 6. Cultural factors may play important role in menstruation

C. Educational Topics 1. Pads and tampons a) Variety of disposable products available b) Deodorants and increased absorbency from chemicals → irritation to mucosal lining c) Eco-friendly menstrual products → reusable pads, cups, sponges d) Determine amount of bleeding → frequency and type of pad or tampon use and change e) Use tampons with minimum absorbency needed to control menstrual flow to avoid complications such as toxic shock syndrome (TSS) f) Change every 3 to 6 hours g) Hand hygiene before and after insertion and removal h) Avoid using tampons in the absence of a heavy menstrual flow i) May want to use tampons during day and pads at night j) Individual need and comfort 2. Vaginal sprays and douching a) Sprays can cause itching, burning, rashes, other problems; external use only b) Douching as hygiene practice unnecessary (1) Upsets normal vaginal flora (2) Essential to avoid douching during menstruation (3) Contraindicated during pregnancy 3. Cleansing the perineum a) Secretions that continually bathe vagina odor-free in vagina b) Combined with perspiration and air → develop odor c) Keep skin clean and free of bacteria with soap and water d) Cotton panties and clothes loose enough to allow air to circulate e) Wipe from front to back f) If odor persists, see healthcare provider

D. Associated Menstrual Conditions 1. Abnormal uterine bleeding (AUB) 2. Heavy menstrual bleeding (HMB) 3. Intermenstrual bleeding (IMB) 4. Polymenorrhea 5. Oligomenorrhea 6. Amenorrhea a) Absence of menses 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Classified as primary or secondary c) Causes (1) Hypothalamic dysfunction (2) Pituitary dysfunction (3) Chronic anovulation or ovarian failure (4) Anatomic abnormalities d) Diagnosis (1) Thorough history and physical examination (2) Pregnancy test (3) Pelvic exam (4) Specific tests e) Treatment dictated by causative factors 7. Dysmenorrhea a) Painful menstruation b) At or day before onset of menstruation, disappears by end of menses c) Primary defined as cramps without underlying disease (1) Prostaglandins primary cause (2) Treatment: oral contraceptives, NSAIDs, self-care measures d) Secondary: associated with pathology of reproductive tract (1) Endometriosis, pelvic inflammatory disease (PID), cervical stenosis, uterine fibroids, ovarian cysts, benign or malignant tumors, presence of intrauterine device (IUD) (2) Testing: transvaginal ultrasound, hysterosalpingography, and hysteroscopy (3) Treatment: (a) Continuous OC therapy—does not allow ovulation or menstruation (b) Hysterectomy if anatomic disorders, childbearing not desired (c) Presacral neurectomy may control severe dysmenorrhea (4) Self-care measures (a) Some nutritionists suggest vitamins B6 and E, avoiding salt (b) Heat—soothing, promotes increased blood flow (c) Daily exercise, especially aerobic 8. Premenstrual syndrome (PMS) a) Symptom complex characterized by behavioral and physical changes b) Several days to 2 weeks before onset of menstrual flow c) Diagnosis when woman experiences one to three troublesome symptoms 9. Premenstrual dysphoric disorder (PMDD) a) More serious form of PMS b) Depressive disorder c) Relieved by menstruation, occurs in most cycles d) Symptoms (1) Psychologic (2) Neurologic (3) Respiratory 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Gastrointestinal (5) Urinary (6) Dermatologic (7) Mammary (8) Musculoskeletal e) Cause unknown f) Evidence suggests progesterone, estradiol levels involved g) May include abnormal sensitivity to hormonal changes h) Risk factors i) Diagnosis generally made after woman keeps menstrual calendar for 3 months j) Daily symptoms rated on scale of 0 to 4 k) Treatment: selective serotonin reuptake inhibitor (SSRI) may benefit woman with PMDD

E. Nursing Management for the Woman with PMS 1. Help woman identify specific symptoms, develop healthy behaviors 2. Restrict intake of foods containing methylxanthines (chocolate, cola, coffee) 3. Restrict intake of alcohol, nicotine, red meat, animal fats, sugar, salt 4. Increase intake of complex carbohydrates, protein, vegetable oils 5. Supplementation a) 50 to100 mg daily of vitamin B6 b) 1,200 mg per day of calcium → may reduce physical, psychologic symptoms c) 400 mg magnesium → may decrease fluid retention, bloating d) Vitamin E 400 IU daily → may reduce cramping, breast tenderness

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Herbal remedies 7. Aerobic exercises 8. Empathetic relationship 9. Journal to identify events associated with PMS 10. Stress reduction education, self-care groups, self-help literature

IV.

Health Promotion Education A. Value of health maintenance and disease prevention B. Lifestyle choices that promote health and well-being 1. Eating nutritious, balanced diet 2. Maintaining normal weight for height 3. Performing regular aerobic exercise and weight training several times per week 4. Getting adequate sleep 5. Avoiding smoking and/or stopping smoking 6. Consuming alcohol in moderation 7. Managing stress effectively 8. Developing enjoyable hobbies and leisure activities 9. Developing an inner life in some form (religion, spirituality, personal reflection, yoga) 10. Fostering bonds of support and affection with family and friends 11. Obtaining regular health screenings and assessments 12. Ensuring that immunizations are up to date 13. Health screening recommendations vary by age, as do recommendations for vaccines 14. See Table 3-2: Recommended Screening Tests for Low-Risk Women, p. 41–42

C. Body piercings and tattoos 1. Tattooing → application of minute amounts of pigments into skin with indelible inks 2. Body piercing sites → multiple 3. Health risks a) Infection such as hepatitis B, C, and HIV b) Allergic reactions c) Local swelling, burns, granuloma, keloid formation 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Oral piercing associated with tooth and gum damage 4. Pregnant or breastfeeding → nipple piercing associated with mastitis, damaged milk ducts, difficulty with breastfeeding, galactorrhea

D. Education about risks 1. Information about infection, permanent scarring, keloid formation, care afterward 2. Avoid passing judgment, making generalizations

Menopause A. Definition: absence of menstruation for 1 full year 1. Time of transition 2. End of reproductive abilities 3. Occurs between 45 and 58 years of age 4. Not all physiologic mechanisms initiating menopause precisely understood 5. Onset occurs when estrogen levels drop because of cessation of ovarian function 6. Onset influenced by: woman’s overall health, weight, nutrition, lifestyle, culture, genetic factors 7. Climacteric, or change of life: host of psychologic and physical alterations that occur around the time of menopause

B. Perimenopause 1. Time before menopause during which woman moves from normal ovulatory cycles to cessation of menses 2. Can last 5 to 8 years 3. Symptoms vary significantly a) 80% of women report some degree of vasomotor symptoms (hot flashes) b) Mood and cognitive changes common c) Changes in sexuality 4. Contraception remains a concern a) Fertility decreases, risk of spontaneous abortion increases b) Female sterilization most commonly used method among women older than 35 c) Hormonal contraceptives continue to be popular; noncontraceptive benefits d) Other contraceptive options

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Exercise, calcium, vitamin D may help

C. Psychologic Aspects of Menopause 1. Psychologic adaptation to menopause multifactorial a) Dealing with other life circumstances b) Personal factors c) Stressors 2. Help women to understand the basic physiology of menopause and provide education, supportive resources, and encouragement 3. Help women understand changes, deal with feelings 4. Alert for signs that distinguish hormonal mood swings and depression

D. Physical Aspects of Menopause 1. Changes in the reproductive system a) Shift from cyclic to noncyclic hormonal pattern b) Ovulation generally ceases 1 to 2 years before menopause c) Estrogen levels decline → physiologic changes (1) Uterine lining thins (2) Myometrium, fallopian tubes, ovaries atrophy (3) Vaginal mucosa loses elasticity, thins (4) Loss of cervical gland function (5) Change in vaginal ecology → atrophic vaginitis (6) Pubic hair thins, grays, may disappear (7) Labia shrink, lose pigmentation (8) Loss of pelvic tone and support; Kegel exercise, regular sexual activity (9) Breasts lose density d) Sexual functioning declines 2. Vasomotor changes a) Hot flash → typically described as feeling of heat rising from chest, spreading to neck, face b) Night sweats c) May occur 20 to 30 times a day 3. Changes in the musculoskeletal system and skin a) Osteoporosis → decrease in bone strength related to diminished bone density and bone quality b) See Table 3–3: Risk Factors for Osteoporosis, p. 45 (1) Personal history of fracture after age 50 (2) Current low bone mass (3) History of fracture in a first-degree relative (4) Being female

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Being thin (weight less than 127 lb and/or having a small frame) (6) Advanced age (7) Family history of osteoporosis, especially a maternal hip fracture (8) Use of certain medications (e.g., corticosteroids, chemotherapy, barbiturates, anticonvulsants) (9) Abnormal absence of menses; early onset of menopause (10) Anorexia nervosa (11) Low lifetime intake of calcium (12) Vitamin D deficiency (13) Current cigarette smoking, excessive alcohol use (14) Inactive lifestyle (15) Being Caucasian or Asian c) Collagen and elastin weaken → skin appears looser, thinner, wrinkles (1) Nurses can remind women to wear sunscreen d) Evidence suggests estrogen regulates weight, fat metabolism (1) Change in fat distribution (2) Total body fat increases (3) Calculate waist to hip ratio → less than 0.80 4. Changes in the cardiovascular system a) Shift in lipid and lipoprotein levels b) Normal estrogen level → higher levels of high-density lipoprotein (HDL) cholesterol c) Lower levels of low-density lipoprotein (LDL) cholesterol d) Cardiovascular disease (CVD) number one killer of women in United States e) Coronary heart disease (CHD) major cause of heart attacks in women f) See Table 3–4: Risk Factors for Coronary Heart Disease in Women, p. 45 (1) Family history of heart disease (2) Advancing age—over 55 or postmenopausal (3) Overweight and obesity (4) Cigarette smoking and/or tobacco use (5) Sedentary lifestyle (6) Hypertension (7) Diabetes (8) Elevated cholesterol (9) Race (highest incidence in African American women) g) Metabolic syndrome predisposing factor for CHD, individual has three or more of the findings: (1) Waist > 35 inches (2) Triglycerides > 150 mg/dL (3) HDL < 50 mg/dL (4) BP > 130/85 mmHg (5) Fasting glucose levels > 100 mg/dL 5. Changes in cognitive function a) Memory, cognitive function change with advancing age 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Declining estrogen might contribute to loss of function c) Change influenced by lifestyle, genetics, socioeconomic status d) Cause of Alzheimer disease (AD) unknown; risk factors include: (1) Specific genotypes (2) Family history (3) Obesity (4) Diabetes (5) Elevated cholesterol (6) Hypertension (7) Inflammation e) No therapies that slow the progression of the disease f) Cholinesterase inhibitors and N-methyl-D-aspartate antagonists only medications approved by FDA for treating cognitive dysfunction g) Lifestyle changes (1) Exercise at least 30 minutes 5 days per week. (2) Quit smoking. (3) Maintain a healthy blood pressure. (4) Maintain a normal weight. (5) Eat a healthy diet; research shows Mediterranean or DASH is best. (6) Stay mentally active with writing, playing games, reading, or learning something new. (7) Get enough sleep. (8) Stay socially engaged. (9) Prevent diabetes. (10) Deal with depression, anxiety, and other mental health concerns.

E. Premature Menopause 1. Premature ovarian insufficiency (POI) 2. Occurs in about 0.1% of women by the age of 30 and 1% of women by the age of 40 3. 4 to 6 months of no menses in women under the age of 40 years who have elevated FSH and low estradiol levels 4. Retain intermittent ovarian function; although difficult, pregnancy may occur 5. Long-term health a consideration; strengthen muscle and maintain bone mass

F. Medical Therapy 1. Menopausal hormone therapy a) Menopausal hormone therapy (MHT) → administration of specific hormones to alleviate symptoms b) Estrogen therapy (ET): only given to women who have undergone a hysterectomy c) Estrogen-progestogen therapy (EPT): used for women with intact uterus

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) ET never given alone to woman with uterus because it increases risk of endometrial cancer e) Prescribed orally; transdermally (patch); topically as a gel, lotion, mist, or cream; and through a vaginal ring (1) Daily or cyclic (2) Women with decreased libido experience improvement with testosterone added to HT f) MHT remains the most effective therapy for moderate to severe menopausal vasomotor symptoms g) Decision to use MHT is individual one based on quality of life, health priorities, and personal risk factors h) Local low-dose vaginal estrogen recommended to treat vaginal dryness or dyspareunia i) MHT effective for the prevention of fractures related to osteoporosis in women who are at risk before age 60 or within 10 years of menopause j) Risk of venous thromboembolism and stroke does increase with MHT, but absolute risk is rare in women younger than age 60 k) The risk of breast cancer is complex; MHT should not be used in breast cancer survivors l) Estrogen-alone MHT may decrease coronary heart disease in women younger than age 60 and within 10 years of menopause 2. Bioidentical hormones → structurally identical to those produced by ovaries a) Not proven safer b) Not approved by FDA c) Use is not recommended 3. Prevention and treatment of osteoporosis a) More than 54 million adults have osteoporosis and low bone mass b) Bone mineral density (BMD) testing useful in identifying those at risk c) BMD testing of all women ages 65 and older and all men ages 70 and older d) Diagnosis and treatment of osteoporosis based on comprehensive approach e) BMD testing indicated for premenopausal or postmenopausal women with risk factors, certain medical conditions, certain medications (1) Eating disorders (2) Thyroid disorders (3) Leukemia (4) Rheumatoid arthritis (5) Multiple sclerosis (6) On medications such as corticosteroids, anticonvulsants f) Measure height at each visit g) Prevention of osteoporosis primary goal (1) Adequate intake of calcium and vitamin D (2) Regular weight-bearing, muscle-strengthening exercises (3) Smoking cessation (4) Moderate intake of alcohol (5) Fall-prevention strategies 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(6) 1,200 mg of calcium, increasing to 1,500 mg if patient is not on hormone therapy (7) Vitamin D supplement of 1,000 to 2,000 international units per day h) For women who are unable or unwilling to take estrogen, other medications are available (1) Bisphosphonates are calcium regulators (2) Selective estrogen receptor modulators (SERMs) preserve the beneficial effects of estrogen (3) Salmon calcitonin is a calcium regulator (4) Parathyroid hormone activates bone formation (5) Receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor decreases bone resorption and increases bone mass and strength 4. Prevention of coronary heart disease a) Cardiovascular disease (CVD) leading cause of death in women in United States b) Prevention begins with lifestyle choices, modifications c) Women need to be familiar with signs of myocardial infarction (1) Pain in neck, back, epigastric region (2) Loss of appetite (3) Shortness of breath (4) Nausea or vomiting (5) Weakness in shoulder, arms, chest (6) Women more likely than men to delay seeking treatment and more likely to die from attack 5. Complementary and alternative therapies a) Black cohosh → mixed results, liver safety issues b) Red clover → no effect on hot flashes e) Ginseng → may help moodiness, sleep disturbances c) DHEA: dietary supplement that may help with hot flashes, further research needed d) Phytoestrogens → plant products, inconsistent results e) Weight-bearing exercises → increase bone mass, potentiating effect of estrogen (1) Improves cholesterol profiles, overall health f) Pelvic floor exercises (Kegel) g) Vaginal lubricants, adequate foreplay → maintain satisfactory sexual experience h) Stress management and relaxation techniques

G. Nursing Management for the Woman Experiencing Menopause 1. Some women may need counseling 2. Help menopausal woman achieve high-level functioning a) Provide support for woman’s views and feelings (1) Discuss areas of deep concern, including history of abuse, current distress, life problems (2) Referrals as necessary (3) Explore question of woman’s comfort during sexual intercourse 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Explain ways to address dryness, shrinking of vagina 3. Adequate information about changes taking place in their bodies and their lives and support in adjusting to the changes that occur

VI.

Focus Your Study

VII.

Activities 1. Individual Assign students to identify three lifestyle choices they consider healthy in their lives. Have students research the effects of their choices on long-term women’s health. 2. Small Group Divide the class into small groups of three to five students. Assign each group a topic to research in complementary health approaches and women’s health. The rubric should include identifying the effects of supplements on women’s health. Instruct the groups to substantiate their reports with APA-formatted citations and to be prepared to share their reports with the entire class. 3. Large Group Using 35-, 50-, and 60-year-old women as examples, discuss and role-play taking a reproductive history.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 4 Family Planning Overview of Family Planning............................................................................

Fertility Awareness–Based Methods...............................................................

Spermicide........................................................................................................

Barrier Methods of Contraception...................................................................

Long-Acting Reversible Contraception.............…………………………………………….

Hormonal Contraception..................................................................................

Postcoital Emergency Contraception...............................................................

Operative Sterilization......................................................................................

Male Contraception..........................................................................................

Clinical Interruption of Pregnancy....................................................................

Preconception Counseling……………………………………………………………………………

Focus Your Study...............................................................................................

Activities............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Overview of Family Planning

A. Demographics 1. In 2014 → more than 20 million women in United States of reproductive age were at risk for unintended pregnancies due to unmet contraceptive needs 2. 45% of all U.S. pregnancies unintended a) In 2011, 42% of 6.1 million pregnancies ended in abortion 3. Millions of women in United States in need of contraceptive services a) Affordable Care Act requires insurance companies to cover contraception as a preventive health measure b) Some organizations have a religious exemption from this requirement c) Millions of women remain in need of publicly funded contraceptive care (Medicaid) 4. Of reproductive-age women living in developing countries, 225 million have unmet modern contraceptive needs a) Maternal morbidity and mortality remain major health challenges b) 99% of preventable maternal deaths occur in the poorest countries with unmet contraceptive needs c) Of these preventable deaths, more than half are from sub-Saharan Africa d) Lack of contraceptive services in developing countries

B. Contraception 1. Women who are able to use contraception and plan the desired number of pregnancies benefit in several ways a) Healthier with lower incidence of sexually transmitted infections, including HIV b) Lower rates of induced, often unsafe, abortions c) Fewer unwanted pregnancies and births d) Better educated Children healthier and better educated

C. Choosing a Method of Contraception 1. Decision made individually or jointly 2. Leading methods in United States a) Combined oral contraceptive (COC) pill for women younger than 35 years b) Sterilization in women older than 35 years c) Use of male condom to prevent STIs 3. Decisions should be made voluntarily with full knowledge a) Outside factors influence choice b) Consistency of use outweighs absolute reliability

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. See Table 4–1: Factors to Consider in Choosing a Method of Contraception, p. 53 a) Effectiveness of method b) Safety of method c) Woman’s age and future childbearing plans d) Contraindications in health history e) Religious, cultural, or moral factors f) Personal preferences, biases g) Lifestyle of patient h) Cost i) Partner’s support, willingness to cooperate j) Personal motivation to use method k) Woman’s weight in pounds or percent over ideal body weight

II.

Fertility Awareness–Based Methods

A. FAB Methods 1. Require a woman to monitor her fertile window and use a barrier method during that time 2. Most fertile 5 days before ovulation until 1 day post-ovulation 3. Natural family planning (NFP) → abstain completely during fertile days a) Free, safe, acceptable to many whose religious beliefs prohibit other methods 4. All FAB methods, including NFP, require extensive initial counseling a) Best for women with regular menstrual cycles b) Interfere with spontaneity c) Not ideal for those with irregular cycles, breastfeeding, perimenopause

B. Standard Days Method 1. Good for women with regular menstrual cycles between 26 and 32 days a) Intercourse avoided, or a barrier method used, during cycle days 8 through 19 b) CycleBeads® or its software program is useful when using this method

C. Calendar Rhythm Method 1. Assumption ovulation tends to occur 14 days (plus or minus 2 days) before start of next menstrual period a) Woman records her menstrual cycle for 6 months to identify shortest and longest cycles b) First day of menstruation is first day of cycle c) Fertile phase calculated from 18 days before end of shortest recorded cycle through 11 days from end of longest recorded cycle d) For effective use, she must abstain from intercourse during fertile phase or use barrier method during that time

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Billings Ovulation Method 1. Assessment of cervical changes that occur during menstrual cycle 2. During follicular phase of cycle → mucus is nonmalodorous, thick, white, sticky 3. At ovulation → mucus more clear, water, stretchable (spinnbarkeit) a) Friendly to sperm b) Characteristic fern pattern 4. Luteal phase → cervical mucus thick, white, and sticky a) Forms network that traps sperm b) Makes passage upward into female reproductive tract difficult 5. Woman abstains from intercourse for one entire menstrual cycle a) Assess cervical mucus daily b) Assumes that peak day of wetness and clear stretchable mucus is day of ovulation c) Abstain from first noticing mucus becoming clearer, more elastic, slippery until 4 days after peak wet mucus

E. Two-Day Method 1. Woman’s ability to distinguish difference between progesterone-mediated and estrogenmediated cervical mucus 2. If she notices cervical secretions of any type either yesterday or today, she is fertile today 3. If no secretions were noted today or yesterday, she is not fertile today

F. Symptothermal Method 1. Recording various indicators of fertility by the couple for a number of months a) Cycle length b) Frequency and timing of coitus c) Cervical mucus changes d) Secondary signs of ovulation e) Changes in basal body temperature (BBT)

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Training courses available

G. Basal Body Temperature Method 1. Incorporated into symptothermal method 2. Provides objective record of fertile days 3. Used to detect ovulation by an increase in the basal temperature during the menstrual cycle 4. Requires the woman to take her temperature every morning upon awakening 5. After 3 to 4 months of recording temperatures, if she has regular cycles, she should be able to predict when ovulation will occur 6. To avoid conception, the woman and her partner abstain from intercourse or use a barrier method on the day of the temperature rise and for 3 days following

H. Other Options 1. Lactational amenorrhea method (LAM) a) Breastfeeding woman for first 6 months after childbirth b) High levels of prolactin should prevent ovulation c) Most reliable when used with a barrier method 2. Abstinence a) Primary → woman who has never had sexual intercourse b) Secondary → woman chooses to abstain for a period of time 3. Coitus interruptus a) Requires that male withdraw from female’s vagina when he feels ejaculation is impending b) Demands great self-control on part of man c) Man may not be aware he has released pre-ejaculatory fluid 4. Douching a) Ineffective, not recommended b) May facilitate conception

III.

Spermicide

A. Nonoxynol-9 (N-9) Approved for Use in United States 1. Cream, gel, foam, vaginal film, suppository, cervical sponge 2. N-9 minimally effective alone → increases in conjunction with barrier method of contraception a) Diaphragm b) Cervical cap c) Male and female condoms 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Does not offer protection against STIs

IV.

Barrier Methods of Contraception A. Prevent Transport of Sperm Up Reproductive Tract of Woman to Ovum 1. Male and female condom, diaphragm, cervical cap, cervical sponge 2. Made of latex, silicone, or polyurethane 3. Often used in conjunction with N-9 to increase contraceptive effectiveness 4. Proactively decide which type to use and then take action 5. Few side effects 6. Good choice for women who: a) Have contraindication to using specific method such as oral contraceptives, combined oral contraceptives (COCs), intrauterine contraception (IUCs) b) Are opposed to taking systemic medications c) Are in early postpartum period or lactating d) Need backup method of contraception e) Have intercourse rarely or sporadically f) Are perimenopausal but smokes 7. Before insertion, wash hands with soap and water 8. Avoid oil-based products, vaginal medications → negative effect on latex 9. Can be worn for up to 24 or 48 hours 10. Cleaned with soap and water after use 11. Not shared with other women 12. After intercourse, should remain in place for 6 to 8 hours 13. Female barrier methods more effective when used with male condom 14. Be alert for signs of toxic shock syndrome (TSS)

B. Male Condom 1. Viable means of contraception when used consistently and properly 2. Provide protection from STIs 3. Condom applied to erect penis → rolled from tip to end of shaft a) Before vulvar or vaginal contact b) Most have reservoir at end for ejaculate

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Water-soluble lubricants only 5. Remove penis from vagina while still erect, holding condom rim to prevent spillage 6. Effectiveness determined by use a) Small, lightweight, disposable, inexpensive b) No side effects c) Polyurethane, silicone, lambskin condoms for men allergic to latex d) Require no medical examination or supervision e) Visual evidence of effectiveness f) Decrease transmission of STIs 7. Slippage, risk of breakage, perineal or vaginal irritation, dulled sensation disadvantages

C. Female Condom 1. Thin polyurethane sheath with flexible ring at each end a) Closed end with inner ring fits over cervix like diaphragm b) Second ring remains outside vagina, covers portion of perineum c) Covers base of penis during intercourse 2. OTC, one-time use a) High cost, noisy, cumbersome feel

D. Diaphragm 1. Barrier method that consists of steel band that forms ring a) Covered with latex or silicone b) Ring lodges high in vagina covering cervix c) Used with spermicidal cream or gel 2. Three types available a) Wide-Seal Omniflex b) Arcing-Style c) Caya → only type that does not require a fitting 3. Woman must be fitted by healthcare provider and rechecked for size with weight gain/loss 4. Inserted before intercourse, approximately 1 teaspoonful of spermicidal gel placed around ring and in cup a) Inserted through vagina and covers cervix b) Last step in insertion is to push edge of diaphragm under pubic symphysis → may result in popping sensation c) Correct placement of diaphragm can be checked by touching cervix with fingertip through cup

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. More than 6 hours elapse between insertion and intercourse → additional spermicidal gel inserted into vagina 6. Periodically diaphragm should be held up to light or filled with water a) Inspect for holes, tears b) Can last for years c) Wash and dry after each use → store in clean dry container 7. Some couples feel diaphragm interferes with spontaneity a) Potentially reduces incidence of cervical gonorrhea, chlamydia b) Protects against human papilloma virus (HPV) 8. Woman has to touch genitals to insert and check a) Very obese, short fingers → difficulty b) Not recommended for history of urinary tract infection (UTI)

E. The Cervical Cap 1. Used with a spermicide inside the cap 2. Placement requires it be inserted prior to coitus and left in for 6 to 8 hours afterward 3. Should not remain in the vagina longer than 48 hours due to risk of TSS 4. FemCap cervical cap: reusable, looks like a small sailor’s cap, made of soft silicone

F. Contraceptive Sponge 1. Available without a prescription 2. Pillow-shaped, soft, absorbent synthetic sponge containing spermicide 3. Designed to fit over cervix 4. Releases spermicide N-9 (gradually over 24-hour period) 5. Moisten before use to activate spermicide → insert into vagina 6. Worn up to 24 hours 7. Advantages a) Professional fitting not required b) May be used for multiple acts of coitus for up to 24 hours c) One size fits all 8. Problems a) Difficulty removing b) Irritation, allergic reactions c) Vaginal dryness due to absorption of vaginal secretions d) Higher failure rate than diaphragm for women who have borne children

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Long-Acting Reversible Contraception A. Intrauterine Contraception 1. Designed to be inserted by qualified healthcare provider, left in place 2. Provides continuous contraceptive protection for 3 to 10 years 3. Copper IUC (ParaGard T 380A) a) Small, T-shaped device that has copper covering parts of its stem and arms b) Not an option for women allergic to copper c) Choice for women who have medical conditions that preclude use of other contraceptives, hormonal or barrier d) Effective contraception for 10 years 4. Mirena levonorgestrel intrauterine system (LNg-IUC) a) 5 years of protection b) Progestin-only 5. The Skyla LNg-IUC a) Total of 13.5 mg of levonorgestrel b) 3-year indication c) Progestin-only 6. Copper IUC local inflammatory or atrophic effects on endometrium 7. All IUC produces a spermicidal intrauterine environment 8. Advantages a) High rate of effectiveness b) Continuous contraceptive protection c) Non-coitus-related contraception d) Relative inexpensiveness over time e) Excellent contraceptive option for women with diabetes f) Used in women with history of breast cancer, cesarean birth, or uterine or cervical surgery 9. Adverse reactions a) Discomfort b) Increased bleeding during menses c) Increased risk of pelvic infections for approximately 3 weeks following insertion d) Perforation of uterus during insertion e) Unscheduled bleeding f) Dysmenorrhea g) Expulsion of device 10. Contraindications a) Current pregnancy 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Caution woman to use condom in addition if multiple sex partners → STI 11. Insertion a) Into uterus with strings protruding through cervix into vagina b) Any time during cycle c) Instructed to check strings weekly for 1 month → after each menses 12. Contact healthcare provider a) If exposed to STI b) Late period, abnormal spotting or bleeding c) Dyspareunia d) Abdominal pain e) Abnormal discharge f) Signs of infection g) Missing strings, lengthening of strings

B. Nexplanon 1. Replaced Implanon 2. Radiopaque, single-capsule implant inserted subdermally in woman’s upper underarm 3. 68 mg of etonogestrel, a progestin; releases up to 45 mcg the first year, 40 mcg the second year, and 20 mcg the third year 4. Good contraceptive method for 3 years 5. Prevents ovulation 6. Effective continuous contraception removed from the act of coitus 7. Side effects: spotting, irregular bleeding or amenorrhea, increased incidence of ovarian cysts, weight gain, headaches, fluid retention, acne, hair loss, mood changes, depression

VI.

Hormonal Contraception

A. Combination Estrogen–Progestin Approaches 1. Inhibit release of an ovum, creating atrophic endometrium 2. Maintaining thick cervical mucus 3. Limit participants to those weighing less than or equal to 198 pounds 4. Combined oral contraceptives a) Commonly called birth control pills or “the pill” b) Highly successful, safe, readily reversible c) Taken daily for 21, 28, or 84 days d) Day 1 start → begins taking pill on first day of menstrual cycle; no backup contraception required 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Sunday start → begins taking pill on Sunday after first day of menstrual cycle and ends packet on a Saturday; backup contraception necessary during first 7 days of use f) Quick start → begins taking pill in practitioner’s office; backup method necessary for 7 days g) 21- or 28-day COC pack—always begin new pack on the same day h) Pill taken at approximately same time each day i) Extended use COCs: four withdrawal bleeds per year or no withdrawal bleeding at all j) Estrogen → either ethinyl estradiol (EE) or mestranol (1) Originally high levels of estrogen → risks (2) Lowered estrogen component → decreased risk k) Progestins → 10 formulations (1) Inhibit ovulation l) Low-dose pills (1) Safe, safer if smokers did not take them (2) Weaker cycle control → breakthrough bleeding (3) Side effects → estrogen or progestin related m) See Table 4–2: Side Effects Associated with Combined Oral Contraceptives, p. 64 (1) Estrogen effects (a) Alterations in lipid metabolism (b) Breast tenderness, engorgement, increased breast size (c) Cerebrovascular accident (d) Changes in carbohydrate metabolism (e) Chloasma (f) Fluid retention; cyclic weight gain (g) Headache (h) Hepatic adenoma (i) Hypertension (j) Leukorrhea, cervical erosion, ectropion (k) Nausea (l) Nervousness, irritability (m) Thromboembolic complications (2) Progestin effects (a) Acne, oily skin (b) Breast tenderness; increased breast size (c) Decreased libido (d) Decreased high-density lipoprotein (HDL) cholesterol levels (e) Depression (f) Fatigue (g) Hirsutism (h) Increased appetite; weight gain (i) Increased low-density lipoprotein (LDL) cholesterol levels (j) Oligomenorrhea, amenorrhea (k) Pruritus (l) Sebaceous cysts 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

n) Absolute contraindications (1) Pregnancy (2) History of thrombophlebitis, thromboembolic disease (3) Acute or chronic liver disease of cholestatic type with abnormal liver function tests (4) Presence of estrogen-dependent carcinomas (5) Undiagnosed uterine bleeding (6) Heavy smoking (7) Gallbladder disease (8) Hypertension (9) Diabetes (10) Migraine with visual disturbances (11) Hypercoagulable disorders (12) Hyperlipidemia o) Relative contraindications (1) Migraine headaches without visual disturbances (2) Epilepsy (3) Depression (4) Oligomenorrhea (5) Amenorrhea p) Noncontraceptive benefits (1) Relief of menstrual symptoms and premenstrual syndrome (2) Cramps diminish (3) Flow decreases (4) Cycle more regular (5) Mittelschmerz is eliminated (6) Reduction in incidence of ovarian, endometrial, and colorectal cancer; menstrual migraines; iron deficiency anemia (7) Improvement in bone mineral density (8) Treatment of acne, hirsutism (9) Treatment of pelvic pain due to endometriosis (10) Treatment of bleeding due to leiomyomas (11) Assists with some physiologic changes experienced by women during perimenopause q) Patient contacts healthcare provider (1) Becomes depressed (2) Develops breast lump (3) Becomes jaundiced (4) Abdominal or leg pain, severe (5) Chest pain, severe, or shortness of breath (6) Headaches, severe, or dizziness (7) Eye vision loss or blurring (8) Speech problems

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Transdermal hormonal contraception a) Weekly contraceptive skin patch → Xulane b) Applied weekly for 3 weeks to one of four sites c) During week 4 → no patch → menses typically occurs d) Highly effective in women who weigh less than 198 lbs. e) Patch as safe and effective as COCs f) Risk of venous thromboembolism (VTE) 6. Vaginal contraceptive ring a) NuvaRing → flexible, soft vaginal ring inserted for 3 weeks and removed for 7 days b) Fits virtually all women

B. Progestin Contraceptives 1. Progestin-only pills a) Also called minipill b) Primarily by nursing mothers → does not interfere with breast milk production c) Women who have contraindication to estrogen component d) Major problems: amenorrhea or irregular bleeding patterns e) Slightly less effective than a COC 2. Long-acting progestin contraceptives a) Depo-Provera and Nexplanon b) Lactating women c) Women who cannot use estrogen or copper IUC d) Women who forget to take COCs daily e) Those not bothered by unscheduled bleeding f) Depo-Provera (1) Long acting, injectable, progestin only (2) Intramuscular (im) or subcutaneous (sc) (3) Effective birth control for 3 months (4) Subsequent injections scheduled every 10 to 13 weeks (5) SC can be self-administered (6) Suppresses ovulation (7) Safe, convenient, private, and relatively inexpensive (8) Blocks luteinizing hormone (LH) → suppress ovulation g) Side effects (1) Unscheduled bleeding (2) Headache (3) Weight gain (4) Breast tenderness (5) Hair loss (6) Depression (7) Return of fertility delayed average of 10 months (8) Associated with bone demineralization → is reversible 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VII.

Postcoital Emergency Contraception 1. Once known as the morning after-pill 2. Indicated when woman is worried about pregnancy because of unprotected intercourse, sexual assault, or possible contraceptive failure 3. Taken 72 hours, but up to 5 days, can reduce risk of pregnancy after single act of unprotected intercourse by at least 74% 4. High doses of levonorgestrel and ethinyl estradiol (Yuzpe regimen) 5. High doses of levonorgestrel (Plan B®, Plan B One-Step®) 6. Ulipristal acetate, a progesterone agonist-antagonist 7. Placement of Copper IUC within 5 days → effective emergency contraceptive 8. Healthcare providers counsel women about availability of EC during routine screenings and appointments

VIII.

Operative Sterilization

A. Surgical Procedure to Permanently Prevent Pregnancy 1. Tubal ligation, vasectomy 2. Theoretically reversible; permanency of procedure should be stressed and understood

B. Vasectomy 1. Severing vas deferens in both sides of scrotum 2. 3 months and 15 to 20 ejaculations to clear remaining sperm 3. Sperm count checked 4. Side effects a) Pain b) Infection c) Hematoma d) Sperm granulomas e) Spontaneous reanastomosis 5. Microsurgery can sometimes reverse

C. Tubal Ligation 1. Female sterilization a) Laparotomy following C-section, other abdominal surgery b) Minilaparotomy in postpartum period c) Laparoscopy done postabortion, interval period 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Done at any time the woman is not pregnant; postpartum period ideal time e) Tubes ligated, clipped, electrocoagulated, banded, or plugged 2. Complications a) Regret b) Coagulation burns on bowel c) Bowel perforation d) Pain e) Infection f) Hemorrhage g) Adverse anesthesia effects

IX.

Male Contraception A. Vasectomy, Condom 1. Only forms available in United States 2. Hormonal contraception under study a) Side effects of too much testosterone b) How to stop pituitary LH and FSH to block testicular cell function c) How to interfere with sperm production d) How to disrupt transport of mature sperm

B. Nursing Management for the Woman Choosing a Contraceptive Method 1. Provide information and guidance about contraceptive methods 2. Men encouraged to participate in contraceptive counseling 3. Complete history and assessment for medical contraindications to specific methods 4. Learn about woman’s lifestyle 5. Attitudes about birth control may be influenced by cultural factors a) Gender inequities b) Acquiescence to nurses decision for woman c) Attitudes toward bleeding d) Roman Catholic Church’s views e) Value of large family, lack of stigma for unplanned, or adolescent pregnancy 6. Once woman chooses a method, help her learn to use it effectively 7. See Teaching Highlights: Using a Method of Contraception, p. 68 a) Discuss factors to consider → supportive atmosphere b) Review reasons for selecting → provide accurate information c) Discuss advantages, disadvantages, risks → focus on open discussion d) Describe correct procedure → break down into small steps e) Provide information regarding unusual circumstances → written handout 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Stress warning signs → arrange to talk with woman again soon g) Evaluation

Clinical Interruption of Pregnancy A. Abortion → Legalized in United States 1973 1. Much controversy → moral, legal considerations 2. Physical and psychosocial factors 3. Decision made by woman or couple involved 4. 1 in 5 pregnancies ends in abortion worldwide

B. Medical Interruption of Pregnancy 1. Medical abortion available in United States 2. Provides effective alternative to surgical abortion 3. Combination of mifepristone, an antiprogesterone, and misoprostol, a prostaglandin analog that causes smooth muscle to contract, leads to complete abortion in 92% of women 4. Mifepristone combined with vaginal misoprostol used up to 70 days results in complete abortion 92% of the time 5. Endometritis risk with any abortion 6. Misoprostol inhibits local immunity

C. Surgical Interruption of Pregnancy 1. First trimester a) Easier, safer than in second trimester b) If less than 8 weeks’ gestation, manual vacuum aspiration can be performed c) After 8 weeks’ gestation, cervix dilated mechanically with metal dilators, osmotically with Laminaria japonica, or medicinally with misoprostol or mifepristone; anesthetized using a paracervical block 2. Major risks a) Perforation of the uterus b) Laceration of the cervix c) Systemic reaction to the anesthetic agent d) Hemorrhage e) Retained products of conception f) Infection 3. Second trimester a) Greater than 13 weeks’ gestation up to 24 weeks or as per state law

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Medical termination: misoprostol; woman will need to labor and pass the fetus in the hospital c) Surgical termination: using dilation of cervix and evacuation of products of conception (D&E) d) May combine vacuum aspiration with use of appropriate instrumentation

D. Nursing Management for the Woman Having an Abortion 1. Decision to terminate a) Unwanted/unintended pregnancy b) Sexual assault c) Lack of finances d) Woman’s health e) Health of fetus f) Assist in finding postprocedure support 2. Verify pregnancy a) By 5 weeks’ gestation if possible b) Provide information about methods and associated risks c) Available alternatives and implications d) Encourage to verbalize feelings e) Provide support before, during, and after procedure f) Monitoring vital signs, intake and output (I&O) g) Providing for comfort h) Patient self-care i) Importance of postabortion checkup j) Use of reliable contraception postprocedure

XI.

Preconception Counseling

A. Preconception Health Measures 1. Health assessment: known or suspected risks 2. Modifiable risk factors a) Smoking b) Alcohol c) Social drugs and street drugs d) Caffeine e) Medications f) Environmental hazards 3. Physical examination a) Both partners physical examination to identify health problems that might affect pregnancy b) Woman may have laboratory tests c) Women assessed for mental illness 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Nutrition a) Nutritious diet that contains ample quantities of all essential nutrients b) Calcium, protein, iron, B complex vitamins, vitamin C, magnesium, and folic acid c) Consumption of balanced diet with appropriate distribution of food pyramid groups 5. Exercise a) Woman to establish regular exercise plan b) Aerobic conditioning and general toning c) Woman generally encouraged to continue during pregnancy d) Prepregnancy obesity puts woman at risk for a variety of complications

B. Contraception 1. Women who take birth control pills advised to stop the pill and have two or three normal menses before attempting to conceive 2. Women using intrauterine device advised to have it removed and wait 1 month attempting to conceive before

C. Conception 1. Personal and emotional experience 2. Even if a couple is prepared, they may feel some ambivalence, which is a normal response 3. Healthcare provider should remind overly zealous couple moderation is always appropriate

XII.

Focus Your Study

XIII.

Activities 1. Individual Using the standard drug card format, have students make drug cards for combined oral contraceptives (COCs), minipills, mifepristone, misoprostol, and laminaria. 2. Small Group Divide the class into small groups of three to five students. Assign the groups to research support and counseling services in your area for birth control and abortion information. Have the groups present their findings to the class. 3. Large Group Contact local agencies and invite a certified nurse-midwife (CNM) and/or a nurse practitioner (NP) to come to your class and discuss contraceptive counseling and services for teens and lowincome women.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 5 Commonly Occurring Infections Care of the Woman with a Lower Genital Tract Infection (Vaginitis)...............

Care of the Woman with a Sexually Transmitted Infection..............................

Care of the Woman with an Upper Genital Tract Infection (Pelvic Inflammatory Disease).................................................................

Care of the Woman with a Urinary Tract Infection...........................................

Focus Your Study................................................................................................

Activities.............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman with a Lower Genital Tract Infection (Vaginitis)

A. Vaginitis → most common reason women seek gynecologic care 1. Symptoms a) Vaginal discharge b) Vulvar irritation and pruritus c) External dysuria d) Dyspareunia (painful sexual intercourse) e) Bleeding with intercourse f) Foul odor 2. Bacterial Vaginosis a) Most prevalent vaginal infection in United States b) Etiology related to change in normal vaginal flora c) Increase in vaginal pH from variety of causes d) Gardnerella vaginalis and Mycoplasma hominis most common e) Symptoms (1) Excessive thin, watery, white or gray vaginal discharge, foul odor (2) Vaginal pH usually >4.5 f) Increased risk of pelvic inflammatory disease (PID), HIV, abnormal cervical cytology, postoperative cuff infections after hysterectomy, postabortion PID g) Treatment (1) Nonpregnant (a) Metronidazole (Flagyl) 500 mg orally (PO) twice daily (BID) for 7 days (b) Metronidazole gel (0.75%): one full applicator intravaginally, once daily for 5 days (c) Clindamycin 2% cream, one full applicator at bedtime (HS) for 7 days (d) See Drug Guide: Metronidazole (Flagyl), p. 75 (2) Pregnant (a) Metronidazole was considered a potential teratogen for many years → studies have not shown this 3. Vulvovaginal Candidiasis (VVC) a) Candidiasis → very common b) Candida albicans → most common pathogen (1) Predisposing factors c) Symptoms and signs (1) Thick, white, nonmalodorous discharge with severe itching, dysuria, dyspareunia (2) Male partner → rash, excoriation of skin of penis, pruritus (3) Vaginal pH usually 4 to 4.5 or less (4) Labia swollen, excoriated (5) Speculum exam d) Treatment (1) Over-the-counter (OTC) or prescription intravaginal agents 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Intravaginal butoconazole, clotrimazole, miconazole, ticonazole cream, tablets, suppositories, nystatin, and terconazole and orally, fluconazole (3) 1-day regimen (4) 3-day, 5-day, and 7-day treatment regimens (5) Treatment of male partner e) Recurrent → four or more episodes in 1 year (1) Test for elevated blood glucose (2) Evaluate for immunosuppression f) Pregnant → topical azole preparations for 7 days g) Nursing Management for the Woman with Vulvovaginal Candidiasis (1) Nursing assessment and diagnosis (a) Suspect VVC → intense itching, thick, nonodorous white discharge (b) Those susceptible → HIV positive, immunosuppressed, pregnant, have diabetes mellitus (c) Nursing diagnoses (i) Skin Integrity, Risk for Impaired (ii) Knowledge, Readiness for Enhanced (d) Nursing plan and implementation (i) Factors contributing to VVC (ii) Ways to prevent recurrences (e) Evaluation (i) Expected outcomes (a) Symptoms relieved, infection cured (b) Woman able to identify self-care measures to prevent further episodes

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

II.

Care of the Woman with a Sexually Transmitted Infection

A. Sexually transmitted infection (STI) or sexually transmitted disease (STD) → most common reason for outpatient, community-based treatment of women 1. More than one can occur at same time

B. See Table 5–1: Summary of Common Vaginal and Sexually Transmitted Infections, p. 77 C. Disease → organism → diagnosis → treatment (nonpregnant/pregnant) 1. VVC → Candida albicans → wet-mount hyphae → topically applied azole drugs 2. BV → Gardnerella vaginalis, mycoplasma hominis → wet-mount clue cells → Metronidazole or clindamycin/metronidazole 3. Trichomoniasis → Trichomonas vaginalis → wet-mount trichomonads → Metronidazole or tinidazole 4. Syphilis → Treponema pallidum → dark-field examination, Venereal Disease Research Laboratories (VDRL), Rapid Plasma Reagin (RPR), microhemagglutination assay-Treponema pallidum (MHA-TP) → Benzathine, Penicillin G 5. Herpes genitalis →herpes simplex virus → herpes culture or titer → acyclovir 6. Chlamydia → Chlamydia trachomatis → chlamydia culture → doxycycline or azithromycin/azithromycin or amoxicillin 7. Gonorrhea → Neisseria gonorrhoeae → gonorrhea culture → ceftriaxone, azithromycin, doxycycline 8. AIDS → HIV → enzyme-linked immunosorbent assay (ELISA) test and Western blot → varies 9. Condylomata acuminata → human papilloma virus → Virapap, biopsy, Pap smear, colposcopy → cryotherapy, trichloroacetic acid (TCA), bichloracetic acid (BCA), podophyllum, podofilox, excision 10. Pediculosis pubis → Phthirus pubis → microscopic identification of lice or nits → permethrin 1% liquid or malathion 0.5% lotion /permethrin 1% liquid 11. Scabies → Sarcoptes scabiei → confirmation of symptoms or scraping of furrows → permethrin 5% cream or crotamiton 10% cream or lotion/ permethrin 5% cream

D. Prevention of Sexually Transmitted Infections 1. Effective prevention and control based on a) Education and counseling on safer sexual behavior b) Identification of infected, asymptomatic individuals and symptomatic people not likely to seek diagnostic and treatment services 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Effective diagnosis and treatment of people with an STI d) Evaluation, treatment, counseling, and education for sex partners of people with an STI e) Pre-exposure vaccination of individuals at risk for vaccine-preventable STIs f) Expedited partner therapy (EPT) 2. Lowest risk → abstain from sexual intercourse a) Monogamous relationship with partner who is free of infection b) Nurses educate and counsel → tailored to individual needs, specific risk factors

E. Trichomoniasis 1. Trichomonas vaginalis → protozoan 2. Most common curable STI 3. Coinfection with other STIs common → HIV transmitted more easily 4. Often asymptomatic, mild symptoms a) Yellow-green frothy discharge, vulvar itching b) Dysuria and dyspareunia c) Microscopic visualization, vaginal pH of 5 or higher, positive whiff test d) Pregnant → increased risk for premature rupture of membranes 5. Diagnosis a) Microscopic visualization of mobile trichomonads and increased leukocytes (Figure 5-3) b) Vaginal pH of 5.0 or higher c) Positive whiff test d) Two other tests with greater sensitivity than the wet-mount preparation are also available and are performed on vaginal secretions (CDC, 2015) (1) Nucleic acid amplification test (NAAT) (2) Aptima T. vaginalis assay 6. Treatment → metronidazole in single 2-g dose, tinidazole, single 2-g oral dose a) Metronidazole 500 mg twice daily for 7 days for both male and female sexual partners b) Avoid intercourse until both are cured

F. Chlamydial Infection 1. Chlamydia trachomatis a) Most common bacterial STI in United States b) Major cause of nongonococcal urethritis (NGU) in men c) Similar infection in women to gonorrhea d) Pelvic inflammatory disease (PID), infertility, and ectopic pregnancy (1) Newborn exposure 2. Symptoms a) Thin or mucopurulent discharge b) Cervical ectropion 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Burning and frequency of urination d) Lower abdominal pain e) Up to 50% of women asymptomatic 3. Diagnosis a) Nucleic acid amplification testing (NAAT) most sensitive b) Polymerase chain reaction (PCR) assay and antigen detection c) May be made after treatment of male partner for NGU 4. Treatment a) Single-dose azithromycin 1 g orally, doxycycline 100 mg by mouth for 7 days b) Sexual partners should be treated c) Abstinence for 7 days following treatment 5. Annual screening a) All sexually active adolescent females, women age 20 to 25 even if asymptomatic b) Women older than age 25 at risk c) Screening for high-risk pregnant women (1) First prenatal visit and third trimester d) Endocervical, urethral, or urine specimens

G. Gonorrhea 1. Neisseria gonorrhoeae bacterium 2. Second most commonly reported STI in United States a) Highest rates in females aged 15 to 24 years b) Men symptomatic c) Women often asymptomatic 3. Pregnant woman infected after third month of gestation a) Mucous plug prevents infection from ascending b) Newborn exposure: at risk of developing ophthalmia neonatorum c) Cervical culture during initial prenatal exam 4. Symptoms a) Purulent, greenish-yellow vaginal discharge b) Dysuria and urinary frequency c) Vulvar inflammation, swelling d) Cervix may appear swollen and eroded e) Cervicitis, acute cystitis, or vaginitis f) Bilateral lower abdominal or pelvic pain 5. Treatment a) Nonpregnant → antibiotic therapy with ceftriaxone intramuscularly or with cefixime orally b) Combined with azithromycin or doxycycline orally

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Additional treatment may be required if cultures remain positive 7 to 14 days after completion of treatment d) Treat all sexual partners e) Recommend abstinence 7 days following treatment f) Retesting recommended 3 months following treatment 6. Education a) Need to verify cure b) Abstinence or condom until cure confirmed c) All sexual partners should be treated d) Signs that infection worsening

H. Herpes Genitalis 1. Herpes simplex virus (HSV) 2. Recurrent, lifelong infection a) Spread through vaginal, anal, oral sex b) Skin to skin c) At least 50 million people infected d) HSV-1 and HSV-2 3. Primary episode → single, multiple blisterlike vesicles a) Genital area, vaginal walls, cervix, urethra, anus b) Within a few hours of exposure → 20 days c) Vesicles rupture → painful, open ulcerated lesions d) Genital pruritus, tingling e) Flulike symptoms f) Lesions heal → 2 to 4 weeks g) Most severe episode 4. Dormant phase → reside in nerve ganglia of affected area a) May or may not recur b) Less severe than primary episode c) Triggers (1) Emotional stress (2) Menstruation (3) Ovulation (4) Pregnancy (5) Frequent or vigorous intercourse 5. Diagnosis a) Clinical appearance b) Culture of lesions c) PCR identification, glycoprotein G-based type-specific assay

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Treatment a) No known cure (1) Control symptoms, prevent complications of secondary infections b) Acyclovir, valacyclovir, or famciclovir (1) Start therapy in prodromal period (2) Daily suppressive therapy for those with frequent recurrences (3) Pregnant → oral acyclovir for first episode, severe recurrent (4) Third trimester use → reduce frequency of C-section c) Palliative treatment (1) Keep genital area clean, dry (2) Wear loose clothing (3) Sitz baths (4) Cotton underwear or none at all d) Primary or recurrent lesions will heal without treatment

I. Syphilis 1. Treponema pallidum 2. More common in men than women a) Acquired through vaginal, oral, or anal sex 3. Early → primary stage → chancre a) Slight fever, weight loss, malaise b) Chancre for about 4 weeks and then disappears 4. Secondary → 6 weeks to 6 months a) Skin eruptions (condylomata lata); wartlike and highly infectious b) Acute arthritis c) Enlargement of liver, spleen d) Nontender enlarged lymph nodes e) Iritis f) Chronic sore throat with hoarseness g) Latent phase with no lesions may be followed by a tertiary stage. h) Transplacental transmission (1) Intrauterine growth restriction, preterm birth, stillbirth (2) Serologic testing of every pregnant woman 5. Diagnosis a) Early primary → dark-field microscopic examination of chancre b) VDRL, Rapid Plasma Reagin (RPR), or fluorescent treponemal antibody absorption test (FTA-ABS) 6. Treatment a) Pregnant and nonpregnant → less than 1 year duration (1) million units of benzathine penicillin G intramuscularly once a week for 3 weeks

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Tertiary syphilis treated with 2.4 million units of benzathine penicillin G intramuscularly at 1 week intervals for 3 doses (3) Doxycycline or tetracycline for allergy

J. Human Papilloma Virus/Condylomata Acuminata 1. Viral a) 100 HPV subtypes (1) Transmission through vaginal, oral, or anal sex (2) Incidence of HPV infection is 14.1 million mostly in women (3) Link with cervical and anorectal cancers 2. Symptoms a) Most HPV infections are unrecognized, asymptomatic, or subclinical b) Single or multiple soft, grayish pink, cauliflower-like lesions in genital area c) May cause itching, be friable, painful d) Incubation 3 weeks to 3 years e) All atypical pigmented and persistent warts should be biopsied, treated promptly 3. Treatment a) Patient-applied therapies (1) Podofilox solution or gel, imiquimod cream, or sinecatechin ointment. b) Provider administered (1) Cryotherapy (2) Topical podophyllin, TCA, BCA c) Surgical removal d) Intralesional interferon, laser surgery e) Topical cidofovir f) Imiquimod, podophyllin, podofilox, sinecatechin ointment not during pregnancy g) Frequent Pap smears to monitor cervical cellular changes h) Use of condoms can reduce transmission i) Vaccine (1) Gardasil (2) Cervarix (3) CDC recommends 3-dose HPV vaccine be routinely given to boys ages 11 to 12

K. Pediculosis Pubis (Pubic or Crab Lice) 1. Pthirus → grayish, parasitic “crab” louse 2. Symptoms a) Itching, usually in pubic area 3. Treatment a) 1% permethrin liquid or mousse (1) Applied to clean hair, saturating hair (2) Remove after 10 minutes with warm water 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Malathion applied to dry hair, massaged in, allowed to air dry b) Retreatment may be necessary c) Linens, towels, clothing → machine washed, dried in hot dryer for 20 minutes (1) Dry-cleaned (2) Sealed in airtight bag for 2 weeks d) Both partners treated and tested for other STIs

L. Scabies 1. Sarcoptes scabiei → parasitic itch mite 2. Symptoms a) Itching that worsens at night b) Erythematous, papular lesions, furrows may be present 3. Treatment a) Permethrin cream 5% applied to all body areas (1) Neck down and washed off after 8 hours (2) Retreat in 7 days if live mites still exist (3) Can be used during pregnancy b) Crotamiton cream or lotion (1) Thin layer to all body areas from neck down (2) Reapply 24 hours after first application c) Clothing, linens washed and dried in hot dryer or dry-cleaned (1) Sealed in plastic bag for minimum of 72 hours

M. Viral Hepatitis 1. See Table 5–2: Types of Viral Hepatitis, p. 82 a) Type A (1) Fecal–oral, contaminated food/water (2) 15–50-day incubation (3) Not chronic (4) Immunization available b) Type B (1) Blood/body fluids (2) 45–108-day incubation (3) Chronic (4) Immunization available c) Type C (1) Blood/blood products (2) 14–180-day incubation (3) Chronic infection (4) No immunization available d) Type D (1) Blood/body fluids 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) 45–160-day incubation (3) Chronic infection (4) No immunization available e) Type E (1) Fecal–oral (2) 21–56-day incubation period (3) Not chronic (4) Immunization available in China only 2. Symptoms a) Hepatitis A (1) Jaundice, anorexia (2) Nausea, vomiting (3) Malaise, fever (4) Gray-colored bowel movements b) Hepatitis B, C, D (1) Similar symptoms to A (2) Also arthralgias, arthritis, skin eruptions, rash c) Hepatitis E (1) Primarily in East and South Asia (2) Symptoms like hepatitis A

N. AIDS 1. AIDS: serious, often fatal, disorder caused by HIV 2. Alters presentation of STIs, complicates treatment of STI 3. Fetal implications

O. Nursing Management for the Individual with a Sexually Transmitted Infection 1. Nursing Assessment and Diagnosis a) Thorough history to identify women at risk for STIs b) Complaints suggestive of infection (1) Sore or lesion (2) Increased or malodorous vaginal discharge (3) Burning with urination (4) Dyspareunia (5) Bleeding after intercourse (6) Pelvic pain (7) Woman asymptomatic but may report symptoms in her partner c) Nursing Diagnoses (1) Family Processes, Interrupted (2) Knowledge, Readiness for Enhanced d) Cultural Competence (1) STI rates in United States → racial minorities have highest rates 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) African American > Native Americans/Alaska Native > Hispanic populations (i) Significantly greater rates of gonorrhea and chlamydia than Caucasians e) Nursing Plan and Implementation (1) Provide information about infection (2) Prevention of reinjection (3) Abstain from sexual activity, if necessary, during treatment (4) Condom use (5) Encourage woman to explore feelings (a) Matter of fact versus embarrassing, shameful (b) Straightforward acceptance by nurse f) Health promotion education (1) Risk increases with number of partners (a) Plan ahead → develop strategies to refuse sex (b) Limit number of sexual contacts, mutual monogamy (2) Condom use for every act of vaginal, anal intercourse (a) Plan strategies for negotiating condom use with partner (3) Reduce high-risk behaviors (4) Refrain from oral sex if active sores in mouth, vagina, anus, penis (5) Seek care as soon as symptoms noticed (a) Make sure partner gets treated (6) More frequent Pap tests as recommended by caregiver g) Evaluation (1) Infection identified, cured (2) Supportive therapy (3) Woman and partner can describe infection, transmission, implications, therapy (4) Woman copes with impact on self-concept

III.

Care of the Woman with an Upper Genital Tract Infection (Pelvic Inflammatory Disease)

A. Pelvic inflammatory disease (PID) 1. Occurs most often in women of childbearing age, especially sexually active women under age 25 2. More common in women who a) Have had multiple sex partners b) Partner who has had more than one sex partner c) History of PID d) Early onset of sexual activity e) Recent insertion of intrauterine device (IUD) f) Douche regularly

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Definition → clinical syndrome of inflammatory disorders of upper female genital tract a) Any combination or endometritis, salpingitis tubo-ovarian abscess, pelvic abscess, pelvic peritonitis b) Organisms most common → C. trachomatis and N. gonorrhoeae 4. Symptoms a) Bilateral sharp, cramping pain in lower quadrants b) Fever >100.4°F, chills c) Mucopurulent cervical or vaginal discharge d) Irregular bleeding e) Cervical motion tenderness during intercourse f) Malaise, nausea, vomiting g) Possible to be asymptomatic 5. Diagnosis a) Clinical examination to define symptoms b) Cultures for gonorrhea and chlamydia (1) Complete blood count (CBC) with differential, RPR, VDRL (2) C-reactive protein, sedimentation rate often elevated (3) Physical examination c) Ultrasound d) Laparoscopy 6. Treatment a) Outpatient or inpatient based on clinical judgment b) Ceftriaxone plus doxycycline with or without metronidazole c) IV fluids, pain medication d) IV antibiotics often cefoxitin, or cefotetan plus doxycycline, or clindamycin plus gentamicin e) Follow up within 48 to72 hours f) Treat sexual partner

B. Nursing Management for the Woman with Pelvic Inflammatory Disease 1. Nursing Assessment and Diagnosis a) Assessment of risk factors for PID (1) Woman’s history at risk for PID (2) Symptoms b) Nursing diagnoses (1) Pain, Acute (2) Knowledge, Deficient c) Nursing Plan and Implementation (1) Education (a) Woman with IUD and multiple sexual partners (b) Signs and symptoms of PID (c) Importance of completing antibiotics and follow-up 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(d) Possible outcomes of PID → decreased fertility or infertility d) Evaluation (1) Expected outcomes include (a) Describes condition, therapy, possible long-term implications (b) Woman completes course of therapy

IV.

Care of the Woman with a Urinary Tract Infection A. Urinary Tract Infection (UTI) → significant bacteriuria in presence of symptoms 1. Approximately 50% women will experience UTI in lifetime 2. Bacteria enter urinary tract via urethra 3. Causes a) Shortness of female urethra b) Incompetence of urinary sphincter c) Frequent enuresis before adolescence d) Pregnancy e) Urinary catheterization f) Voluntarily suppressing desire to urinate g) Age h) General poor health, lowered resistance 4. Asymptomatic Bacteriuria a) Bacteria in urine without symptoms b) Escherichia coli most common c) In pregnancy (1) 2 to 7% of pregnancies, and as many as 20 to 30% of pregnant women with untreated ASB will develop pyelonephritis (2) Physiology (3) Treatment: amoxicillin-clavulanate, nitrofurantoin, cefixime, fosfomycin d) Woman who has had a UTI susceptible to recurrent infection

B. Lower Urinary Tract Infection (Cystitis and Urethritis) 1. UTIs ascend → important to diagnose early 2. Cystitis → inflammation of the bladder 3. Risk factors a) Sexual intercourse b) Use of diaphragm and spermicide c) Pregnancy d) History of recent UTI

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. E. coli → vast majority of UTIs 5. Symptoms a) Dysuria at end of urination b) Urgency and frequency c) Suprapubic, low back pain d) Low-grade fever e) Hematuria occasionally 6. Diagnosis a) Urine culture b) Bacteriuria dipstick screening (1) High false-positive, -negative rates 7. Treatment a) Depends on causative pathogen (1) Oral (a) Nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMZ) (b) Fluoroquinolones (FQ) such as ciprofloxacin, levofloxacin, gatifloxacin, or norfloxacin reserved for treatment failures and for women with suspected upper UTI infection b) In pregnancy (1) Cystitis may occur in pregnant women (2) Common treatment regimens: oral cephalexin, nitrofurantoin, sulfisoxazole, fosfomycin, ampicillin

C. Upper Urinary Tract Infection (Pyelonephritis) 1. Inflammatory disease of kidneys a) More serious than cystitis (1) Significantly increased risk of preterm labor, preterm birth, development of adult respiratory distress syndrome, septicemia 2. Symptoms a) Sudden onset b) Chills, high temperature c) Costovertebral angle tenderness, flank pain d) Nausea, vomiting, general malaise 3. Physiology a) Edema of renal parenchyma, ureteritis → blockage, swelling of ureter b) Temporary suppression of urinary output → severe, colicky pain c) Vomiting, dehydration, ileus of large bowel d) Significant bacteremia in urine culture, pyuria, presence of white blood cell casts 4. Treatment a) May be hospitalized 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) IV antibiotics, IV hydration c) Urinary analgesics, pain management d) Medication to manage fever e) Blood culture in case of obstructive pyelonephritis f) Bed rest g) Possible catheterization 5. Medications a) Ceftriaxone IV → followed with oral ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin (1) Oral to complete 10 to14 days of therapy 6. Follow-up urinary cultures

D. Nursing Management for the Woman with a Urinary Tract Infection 1. Nursing Assessment and Diagnosis a) Medical history including sexual history (1) Risk factors b) Symptoms (1) Fever, chills, nausea, vomiting, flank or back pain (a) Clean-catch urine sample 2. Nursing Diagnoses a) Pain, Acute b) Knowledge, Deficient c) Fear 3. Nursing Plan and Implementation a) Education (1) Hygiene (2) Signs and symptoms of UTI (3) Reinforce instructions regarding treatments b) Three or more infections yearly → long-term prophylaxis may be needed 4. Health Promotion a) Avoid bladder irritants b) Make regular urination a habit, avoid long waits c) Practice good genital hygiene d) Be aware that initial, vigorous, frequent sexual activity may contribute e) Complete medication regimens f) Do not use medication left over from previous infections g) Drinking cranberry juice or taking cranberry tablets is often recommended to decrease urinary tract infection, evidence does not support its value 5. Evaluation a) Expected outcomes (1) Woman implements self-care measures to help prevent recurrent UTIs 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Woman completes prescribed course of antibiotic therapy (3) Woman can identify signs of recurrent UTI, worsening urinary symptoms (4) Woman’s infection is cured

Focus Your Study

VI.

Activities 1. Individual Assign students to complete drug cards for medications used in treating VVC, BV, chlamydia, gonorrhea, herpes genitalis, syphilis, HPV, PID, UTIs, and PID. 2. Small Group Divide the class into small groups of three to five students. Assign each group a commonly occurring infection to research. The rubric should include statistics regarding demographics, morbidity and mortality, and new research. Instruct students to use APA format for citing resources. Have each small group present its findings to the entire class. 3. Large Group Invite an adult nurse practitioner (ANP) to speak to the class regarding adolescents and older women and UTIs.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 6 Women’s Health Problems

Care of the Woman with a Disorder of the Breast............................................

Care of the Woman During a Pelvic Examination..............................................

Care of the Woman with Vulvitis.......................................................................

Care of the Woman with an Abnormal Finding During Pelvic Examination.....

Care of the Woman with Endometriosis...........................................................

Care of the Woman with Polycystic Ovarian Syndrome...................................

Care of the Woman with Pelvic Relaxation.......................................................

Care of the Woman Requiring Gynecologic Surgery........................................

Focus Your Study...............................................................................................

Activities……………………………..............................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman with a Disorder of the Breast

A. Screening Techniques for the Breasts 1. Breast examination a) Regular cyclic changes in response to hormonal stimulation (1) Mastodynia, mastalgia common b) Menopause → connective breast tissue atrophies (1) Hormone therapy (HT) may cause breast engorgement c) Breast self-awareness (BSA) (1) Need for woman to be aware of how her breasts normally look (2) BSA versus BSE (3) Women at high risk for breast cancer (4) One way for a woman to develop self-awareness (5) Effectiveness determined by woman’s ability to perform correctly d) See Teaching Highlights: Breast Self-Examination, p. 90 (1) Inspection (a) Should do standing or sitting in front of mirror (b) Done in three positions: both arms relaxed at sides, both arms over head, both hands on hips (c) Size and symmetry, shape, contours and direction (d) Thickening or edema (e) Surface of the skin (f) The nipples (2) Palpation (a) Lying down, one hand behind head and other hand to palpate (b) Check each breast lying down, then again sitting up (c) Squeeze nipples to check for discharge (3) Describe and demonstrate correct procedure for BSE (a) Timing (i) Monthly self exams (ii) Every 1–3 years by trained healthcare provider e) Clinical breast examination (CBE) essential element of routine gynecologic examination (1) ACS → CBE every 1–3 years from 20 to 39, yearly thereafter 2. Mammography a) Soft tissue x-ray image of the breast (1) Used to detect lesions before they can be felt b) American Cancer Society (ACS) → annual after age 45, at 40–45 discuss need with healthcare provider, after 55 discuss continued need with healthcare provider c) ACS recommends both mammogram and magnetic resonance imaging (MRI) beginning at age 30 in women at high risk for breast cancer due to gene mutations and/or a strong family history of breast cancer and in women who had radiation to chest between 10–30 years old 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Sensitivity of mammography increases with age (1) Decreases with increased breast density (2) Assessment protocol (a) Mammogram or ultrasound (b) Fine-needle aspiration e) Breast sensitivity varies (1) May be scheduled 2 weeks after onset of menses (2) Compression, not pain (3) Refrain from lotion, powder, deodorant, etc., to torso

B. Benign Breast Conditions 1. Fibrocystic breast change → benign breast disease (BBD) a) Most common benign breast disorder b) Generally not a risk factor for cancer c) Fluctuations in size, rapid appearance/disappearance of breast masses d) Bilateral, cyclic pain, tenderness, swelling just before menses (late luteal phase) (1) Improves to 1–2 days into cycle (2) Physical exam reveals mild irregularity to dense, irregular, nodular “lumpiness” (3) May experience fluid-filled cysts large or small (a) Tend to be mobile, tender, without skin retraction e) Mammography, sonography, magnetic resonance imaging (MRI), palpation, fine-needle aspiration → confirm fibrocystic breast changes f) Medical management (1) Restrict sodium, mild diuretic week before onset of menses (2) Mild analgesic (3) Oral contraceptives (4) Severe (a) Danazol → undesirable side effects (b) Bromocriptine (c) Limit methylxanthine intake, tobacco 2. Fibroadenoma a) Common benign tumor most often seen in women in teens and early twenties b) Asymptomatic, mobile, well-defined, painless palpable mass with rubbery texture c) Ultrasound younger than age 35 (1) Observe and follow versus excision 3. Galactorrhea a) Nipple discharge not associated with lactation (1) Common (2) Generally not significant (3) Varies from white to brown b) Likelihood of malignancy increases → spontaneous discharge (1) From single duct in one breast 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Watery or bloody c) Mammogram for initial evaluation d) Ultrasound → nipple discharge accompanied by palpable mass, positive findings on mammogram 4. Intraductal papilloma a) Tumors growing in terminal portion of duct, sometimes throughout duct system within section of breast (1) Symptoms may include unilateral mass, spontaneous, bloody nipple discharge (2) Most present as solitary nodules b) Typically benign 5. Duct ectasia (comedomastitis) a) Inflammation of the ducts behind the nipple (1) Typically near onset of menopause (2) Not associated with malignancy b) Typically in women who have borne and nursed children (1) Thick, sticky nipple discharge (2) Burning pain, pruritus, inflammation (3) Nipple retraction c) Drug therapy for symptomatic relief 6. See Table 6–1: Summary of Benign Breast Disorders, p. 92

C. Malignant Breast Disease 1. Second leading cause of cancer deaths in women a) Risk is 1 in 8 b) 14% of all cancer deaths c) In United States, most common in non-Hispanic White women 2. Predisposing factors a) Age; incidence increases steadily with age b) Female gender c) History of previous breast cancer d) Have a known BRCA1 or BRCA2 gene mutation, from either parent with mutation e) Family history of first-degree relative with breast cancer (mother, sister, daughter with breast cancer) f) Long-term postmenopausal combined estrogen and progestin hormonal therapy g) Being overweight or obese after menopause h) Alcohol consumption i) No history of pregnancy, first pregnancy after age 30 j) Never breastfeeding a child k) Longer reproductive phase (early menarche [before age 12] and late menopause [after age 55]) l) History of high-dose radiation to chest between ages of 10 and 30 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

m) Physical inactivity n) Smoking 3. Diagnosis a) May originate in duct or epithelium b) 50% upper outer quadrant (1) Metastasize to axillary lymph nodes (2) Distant metastasis → lymph nodes, lungs, liver, brain, bone c) Discovery (1) By woman herself, clinician who palpates or observes an abnormality, or mammogram (2) Painless mass or lump d) Worrisome findings (1) Dimpling of breast tissue (2) Recent, acute nipple inversion (3) Change in breast size or shape (4) Increase of size in breast mass (5) Skin erosion or ulceration (6) Presence of axillary lump e) Routine mammography screening → 2 to 3 years before clinical appearance f) Fine-needle biopsy g) Ultrasonography h) MRI i) Biopsy essential for diagnosis 4. Clinical Therapy a) Treatment decision based on (1) Stage of cancer (2) Optimal treatment for that stage (3) Woman’s age (4) Personal preferences (5) Risks and benefits of each treatment protocol b) Surgery (1) Breast-conserving surgery (BCS) (lumpectomy or partial mastectomy) (2) Simple to total mastectomy (3) Modified radical mastectomy (4) Reconstruction (5) Lumpectomy (a) Stages I or II (b) Followed by radiation therapy (6) Sentinel node biopsy c) Adjunctive therapy (1) Chemotherapy (a) Typically combination of drugs (2) Radiation therapy 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Destroy remaining cells, reduce size of tumor (b) Neoadjuvant therapy (3) Hormone therapy (a) Estrogen receptive (b) Antiestrogen drug such as tamoxifen or toremifene (c) Raloxifene → selective estrogen receptor modulator (SERM) (d) Aromatase inhibitors stop body from making estrogen (e) Prevent return of breast cancer (f) Herceptin → immune system protein that stops HER2/neu (growth-promoting protein) (4) Allopathic and complementary therapies (a) Combined approach (b) Herbal remedies, therapeutic touch, acupuncture, aromatherapy, massage d) Multidisciplinary approach (1) Second opinion (2) Primary care provider (3) Radiotherapist (4) Surgeon (5) Oncologist (6) Nursing specialists

D. Psychologic Adjustment 1. Emotional feelings include fear a) Loss, treatment, death b) Encourage woman to discuss feelings, concerns c) Information 2. Adjustment phases a) Shock (1) “Everything is unreal”; “I can’t understand why this is happening to me” b) Reaction (1) In conjunction with initiation of treatment (2) Coping mechanisms become evident (a) Denial c) Recovery (1) Begins during convalescence following completion of medical treatment (2) Anxiety diminishes, looks to future if successful (3) Depression, social isolation if unsuccessful (4) Looks to family and friends (a) Partner reaction to breast cancer (5) Support groups d) Reorientation (1) Follows recovery (2) Acknowledges breast cancer, returns to living 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Nursing Management for the Woman with Breast Cancer 1. Multidimensional 2. Nursing Assessment and Diagnosis a) Therapeutic communication (1) Ongoing assessment (2) Diagnoses that may apply (a) Knowledge, Readiness for Enhanced (b) Anxiety 3. Nursing Plan and Implementation a) Prediagnosis period (1) Emotional support, clarify misconception, encourage expression of anxiety, urge her to ask questions b) Diagnosed (1) Ensure woman understands condition, treatment options (2) Assist to locate appropriate resources (3) Encourage woman and partner to discuss treatment alternatives with healthcare provider (4) Advocacy c) Preoperative interventions 4. Health Promotion a) Reduce modifiable risks b) Avoiding obesity c) Exercising regularly d) Reducing dietary fat e) Limiting intake of processed meat and red meat f) Limiting alcohol intake 5. Evaluation a) Expected outcomes include (1) Woman able to discuss fears, concerns, questions during period of diagnosis (2) Diagnosis made quickly, accurately, treatment initiated

II.

Care of the Woman During a Pelvic Examination

A. Pelvic exam → health maintenance to disease diagnosis 1. First pelvic exam a) Typically as a teenager (1) Sensitive to teen’s attitudes and concerns 2. Create trusting atmosphere, incorporate practices that help to maintain sense of control a) Nonjudgmental and safe environment

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Educational pelvic exam a) Mirror to watch, pointing out anatomy, drape patient to allow for eye-to-eye contact with practitioner b) Encourage to ask questions, giving feedback 4. Nurse practitioner, certified nurse-midwife, physician perform a) See Clinical Skill 6–1: Assisting with a Pelvic Exam, p. 96 b) Preparation (1) Ensure room is warm (2) Explain procedure → decreases anxiety (3) Ask woman to empty bladder, remove clothing below waist → promotes comfort (4) Have padding on stirrups → decrease discomfort (5) Disposable drape, sitting at end of table → provide exposure to conduct exam (a) Position in lithotomy position, thighs flexed, abducted (b) Feet in stirrups (c) Buttocks extend slightly below edge of examining table (d) Drape woman with sheet → drape helps preserve sense of dignity, privacy c) Equipment and supplies (1) Vaginal specula of various sizes, warmed (2) Gloves (3) Water-soluble lubricant (4) Materials for Pap smear or ThinPrep® Pap test and cultures (5) Light source d) Procedure (1) Examiner dons gloves (2) Explain procedure, let woman know when examiner begins with inspection of external genitalia (3) Let her know when examiner ready to insert speculum (a) Speculum inserted → visualization of cervix, vaginal walls, specimen (4) Lubricate examiner’s fingers prior to bimanual exam (a) Bimanual exam after speculum withdrawn (b) Rectal exam (5) Ask woman to breathe slowly, regularly (6) After examiner finished, move to end of table (a) Face woman (b) Cover with drape (c) Encourage to move to head of table, apply gentle pressure to knees (d) Assist to remove feet from stirrups (i) Assisting important → awkward position; may have difficulty (ii) Provide tissues to wipe lubricant from perineum (iii) Provide privacy while she dresses (a) Be sure she is not dizzy e) Clinical Tip: With examiner’s consent, offer woman hand mirror to watch examination

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Three segments to pelvic exam a) Inspection of vulva b) Inspection of vagina and cervix via speculum exam c) Palpation of cervix, uterus, ovaries via bimanual exam

B. Vulvar Self-Examination 1. Important to promote self-awareness 2. Assume sitting position on bed, chair (pregnant or obese women may find easier to stand) 3. Hold mirror and expose tissues of perineum a) Inspect, palpate b) Palpable masses c) Open sores and lesions d) Areas of marked tenderness

III.

Care of the Woman with Vulvitis

A. Defined as inflammation of vulva, external female genitalia 1. Result of nonpathologic factors a) Douching; feminine deodorant spray; detergents, harsh soaps, bubble bath; colored or perfumed toilet paper; contraceptive creams/foams/suppositories; condoms; dye; synthetic clothing; tight clothing; repetitive motion exercise, frequent shaving; frequent intercourse; deodorant feminine hygiene products; estrogen deprivation 2. Result of inflammation, infection of vagina or cervix a) Vulvovaginitis

B. Difficult to differentiate, by symptoms alone, vulvitis from vaginitis C. Nursing Management for the Woman with Vulvitis 1. Assessment 2. Education about contributing factors 3. Behaviors to avoid 4. Strategies, therapies to improve symptoms

IV.

Care of the Woman with an Abnormal Finding During Pelvic Examination A. Vulvar Lesion 1. Bartholin gland cyst a) Infection resulting in inflammation common b) Unilateral pain, swelling 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Pain ranges from mild discomfort to moderate or severe pain c) Incision and drainage, culture and sensitivity, antibiotic therapy 2. Lichen sclerosus a) Chronic disorder of the vulva b) More common in perimenopausal and postmenopausal women c) Link between lichen sclerosus → autoimmune-related disorders d) Diagnosis by clinical exam confirmed with biopsy e) Appears as white papules, plaques, often with keyhole appearance around vulva, introitus, and anal area f) Treatment includes topical antihistamine for mild cases and high-dose topical steroid cream for difficult cases applied nightly for 6 to 12 weeks and then decreased to once or twice weekly thereafter 3. Vulvar vestibulitis a) Local irritation and inflammation of vulvar vestibule b) Severe pain with vaginal penetration c) Precipitating factors d) No definitive treatment → comfort measures e) Burrow soaks, sitz baths, lubricants, topical anesthetics, local interferon injections, oral antifungal medications, oral tricyclic antidepressants, biofeedback techniques, surgical intervention 4. Vulvar intraepithelial neoplasia a) Cancer of the vulva increasing in occurrence (1) Women in 40s (2) Changes related to increased incidence of human papilloma virus (HPV) infections (3) Presents with pruritus, lump, flat lesion, or asymptomatic (4) Risk factors vulvar inflammation, immunosuppression from steroid use, smoking, diabetes, HPV, HIV, history of lower genital tract cancer (5) Clinical appearance varies (6) Biopsy necessary (7) Treatment usually involves surgery

B. Cervicitis 1. Acute inflammation of cervix a) Usually from Neisseria gonorrhoeae or Chlamydia trachomatis b) Other causes include intravaginal feminine hygiene products, frequent tampon use, frequent intercourse, presence of foreign body, contraceptive sponge, diaphragm, or tampon c) Symptoms often include yellowish-white vaginal discharge, or purulent discharge d) Dyspareunia common e) Diagnosis and evaluation include pelvic exam, wet-mount smear, cultures, Pap smear f) Treatment based on identified problem

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Abnormal Pap Smear Results 1. Various abnormal findings common → may cause significant anxiety a) Reassurance regarding early detection b) Information about expected further evaluation, treatment, follow-up 2. Pap smear → screens for presence of cellular abnormalities a) Obtain cells from cervix and endocervical canal b) Performed by preparing Pap smear slide c) Liquid-based medium Pap smear increased accuracy (1) Allow for HPV screening, and some sexually transmitted infections (STIs) (2) Screening tool, biopsy for diagnosis 3. Pap smear preparations a) See Professionalism in Practice: Pap Smear Preparation, p. 98 b) Avoid anything in vagina 24 hours before the examination c) 2012 new guidelines for cervical cancer screening issued by U.S. Preventive Services Task Force, American Cancer Society, other groups. See Table 6–2: Screening for Cervical Cancer, p. 98 (1) Women under 21—no screening unless has HIV or is immunocompromised (2) Women 21 to 29—screening with cytology alone every 3 years (3) Women ages 30 to 65—preferred approach: screen with cytology every 3 years and HPV co-testing every 5 years; acceptable approach: test with cytology alone every 3 years (4) Women over 65 years of age who have had adequate prior screening and are not at high risk—do not screen (5) Women who have undergone hysterectomy and have no history of high-grade precancer or cervical cancer—do not screen 4. Bethesda System → standardized method of reporting Pap smear findings a) See Table 6–3: The Bethesda System for Classifying Pap Smears, p. 99 b) Specimen type c) Specimen adequacy d) General categorization (optional) e) Automated review f) Ancillary testing g) Interpretation/result (1) Negative for intraepithelial lesion or malignancy (2) Reports if there are organisms or other nonneoplastic findings h) Other nonneoplastic findings i) Other j) Epithelial cell abnormalities (1) Atypical squamous cells of undetermined significance (ASC-US) (2) Atypical squamous cells cannot exclude HSIL (ASC-H) (3) Low-grade squamous intraepithelial lesion (LSIL) 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) High-grade squamous intraepithelial lesion (HSIL) k) Glandular cell (1) Atypical (2) Endocervical adenocarcinoma in situ (3) Adenocarcinoma (4) Other malignant neoplasms

D. Cervical Abnormalities 1. Most common in women who have never been screened (50%) or screened inappropriately (10%) 2. Almost always caused by HPV 16 or 18 3. Pap smear screening has decreased mortality dramatically a) Preventable disease b) High-risk factors (1) Coitus at early age (<16 years old) (2) History of multiple sexual partners (3) Sex partner with history of numerous sexual partners (4) Exposure to STIs (5) History of HPV infection (6) History of immunosuppressive therapy (chemotherapy), immunocompromised state (HIV) (7) Long-term oral contraceptive use (>5 years) (8) Smoking (9) Antenatal exposure to DES (10) History of dysplasia c) Virtually all cases of cervical cancer associated with HPV infection (1) Bethesda System → three categories for premalignant squamous cell lesions (a) Atypical squamous cells (ASC) (b) Low-grade squamous intraepithelial lesion (LSIL) (c) High-grade squamous intraepithelial lesion (HSIL) (2) Pap smear focus is detection of high-grade cervical disease (3) Category ASC-H includes those changes suggestive of high-grade lesion but lacking sufficient criteria for definitive evaluation and interpretation (a) Immediate colposcopy 4. Colposcopy a) Direct, detailed visualization and examination of cervix (1) Speculum in vagina (2) Cervix isolated (3) 3% acetic acid solution applied → abnormal epithelial cells take on characteristic white appearance (4) Lesions, abnormalities identified, documented (5) Biopsies obtained 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(6) May remove entire lesion → diagnostic and therapeutic 5. Atypical glandular cells (AGUS) a) Cells glandular rather than squamous in origin (1) Atypical endocervical cells (2) Atypical endometrial cells (3) Atypical glandular cells not otherwise specified b) Colposcopy done immediately (1) Repeat Pap with HPV co-testing in 12 months; if either test is positive, refer for colposcopy; if both tests are negative, return to routine testing (2) Test for HPV 16 or 16/18 genotypes (high-risk types); if positive, refer for colposcopy c) Evaluation of Abnormal Cytology d) Endocervical curettage (ECC) → scraping from internal os to external os e) Woman may experience moderate to severe cramplike pains (1) Premedicate with 600 mg ibuprofen, 30 minutes before procedure (2) Small amount of bleeding normal for up to 2 weeks

E. Surgical Treatment for Abnormal Cytology 1. Premalignant, malignant → surgical procedures a) Simple biopsy to radical surgery b) Depends on diagnosis and extent of disease 2. Goals of management to exclude presence of invasive cancer, determine extent, distribution, provide treatment 3. Treatment depends on stage of disease a) Total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), bilateral lymphadenectomy b) May include radiation, chemotherapy 4. Loop electrosurgical excision procedure (LEEP) a) Can be used to treat cervical, vaginal, vulvar intraepithelial neoplasia b) Small electrically hot wire loop can excise entire lesion c) Outpatient, local anesthesia d) Complications minimal e) Slight bleeding normal → moderate to heavy abnormal 5. Cryosurgery a) Negative ECC and no endocervical gland involvement b) Double freezing c) Less widely used due to scarring and now with LEEP available 6. Laser therapy a) Carbon dioxide (CO2) laser used to treat cervical, vaginal, vulvar lesions b) Used when all boundaries visible on colposcopy, ECC negative c) Outpatient, or office, without anesthesia 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Minimal cramping and discharge for 5–7 days e) No tampon use, intercourse, douching for 2 weeks f) Less common with effective use of LEEP 7. Conization a) Performed when entire lesion cannot be visualized or positive ECC sampling b) Cone-shaped section of cervical tissue excised c) Can be diagnostic and therapeutic d) General anesthesia e) Risks include infection, hemorrhage f) Long-term risks: spontaneous abortion, incompetent cervix, preterm labor with future pregnancies g) Prolonged, profuse menstrual period in 2 to 3 cycles h) Less frequent with availability of LEEP

F. Abnormal Uterine Bleeding 1. AUB common gynecologic problem a) Uterine bleeding in absence of pregnancy abnormal in volume, frequency, regularity, or duration b) Chronic or acute 2. Structural causes (PALM) a) Polyp b) Adenomyosis c) Leiomyoma d) Malignancy and hyperplasia 3. Nonstructural causes (COEIN) a) Coagulopathy b) Ovulatory dysfunction c) Endometrial d) Iatrogenic e) Not otherwise classified 4. Systemic diseases: coagulation disorders (von Willebrand disease, thrombocytopenia, acute leukemia, advanced liver disease) 5. Evaluation a) History and physical including pelvic exam, Pap smear b) Exclude organic causes c) Laboratory tests d) Possible additional tests (1) Transvaginal ultrasound (2) Saline infusion sonography (3) Hysteroscopy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) MRI (5) Endometrial biopsy 6. Goals of treatment a) Control bleeding b) Prevent, treat anemia c) Prevent endometrial hyperplasia or cancer d) Restore quality of life 7. Pharmacologic treatment varies a) Combined oral contraceptives (COCs) b) Short-term, high-dose estrogen therapy c) Cyclic progesterone d) Tranexamic acid e) Levonorgestrel intrauterine system 8. Surgical interventions if conservative measures not effective a) Dilation and curettage (D&C) b) Endometrial ablation c) Uterine artery embolization d) Hysterectomy

G. Dysfunctional uterine bleeding (DUB) 1. AUB without demonstrable organic cause 2. Can occur at any age but most common at either end of reproductive age span 3. Surgical intervention limited to cases in which medical therapy contraindicated or has failed

H. Ovarian (Adnexal) Masses 1. Commonly ovarian abnormality a) Can refer to masses in fallopian tubes, broad ligament, bowel, lateral mass of uterus b) 70 to 80% ovarian masses are benign (1) 50% functional cysts 2. Ovarian cysts → physiologic variation in menstrual cycle a) No relationship between benign ovarian masses and ovarian cancer b) Risk factors for ovarian cancer (1) Increased age (2) History of breast cancer (3) Gene mutation (BRCA1 and BRCA2) (4) Family history of breast or ovarian cancer (a) Most fatal → difficult to diagnose, often widespread at detection c) Symptoms of ovarian cancer may include (1) Bloating (2) Increased abdominal size 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Difficulty eating (4) Abdominal or pelvic pain (5) Urinary symptoms d) Risk decreases significantly by bearing children, taking COCs for more than 5 years, tubal ligation e) May be asymptomatic → noted on routine pelvic f) Diagnosis (1) Palpable mass, with/without tenderness (2) Often observation for 1 to2 months → most cysts resolve (a) Oral contraceptives (OCs) for 1 to2 months (3) Still present after 60 days of observation → diagnostic laparoscopy, laparotomy may be considered (4) Surgery not always necessary (a) Mass >6 to7 cm circumference (b) Older than 40 years of age (c) Woman taking OCs (d) Infant, young girl, postmenopausal woman (5) Clear explanation on why initial therapy may be observation

I. Uterine Masses 1. Endometrial polyps → pedunculated overgrowths of endometrium a) Common b) Often accompanied with mid-cycle bleeding or spotting c) Bleeding or spotting after intercourse (1) Prolonged bleeding or spotting with menstrual cycles d) Treatment → dilation and curettage (D&C) using hysteroscopy for visualization 2. Fibroid tumors → leiomyomas a) Most common benign disease entity in women b) Most are asymptomatic, requiring no treatment c) Symptoms (1) Pelvic pain (2) Menstrual irregularities (3) Infertility (4) Most seek treatment for bleeding and pain (5) May be asymptomatic and require no treatment d) Diagnosis (1) Pelvic exam (a) Irregular shaped, enlarged uterus (b) Pelvic ultrasound (c) MRI e) Treatment (1) OCs to control heavy bleeding (2) Hormones → gonadotropin-releasing hormone (GnRH) analogs 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) May be used preoperatively to reduce size of fibroid, decrease complications (b) MRI guided ultrasound of fibroid (3) Myomectomy (4) Uterine artery embolization (a) Radiologic procedure (5) Hysterectomy (6) Levonorgestrel intrauterine system (LNG-IUS) 3. Endometrial cancer a) Most common female genital tract cancer b) High rate of cure if detected early c) Risk factors include (1) Increased age (mean age 60) (2) Obesity with adult weight gain (3) Nulliparity (4) Polycystic ovary syndrome (5) Hereditary nonpolyposis colon cancer syndrome (Lynch syndrome) (6) Early menarche or late menopause (7) Use of tamoxifen 4. Nursing Management for Woman with an Abnormal Finding During a Pelvic Examination a) Nursing assessment generally toward evaluating understanding of findings, implications, psychosocial response (1) Accurate information on etiology, symptoms, treatment options (2) Realistic reassurance (3) Counseling and effective emotional support if malignancy likely (4) If surgery indicated → assist in obtaining second opinion, making decision

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of Woman with Endometriosis A. Presence of endometrial tissue outside the uterine cavity B. Has been found almost everywhere in the body 1. Most common is pelvis 2. Tissue responds to hormonal changes of menstrual cycle → bleeds cyclically

C. Occurs any age after puberty D. Exact cause unknown E. Symptoms 1. Pelvic pain related to menstrual cycle, may be chronic 2. Dyspareunia 3. Infertility 4. Fixed, tender retroverted uterus, palpable nodules in cul-de-sac on pelvic exam

F. Diagnosis → confirmed by laparoscopy G. Treatment 1. Medical a) Observation b) Analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) c) COCs d) Progestins e) Danazol f) GnRH analogs g) Nafarelin acetate and leuprolide acetate 2. Surgical a) Presacral neurectomy for severe dyspareunia or dysmenorrheal b) In advanced cases: hysterectomy with bilateral salpingo-oophorectomy 3. Complementary therapies a) Acupuncture b) Vag Packs c) Yoga d) Massage e) Traditional Chinese herbal medicine f) Spiritual therapies

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

H. Nursing Management for the Woman with Endometriosis 1. Nursing Assessment and Diagnosis a) Accurate history b) Diagnoses that may apply (1) Pain, Acute (2) Coping: Family, Compromised

I. Nursing Plan and Implementation 1. Education 2. Support 3. Referrals

J. Evaluation 1. Woman able to discuss condition, implications for fertility, treatment options 2. After considering alternatives, woman chooses appropriate treatment options

VI.

Care of the Woman with Polycystic Ovarian Syndrome

A. Complex endocrine disorder of ovarian dysfunction B. Symptoms 1. Menstrual dysfunction 2. Hyperandrogenism 3. Obesity 4. Hyperinsulinemia 5. Infertility

C. Diagnosis of PCOS 1. Complaints of hirsutism, menstrual irregularities, acne, difficulty conceiving, and unexplained weight gain 2. Rule out a) Hyperthyroidism, hypothyroidism b) Congenital adrenal hyperplasia c) Cushing syndrome d) Hyperprolactinemia e) Androgen-producing tumors

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Process a) History b) Physical examination c) Ultrasound examination may reveal polycystic changes in one or both ovaries

D. Clinical Therapy 1. Goals a) Decrease effects of hyperandrogenism b) Restore reproductive functioning for women desiring pregnancy c) Protect the endometrium d) Reduce long-term risks, specifically type 2 diabetes and cardiovascular disease e) Menstrual irregularities treated with combined oral contraceptive (COC) or cyclic progesterone f) Antiandrogens used to decrease symptoms of androgen excess

E. Long-Term Implications 1. May increase risk for developing a) Overt type 2 diabetes b) Dyslipidemia c) Hypertension d) Cardiovascular disease e) Endometrial cancer f) Breast cancer g) Ovarian cancer h) Emotion responses

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

F. Nursing Management for the Woman with Polycystic Ovarian Syndrome 1. Role in identification, evaluation, management, follow-up 2. Signs of PCOS negatively impact women’s feelings of femininity 3. Assist woman to recognize feelings, develop ways to develop more positive body image

VII.

Care of the Woman with Pelvic Relaxation

A. Muscles of pelvic floor 1. Form supportive layer that prevents abdominal and pelvic organs from prolapsing 2. Weakened or damaged → cystocele, rectocele, uterine prolapse 3. Contributing factors

B. Cystocele 1. Downward displacement of bladder 2. Symptoms a) Stress incontinence b) Complaints of feeling like something is “falling out” of her vagina c) Complaints of urinary retention, sexual dysfunction, or pelvic pressure 3. Mild → Kegel exercises a) Estrogen may improve in menopausal women 4. More severe a) Meds Detrol, DetrolLA, Oxytol, or Sanctura b) Vaginal pessaries c) Surgery

C. Rectocele 1. Posterior vaginal wall weakened → anterior wall of rectum protrudes forward into vagina a) Pocket → traps stool → constipation 2. Diagnosis a) History and physical 3. Treatment decisions a) Based on size, presence and severity of symptoms, individual situation b) Surgery often indicated

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Uterine Prolapse 1. Prolapse of uterine cervix associated with prolapse of upper vagina 2. Symptoms a) Dragging sensation, backache → relieved when lying down 3. Treatment a) Topical or systemic estrogen b) Vaginal pessaries c) Surgery → often hysterectomy and repair of prolapsed vaginal walls

VIII.

Care of the Woman Requiring Gynecologic Surgery 1. GYN surgeries common, particularly hysterectomies a) Informed decision (1) Indications (2) Risks (3) Success rates (4) Alternatives (5) Effects on childbearing and sexual performance (6) Effects on general functioning of body b) Second opinion c) Concerns (1) General anesthesia (2) Fear of death or disability (3) Concerns about limitation of normal functioning dependency during recovery (4) Financial coverage and potential financial loss (5) Concerns about welfare of family members d) Self-concept (1) Body image affected (2) Loss of reproductive organ 2. Hysterectomy a) Removal of uterus b) Most common non-pregnancy-related surgical procedure in United States for women c) Types (1) Total abdominal hysterectomy (TAH) (2) Bilateral salpingo-oophorectomy (BSO) (3) TAH-BSO (4) Total vaginal hysterectomy (TVH) (5) Laparoscopic-assisted vaginal hysterectomy (LAVH) d) Treatment for several conditions (1) TAH (a) Cancer of cervix, endometrium, ovary (b) Large fibroids 22 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Severe endometriosis (d) Chronic pelvic inflammatory disease (PID) (e) Adenomyosis (2) TVH (a) Pelvic relaxation (b) AUB (c) Small fibroids (d) Repair of vaginal walls at same time (e) Advantages (f) Disadvantages (3) BSO at same time remains controversial 3. Dilation and Curettage a) D&C: most frequent minor gynecologic procedure b) Indications (1) Diagnostic (a) Uterine malignancy, infertility evaluation, investigation of dysfunctional uterine bleeding (DUB) (2) Therapeutic (a) Elective abortion, treatment of heavy bleeding, incomplete abortion, dysmenorrhea, removal of polyps 4. Uterine Ablation a) To treat DUB b) Involve heat source (1) Cautery or balloon filled with hot water (2) Day-surgery setting (3) Often following hysteroscopy/D&C c) Success rate varies 5. Salpingectomy a) Unilateral or bilateral removal of fallopian tube b) For ectopic pregnancy → generally emergency 6. Oophorectomy a) Unilateral or bilateral removal ovary b) Indications (1) Severe PID (2) Malignancy (3) Ectopic pregnancy (4) Symptomatic ovarian cysts c) Will experience (1) Abrupt surgical menopause (2) Can be treated with estrogen replacement

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Vulvectomy a) Simple vulvectomy (1) Removal of labia majora, labia minora, clitoris (2) Leukoplakia and intractable pruritus b) Radical vulvectomy (1) Removal of entire vulva including skin, fat of femoral triangle, pelvic lymph nodes (2) Skin grafts may be necessary (3) Malignant disease c) Associated with marked psychosexual disturbances (1) Decreased sexual arousal levels (2) Low self-image 8. Nursing Management for Women Undergoing Gynecologic Surgery a) Nursing Assessment and Diagnosis (1) Identify woman’s physiologic, psychosocial, and sexual needs as surgery approaches (2) Understand her learning needs (a) Age, cultural background, education level, attitude of partner and family, preoperative status (b) Is cancer diagnosis involved? (c) Self-image b) Nursing diagnoses may include (1) Knowledge, Deficient (2) Fear c) Nursing Plan and Implementation (1) Preoperative teaching may be brief or extensive (2) Include information about procedure (a) Expected preparation (b) Type of anesthesia (c) Possible risks and complications (d) Postoperative care routines (e) Expected recovery time (3) Postoperative care (a) Monitoring of physiologic responses, emotional responses (b) Nursing interventions to facilitate physical and emotional well-being (c) Discuss psychosocial issues d) Evaluation (1) Woman can discuss reasons for surgery, alternatives, aspect of self-care after surgery (2) Woman has uneventful recovery without complications (3) Woman feels she is able to ask questions and obtain support (4) Woman participates in decision making about her care (5) Woman is aware of available resources if she has physical or emotional concerns in the postoperative period

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

A. Infertility 1. Failure to achieve a successful pregnancy after 12 months or more of regular, unprotected intercourse 2. Profound emotional, psychologic and economic impact on couple 3. Sterility absolute factor preventing pregnancy 4. Subfertility couple who has difficulty conceiving because both partners have reduced fertility 5. Primary infertility: women with no prior pregnancies 6. Secondary infertility: couples who have been unable to conceive one or more successful pregnancies

B. Essential Components of Infertility 1. Correlated with possible causes found in Table 6–4: Possible Causes of Infertility, p. 108 2. Infertility due to male (30%) factor, female (60%), or unknown or both partners (10%) 3. Refer for infertility evaluation if unable to conceive after 1 year, after 6 months if female > 35 years old.

C. Initial Investigation: Physical and Psychosocial Issues 1. Easiest and least intrusive, done first: provide information about signs and timing of ovulation, most effective times for intercourse within cycle, fertility-awareness behaviors 2. Take comprehensive history and physical assessment 3. Assess ovarian function, cervical mucus and receptivity to sperm, sperm adequacy, tubal patency, condition of pelvic organs 4. Very emotional and personal issue as couple

D. Assessment of the Woman’s Fertility 1. Evaluation of ovulatory factors a) Testing for ovulation: basal body temperature (BBT), serum testing if irregular menses, progesterone levels during cycle, serum prolactin, TSH, FSH and assessment for PCOS b) OTC urinary ovulation prediction kits c) Endometrial biopsy (EMB) d) Transvaginal ultrasound 2. Evaluation of cervical factors a) During ovulation cervical mucus increases 10-fold and elasticity increases (stretches 8 to 10 cm) b) Ferning capacity increases as ovulation approaches 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) To be receptive sperm, mucus must be thin, clear, watery, profuse, alkaline, and acellular. (Figure 6–5A). Otherwise, it is inhospitable (Figure 6–5B). (1) Intrauterine insemination (IUI) is most appropriate therapy for these issues d) Secretory immunologic reactions: antisperm antibodies causing agglutination or immobilization of sperm. IUI with washed sperm may be an option for this issue. 3. Evaluation of uterine structures and tubal patency a) Relatively uncommon b) Tubal patency and uterine structure evaluated with hysterosalpingography (HSG) or laparoscopy c) Invasive tests used include hysteroscopy and sonohysterography d) HSG (hysterography) (1) Instilation of radiopaque substance into uterine cavity for visualization (2) Injection pressure could have therapeutic effect to flush debris, break adhesions, or induce peristalsis (3) Perform early in follicular phase of cycle e) Hysteroscopy and laparoscopy (1) Hysteroscopy definitive method for diagnosis and treatment of intrauterine pathology (2) Laparoscopy enables direct visualizing of the pelvic organs to evaluate endometriosis and pelvic adhesions

E. Assessment of the Man’s Fertility 1. Some causes are reversible (ductal obstruction, varicocele) 2. Some not reversible (bilateral testicular atrophy secondary to viral orchitis, congenital bilateral absence of vas deferens) 3. Idiopathic male infertility factor is when etiology of abnormal semen analysis is not identifiable 4. Male factor usually defined by semen analysis (sperm quality, quantity, motility) a) Sample obtained after 3 days of abstinence by masturbation, before female partner’s invasive testing. Minimum of two separate analyses are recommended for confirmation (1) Low motility or number can compromise fertility (2) Morphology, motion patterns, and progression important prognostic indicators (3) Quality of sperm decreases with age

F. Methods of Infertility Management 1. Pharmacological Agents a) Clomiphene citrate is often first-line therapy: binds to estrogen receptors in the hypothalamus and pituitary gland, restores ovulation in 70% of women b) Gonadotropins such as human menopausal gonadotropins (nMGs) first line of anovulatory infertile women with low to normal FSH and LH levels; second line in women who fail to ovulate or conceive on clomiphene citrate 26 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Letrosole for ovulation induction: blocks conversion of androgens to estrogens d) Bromocriptine for anovulation related to hyperproactinemia e) GnRH for inducing ovulation but is limited to women who have insufficient endogenous release of GnRH f) Insulin-sensitizing agents for anovulatory women with PCOS that causes insulin resistance and hyperinsulinemia

G. Intrauterine insemination 1. Done with partner’s or donor’s sperm 2. Indicated for seminal deficiencies, anatomical defects related to inadequate deposition of semen, ejaculatory dysfunction, cases of unexplained infertility, some female factory infertility (inhospitable mucus, persistent cervicitis, or cervical stenosis) 3. Donor insemination (DI) alternative option with donor sperm for genetic or multifactorial disorders, single women, lesbian couples a) DI complicated and expensive

H. In vitro fertilization 1. Selectively used in cases in which infertility has resulted from tubal factors, mucus abnormalities, male infertility, unexplained infertility, male and female immunologic infertility, cervical factors 2. Overall success rates 36.8% 3. Woman’s ovaries are stimulated by a combo of fertility medications, one or more oocytes are aspirated from ovaries 34–36 hours after ovulation occurs, fertilized in a lab, then placed into her uterus after normal embryo development begins. a) Occurs over 2 weeks

I. Other assisted reproductive techniques 1. Gamete intrafallopian transfer (GIFT): retrieval of oocytes by laparoscopy; immediate placement of oocytes in catheter with washed, motile sperm; and placement of gametes into the fimbriated end of the fallopian tube. a) Fertilization occurs in fallopian tube instead of in the lab b) May be acceptable option for some religions over ZIFT 2. Zygote intrafallopian transfer (ZIFT) and tubal embryo transfer (TET): eggs are retrieved and incubated with the man’s sperm a) Eggs transferred back into woman’s body at earlier stage of cell division than IVF 3. Preimplantation genetic diagnosis a) Single cell removal from embryo for genetic testing b) Detects single-gene or chromosomal anomaly c) Preimplantation genetic testing called blastomere analysis or preimplantation genetic diagnosis (PGD) 27 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Preimplantation genetic screening (PGS) is used when parents presumed to have normal chromosomes and embryos are screened e) All types can produce false negatives or positives f) Raises ethical concerns

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

J. Adoption 1. U.S. adoptions can be long, expensive, and difficult 2. Some couples choose to do international adoption 3. May need support if unable to be parents through books, websites, support groups

K. Pregnancy after infertility 1. Fear and anxiety common, don’t know where they “fit in” 2. Cautious about impact of treatments on the fetus, need reassurance 3. Nurses should acknowledge their past experiences, validate their fears, and provide support and education

L. Recurrent Pregnancy Loss 1. Distinct from infertility 2. Defined as three or more consecutive pregnancy losses, but definition not standardized 3. Etiologies include chromosomal abnormalities, uterine abnormalities, maternal medical complications, autoimmune disorders, and thrombotic causes

M. Nursing Management for the Infertile Couple 1. Treatment and care costly and taxing, may feel discriminated against due to inability to have children easily 2. Be aware of emotional needs of couple 3. Couples may experience feelings of loss of control, reduced competency and defectiveness, loss of status and ambiguity as a couple, sense of social sigma, stress on marriage 4. Assess and respond to emotional and educational needs using multidimensional needs of the couple 5. Refer as needed to mental health professionals

IX.

Focus Your Study

Activities 1. Individual Assign students a diagnosis or surgical procedure. Have students develop a teaching plan for the 25–30-year-old patient. Have each student identify adjustments to be made for the 65–75year-old patient with the same diagnosis or procedure.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Small Group Break the class into small groups of three to five students. Ask each group to pick one of the individual activities to research. Instruct the students to include pharmacologic therapy, complementary therapy, and the demographics of the patients, as well as the common psychosocial and cultural implications. 3. Large Group Invite a nurse from a gynecologic oncology practice or infertility practice to speak to students about postoperative care, and include case studies with examples of “typical” and “atypical” patients and their procedures.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 7 Social Issues Social Issues Affecting Women Living in Poverty..............................................

Social Issues Affecting Women in the Workplace.............................................

Social Issues Affecting Older Women................................................................

Social Issues Affecting Women with Disabilities...............................................

Social Issues Affecting Lesbian, Bisexual, and Transgender Women................

Female Genital Mutilation (FGM)......................................................................

Focus Your Study................................................................................................

Activities.............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Social Issues Affecting Women Living in Poverty

A. The Feminization of Poverty 1. Single mothers in poverty a) Single-mother–headed households 🡪 36.5% b) Race → minority parents 2. Globally—not just in the United States a) Women work more hours than men but are paid less b) Expected to bear and raise many children and work c) Frequently abused; have few legal rights 3. Poverty linked to lack of literacy and education

B. Economic Effects of Divorce 1. Woman’s standard of living generally decreases significantly, man’s increases a) Lower earning capacity b) Custody of children c) Child support

C. Factors Contributing to Poverty for Working Women 1. Increasing participation in labor force 2. Increased earnings → significant wage discrepancy still exists a) 2012 statistics b) Factors (1) Pink collar occupations (2) Women paid less than men for work in virtually all occupations (3) Smaller pensions and social security benefits due to lower pay 3. Child care expenses a) Single mother → miss work when child sick

D. Public Assistance 1. Often fail to provide adequate assistance 2. Temporary Assistance for Needy Families (TANF) grant program a) Purpose (1) Provide assistance to needy families so children may be cared for in own homes or homes of relatives (2) End dependence of needy parents on government benefits by promoting job preparation, work, marriage (3) Prevent and reduce incidence of out-of-wedlock pregnancies (a) Goals for preventing and reducing 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Encourage the formation and maintenance of two-parent families 3. State has flexibility in designing programs to meet needs of recipients a) Recipients required to find employment after they receive assistance for 2 years b) Live at home (or in adult-supervised setting) and stay in school if unmarried teenage parents c) Pay child support if noncustodial parents

E. Homelessness 1. 2016 estimate—564,708 people homeless on any given night in United States a) Veterans: 6% b) Members of families → 206,286 c) Children: 36% of homeless population 2. Factors contributing to homelessness a) Families headed by single mother b) Lack of affordable housing or low-cost housing c) Job loss d) Unstable economics e) Eroding work opportunities f) Mortgage foreclosure g) Low-paying jobs h) Substance abuse i) Untreated or undertreated mental illnesses j) Poverty k) Recent prison release l) Changes and cuts in public assistance programs m) Poor educational attainment n) Minority race o) High number of children p) Lack of family or social support 3. Health risks of homeless women and children a) Malnutrition predisposes to variety of disorders b) Preventative healthcare services not received c) Inadequate prenatal care d) Increased incidence of low-birth-weight newborns e) Higher rate of infant mortality f) Higher incidence of substance abuse, including alcohol g) Higher rates of sexually transmitted infections h) Higher rates of hepatitis A, B, and C and HIV/AIDS 4. Homelessness in adolescence a) Can be related to disagreements with parents, divorce, prenatal substance abuse, neglect, and abuse. 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Increased risk for commercial sexual exploitation of children (CSEC) c) Adverse outcomes further increased in those in the LGBTQI population

F. Effects of Poverty on Women’s Healthcare 1. Medicaid provides healthcare to low-income in four categories a) Children b) Adults in families c) The elderly d) Blind and disabled 2. Traditionally financing maternity care → 48% of births in United States a) No automatic connections with TANF and Medicaid b) TANF recipients eligible for Women, Infants, and Children nutrition program (WIC) and other programs c) 2010 passage of the Affordable Health Care Act (1) Increase quality and affordability of health insurance (2) Lower the uninsured rate (3) Expand public and private insurance coverage (4) Reduce costs of healthcare 3. Lack of health insurance a major problem a) 2015: 10.5% of non-elderly Americans still did not have health insurance b) Led to decline in preventive services c) Implications for childbearing care 4. Assessing woman’s financial status is part of the initial family assessment a) Resources may be unavailable to buy infant supplies, etc. b) Ask in sensitive manner c) Be knowledgeable about community resources and referrals d) Working with community groups, organizations

II.

Social Issues Affecting Women in the Workplace

A. In 2016, 72.5% of women with children under the age of 18 were employed outside the home 1. Tremendous day-to-day stress → career and family a) Financial pressures

B. Wage Discrepancy 1. Historical trends a) Perception that men are sole breadwinners b) Women in past generations limited to certain occupations c) Women accepted lower salaries in exchange for provisions d) Perception that women who were competitive are viewed negatively 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Increase in societal importance focusing on appearance rather than intellect f) Societal trends that did not support higher education opportunities for women

C. Maternal and Paternal Leave Issues 1. Full-time employment and motherhood challenging a) 1993 Family and Medical Leave Act (FMLA) signed into law (1) Up to 12 weeks unpaid leave from work following birth or adoption or foster child (2) Serious illness of self, spouse, child, parent (3) Continued health insurance benefits (4) Job security to return to person’s former position or one considered comparable (5) Applies to companies with 50 or more employees (6) Employees must work 25 hours per week to be eligible (7) Employees must be in their position for 1 year 2. U.S. parental leave benefits meager compared to other countries a) Paid parental leave is a rule rather than an exception

D. Discrimination Against Pregnant Women 1. Due to stereotypes about pregnancy 2. Pregnancy Discrimination Act of 1978 guarantees a) Pregnant woman cannot be denied job if able to perform major job functions b) Same procedure for using sick leave pay or disability benefits must be used for pregnant woman as for others c) Employee medical coverage must include pregnancy benefits d) Mother can use all maternity benefits without penalty 3. Planning pregnancy a) Acquire information about pregnancy benefits in work setting

E. Child Care 1. 1947 to 2016 → 12% to 60.8% of mothers with small children were employed a) Number of stay-at-home dads has doubled b) 69% of children raised in two-parent households c) 35% of children raised in single-mother households d) 4% of children raised in single-father households 2. Child care costs a large portion of family budget 3. Costs vary based on a) Geographic location b) Age of children c) Children with disabilities d) Type of facility e) Educational level of staff 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Women with college educations and working outside the home a) More likely to enroll children in high-quality child care centers b) Creative approaches by some employers 5. million children live with their grandparents a) Grandparents with guardianship may qualify for benefits

F. Advocacy for Working Women 1. All women should find out prior to accepting employment a) Inquire about maternity, paternity leave, child care benefits, flexible hours, onsite day care b) Flexible break periods to breastfeed or pump breast milk

G. Environmental Hazards in the Workplace and at Home 1. Environmental toxins a) Air, food, water → can lead to adverse health effects b) Gases, chemicals at work and home, substances that contaminate food sources c) Lead-based paint (1) Adverse outcomes in children: learning disabilities, behavioral disturbances, cognitive changes, adverse kidney and nervous system functioning (2) Women during pregnancy: risk for spontaneous abortion, prematurity, low birth rate, intrauterine growth restriction, and brain, kidney, and nervous system dysfunction d) Air pollution (1) Minor problems to serious problems (2) Indoor air pollution → cigarettes, candles, wood-burning stoves, kerosene lamps, oil furnaces, cleaning products, paint, varnish, carpets (3) Pressed-wood products may release formaldehyde gas (4) Radon (5) Cat dander, molds and mildew, dust mites, cockroaches 2. Chemicals a) Only 1,500 of 80,000 chemicals in industry tested b) May harm unborn children (1) Increased risk working around paints, varnishes, sealants, dry cleaning chemicals, synthetic perfumes, hair and clothing dyes, organic solvents (2) Chemicals in home → polyvinyl chloride (PVC) releases harmful chemicals when heated (3) Beauty products → phthalates 3. Pesticides a) Vague symptoms b) Increased risk of cancer c) Nervous system abnormalities d) Birth defects 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Endocrine abnormalities f) Hormonal imbalances g) Liver damage h) Kidney failure (1) Organochlorines degrade slowly (a) Passed from mothers to babies in womb and breast milk i) Pesticide residue in produce, fish, meats j) Mercury and PCBs found in certain types of fish k) Commercially raised meat animals contain antibiotics 4. Biological and chemical toxins a) Nurses exposed (1) Toxoplasmosis, rubella, cytomegalovirus, herpes simplex, hepatitis B (2) HIV via needle stick (3) Latex allergy b) Occupational Safety and Health Administration (OSHA) 5. Nurses need to educate women, childbearing families about risks they face

III.

Social Issues Affecting Older Women

A. Economic Vulnerability of Older Women 1. Older women more likely to be widowed, live alone, be disabled, or be poor a) Older women of color highest poverty rate 2. Factors a) Older women tend to have less educational preparation than older men b) Women must stretch financial resources further because of longer life expectancy c) Historically, women economically dependent on men d) Typically earn less, work in jobs without pension benefits, limited benefits e) Intermittent employment common → decreases social security and retirement benefits f) Generally have more family caregiving responsibilities than men g) Husband’s long, costly illness and decrease or loss of his pension following his death can negatively impact a woman’s financial resources h) Women are living longer, more likely to have out-of-pocket medical expenses after the age of 65 i) Women spend twice as much as men on long-term care expenses

B. Elder Abuse 1. See Table 7–2: Definitions of Elder Abuse, p. 130 2. Definition a) Any deliberate action, or lack of action, that causes harm to an elderly person b) Difficult to determine

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Five categories a) Physical abuse (1) Any physical pain or injury that is intentionally inflicted upon an elderly person by caregiver or person in position of trust (2) Includes sexual assault, physical attacks, unreasonable physical restraint, prolonged deprivation of food and water b) Financial abuse (1) Any theft or misuse of elderly person’s property or money by a caregiver or person in position of trust c) Neglect (1) Failure on part of caregiver to provide adequate reasonable care, which is the degree of care that a reasonable person would provide d) Psychologic abuse (1) Intentional infliction of mental suffering on an elder by a caregiver or person in position of trust (2) Includes, but not limited to, verbal assaults, threats, humiliation, intimidation, isolation e) Abandonment (1) Desertion of an elder by any person responsible for the care and custody of that elder, under circumstances in which a reasonable person would continue to provide care 4. Nursing responsibility a) If you suspect elder abuse → take steps to address the problem when it is identified

C. Implication of Aging for Women’s Health and Healthcare 1. Older women often face health problems a) Hypertension, coronary artery disease, arthritis, diabetes, osteoporosis, dementia, depression b) Heart disease, cancer, and chronic lower respiratory disease → leading causes of death for all women age 65 or older c) By age 65, half of all women have developed two or more chronic diseases 2. Older women face multiple barriers in obtaining adequate healthcare services a) Lack of transportation b) Lack of private health insurance coverage c) Excessive medical costs 3. Polypharmacy a) Elderly women: multiple healthcare providers b) Multiple medications with possible side effects or dangerous interactions c) Polypharmacy may be justified; may be inadvertent d) Nutritional supplements → can interact with prescription medication (1) Maintain a medication list (2) Fill prescriptions at same pharmacy 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Provide family member or care provider with updated medication list e) Diminished kidney and liver function → central nervous system (CNS) medications may cause forgetfulness, confusion, disorientation, inability to concentrate

IV.

Social Issues Affecting Women with Disabilities A. Definitions of Disability 1. Chronic physical or health problem or impairment that restricts an individual’s ability to perform one or more major activities 2. Work disability restricts individuals from employment 3. Severe disabilities prohibit individuals from performing basic activities of daily living without assistance

B. Types of Disabilities 1. Developmental disabilities create severe limitations in three or more of these areas a) Self-care b) Receptive and expressive language c) Learning d) Mobility e) Self-direction f) Ability to live alone g) Financial independence 2. Intellectual disability most common 3. Women with intellectual disabilities often faced mandatory sterilization in early to mid-20th century a) Human rights → sexual choices b) May pursue prenatal care services later than other women c) Failure to recognize signs and symptoms related to pregnancy d) Common to request termination services and sometimes after gestational age limit e) 25% of women with intellectual disabilities who give birth become involved with Child Protective Services (CPS) f) Additional social support, parenting education, peer support, modified teaching methods

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Learning disabilities can inhibit educational attainment and employment 5. Common neurologic disabilities 6. Psychiatric disabilities 7. Sensory disabilities

C. Economic Vulnerability of Women with Disabilities 1. Only 18% of women with disabilities employed a) Many part time 2. Barriers to employment a) Lack of education and training b) Transportation c) Disability access d) Need for special accommodations e) Rural areas; fewer employment options f) American with Disabilities Act (ADA) intended to reduce barriers 3. Typically earn less than women who are not disabled a) Greater number live in poverty

D. Violence Against People with Disabilities 1. Women with disabilities twice as likely to be victims of domestic violence than nondisabled women a) 50% of disabled women will experience abuse or violence

E. Effects of disability on women’s healthcare 1. Health services often suboptimal a) Barriers b) Receive less preventive care c) Assumption that the disabled are not sexually active → not screened for sexually transmitted infections (STIs)

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Social Issues Affecting Lesbian, Bisexual, and Transgender Women A. Quality of Life 1. Employment and housing discrimination 2. Discrimination involving marriage, domestic life, and parenting issues 3. General social discrimination

B. Employment Discrimination 1. Most common complaint to American Civil Liberties Union (ACLU) is from LGBTQI individuals 2. Private sector and military a) Don’t Ask, Don’t Tell Repeal Act of 2010 (1) Allows military service members to be openly gay or lesbian and serve in the military

C. Marriage Discrimination 1. In 2015, same-sex marriage became legal in all 50 states

D. Spousal Benefits 1. Married LGBTQI families now have equality and receive the following benefits: a) Social security benefits b) Tax return benefits for joint filing c) Estate tax and estate planning benefits d) Estate and gift tax exemptions e) Estate tax portability f) Life estate trusts g) Veteran and military benefits h) Federal employee benefits i) Immigration benefits

E. Housing Discrimination 1. Fair Housing Act a) Protects various groups b) Generally does not apply to LGBTQI community

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Some states and municipalities have enacted antidiscrimination laws 3. Some states discriminate on basis of sexual orientation 4. May not be able to use combined income to determine eligibility for mortgage

F. Parenting Issues 1. Second-parent adoption 2. Many lesbian women wish to adopt a) Barriers b) Policies, legislation 3. Foreign adoptions not necessarily easier 4. Discriminatory tax laws because partners/parents not legally married

G. Social Barriers 1. Discrimination, danger a) Treated rudely, ostracized 2. Hate crimes 3. Acceptance of gay men and women on rise

H. Effects of Discrimination on Lesbian, Bisexual, Transgender, and Intersex Women’s Healthcare 1. Healthy People 2020 acknowledged sexual orientation as risk factor a) Lack of insurance (1) Less likely than heterosexual women to have health insurance b) Fear of discrimination on part of providers c) Provider ignorance of lesbian and bisexual women’s healthcare needs (1) Increased risk of suicide (2) Increased risk of homelessness (3) Increased risk of violence (4) Increased risk of obesity (5) Increased risk of depression rates (6) Increased tobacco use (7) Higher incidence of alcohol use (8) Increased risk of substance abuse disorders (9) Lack of screening for female-related cancers

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Female Genital Mutilation

A. FGM: practice of removing all or part of a girl’s or woman’s genitalia for cultural reasons B. Origin and demographics 1. Performed most commonly in sub-Saharan Africa and to a lesser extent in Asia and the Middle East 2. Reasons a) Perceived improved hygiene b) Social acceptance c) Marriageability d) Preservation of virginity/reduction of female sexual desire e) Male sexual desire f) Religious requirement 3. Varying degrees of mutilation a) Complete removal of external genitalia to complete removal of clitoris

C. Health problems 1. Bleeding 2. Infection 3. Urinary tract infections 4. Urinary strictures 5. Reproductive tract infections 6. Infertility 7. Painful intercourse 8. Difficulties relating to childbearing

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students review Healthy People 2020. Have students identify issues that are identified that are specific to women, issues that have been resolved or improved, and issues that have not been improved. Have each student write a short paper (one to two pages, references cited using APA format) linking health issues to other social issues affecting women.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Small Group Divide the class into small groups of three to five students. Have each group identify an issue of interest to group (or assign an issue to each group). Ask the groups to use the Internet and other available resources to identify community support resources for their assigned health or social issue. Instruct each group to compile a resource list with phone numbers and addresses and to confirm the resources by calling or visiting to determine the available services. 3. Large Group Invite a community nurse or social worker to you classroom to discuss the procedures necessary for unemployed mothers to access healthcare services, housing assistance, and so on.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 8 Violence Against Women Endemic in Society............................................................................................

Historic Factors Contributing to Violence Against Women.............................

Domestic Violence............................................................................................

Sexual Assault...................................................................................................

Sex Trafficking...................................................................................................

Focus Your Study..............................................................................................

Activities............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Endemic in Society

A. Intimate partner violence (IPV) and sexual assault B. Statistics 1. IPV declined between 1994 and 2010 a) Rates of violence are higher among lesbian and bisexual woman b) Older woman can be victims of intimate partner violence c) Estimated health-related costs of violence against women: $8.3 billion annually in United States d) Controlling individuals are more likely to be physically assaultive

C. Role of healthcare providers, organizations 1. Healthy People 2020: IPV prevention for violent behavior national priority 2. Nursing role

II.

Historic Factors Contributing to Violence Against Women 1. Patriarchal societies 2. Legal status of women improved 3. Traditional view of rape 4. Violence against women and girls now being used as weapon of war

III.

Domestic Violence

A. Defined (intimate partner violence [IPV]) 1. Pattern of coercive behaviors and methods used to gain and maintain power and control by one individual over another in an adult intimate relationship

B. Common in the United States 1. 1 in 4 women will experience domestic violence 2. Forms of abuse a) Physical abuse (1) Pushing (2) Shoving (3) Slapping (4) Hitting with fist or object (5) Kicking (6) Choking (7) Threatening with a gun or knife 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(8) Forcing alcohol or drug abuse b) Emotional abuse (1) Constant criticism (2) Name calling (3) Unreasonable demands (4) Damaging relationship with children and others c) Sexual abuse (1) Forced sex (2) Sexually demeaning treatment d) Isolation (1) Controlling who she sees and where she goes (2) Jealousy to restrict actions (3) Interfering with job (4) Forbidding her to see friends and family (5) Limiting outside involvement e) Economic abuse (1) Preventing her from getting a job or keeping a job (2) Controlling the money; having her ask for money (3) Destroying her property (4) Making all the financial decisions f) Coercion threats g) Intimidation h) Using others i) Male privilege j) Stalking (1) See Figure 8–2: The power and control wheel, p. 141 3. Abuse typically begins slowly, subtly 4. Consequences of abuse profound a) Physical consequences b) Adverse psychologic consequences (1) Post-traumatic stress disorder (2) Depression (3) Antisocial behavior (4) Anxiety (5) Suicidal behavior (6) Low self-esteem (7) Fear of intimacy c) Social consequences

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Contributing Factors 1. Childhood experiences 2. Male dominance in the family 3. Marital conflict 4. Unemployment/low socioeconomic status 5. Traditional definitions of masculinity/hypermasculinity 6. Internalized homophobia (within lesbian relationships)

D. Common Myths about Battering and Women with Abusive Partners 1. Battering occurs in a small percentage of the population a) As many as 1 in 4 are victims; widely underreported crime 2. Women who are abused provoke men to beat them; women push men beyond the breaking point and incite physical violence a) People are responsible for their individual behavior b) Batterers violent because of their own inadequacies 3. Alcohol and drug abuse cause battering a) Claims that substance abuse causes domestic violence are false b) Alcohol and drug reduce batterer’s inhibitions, increasing likelihood of violent acts 4. Battered women can easily leave situation a) Difficult → society, finances, support b) Battered women may fear for her safety, the safety of her children, and those that help her 5. Domestic violence is a low-income or minority issue a) All sectors of society 6. Battered women will be safer when they are pregnant a) Battering may escalate in intensity

E. Cycle of Violence 1. Tension-building phase a) Batterer demonstrates power and control b) Woman may blame self, believe she can prevent escalation 2. Acute battering incident a) Typically triggered by external event, or internal state of batterer b) Batterer blames woman for abuse 3. Tranquil phase or honeymoon period a) Characterized by extremely loving, kind, contrite behaviors by batterer 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) May be absence of tension and violence

F. Characteristics of Batterers 1. All racial, ethnic, religious groups 2. All professions, occupations, socioeconomic strata 3. Commonalities a) Feelings of insecurity, inferiority b) Powerlessness, helplessness → conflict with assumptions of male supremacy c) May feel undeserving of partners d) Jealousy and possessiveness hallmarks of abusers e) May select partner they feel to be vulnerable f) May lack respect toward women in general g) May have been abused

G. Nursing Management for the Woman Experiencing Domestic Violence 1. Women enter healthcare system in many different settings a) Physician’s office b) Emergency department c) Obstetric services d) Psychiatric-mental health 2. May have no visible injuries 3. Women may return to abusive situations a) Statistics show risk for homicide, additional violence → greatest during separation, attempts at separation 4. Nursing Assessment and Diagnosis a) Universal screening advocated b) Importance and need for comprehensive education and training c) Nurses may be hesitant to ask questions d) Basic screening questions useful in identifying women who are experiencing abuse e) Signs that may indicate woman in abusive relationship include (1) Neurologic (2) Gynecologic (3) Obstetric (4) Gastrointestinal (5) Musculoskeletal (6) Psychiatric (7) Constitutional (8) Trauma (9) Other signs f) Nurse alert for cues of abuse

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Hesitation in providing details (2) Inappropriate affect for situation or about injury and how it occurred (3) Defensive injuries (4) Delayed reporting (5) Pattern of injury (6) Inappropriate explanation (7) Vague complaints without accompanying pathology (8) Lack of eye contact (9) Increased anxiety in presence of possible batterer g) Arrange for private place in which woman can feel safe (1) Encourage woman to talk about her injuries and home situation (2) Demonstrate willingness to talk about violence (3) Remain nonjudgmental 5. Assessment a) Determine sense of history and pattern of abuse b) Information about strengths, support system c) Cultural context d) Building relationship based on trust, understanding, advocacy e) Record extent of injuries f) Note woman’s exact words g) Describe incident 6. Diagnoses a) Powerlessness, Risk for b) Knowledge, Readiness for Enhanced 7. Nursing Plan and Implementation a) Reestablish feeling of control (1) Provide information that woman can understand b) Supportive counseling, reassurance (1) Acknowledge and support woman for discussing situation (2) Let woman work through story at her own pace (3) Let woman know that she is believed, feelings reasonable and normal (4) Anticipate ambivalence in relationship with batterer (5) Assist in identifying specific problems, support realistic ideas (6) Help clarify woman’s beliefs and myths (7) Stress that no one should be abused → abuse is not her fault 8. Health promotion education a) If woman returns to abusive situation → encourage her to develop an exit/safety plan for self and children (1) Pack a change of clothes for herself and her children (2) Ask a neighbor to call the police if violence begins (3) Have money and identification documents ready (4) Have a plan of where to go regardless of time of day or night 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Identify friends and family who know about the situation and are willing to help (6) Have a planned escape route and emergency numbers to call 9. Community-based nursing care a) Inform woman of services available (1) Hospital (2) Agencies (3) Community (4) Phone numbers b) Needs of abused women (1) Medical treatment for injuries (2) Temporary shelter (3) Legal assistance (4) Financial assistance (5) Job training, employment counseling (6) Counseling c) Network of community agencies (1) Emergency department services (2) Shelters (a) Contacted through community crisis line (3) Legal services and options (a) Vary according to state laws and services (b) Restraining/protective order (c) Legal advocacy services (4) Financial services (5) Employment training or placement (6) Counseling or advocacy 10. Evaluation a) Woman receives compassionate, respectful, individualized medical attention b) Woman recovers from physical effects of physical and sexual abuse c) Woman has information she needs to make a decision about future based on thoughtful consideration of alternatives d) Woman able to identify culturally appropriate community resources available to her, develops strategies for keeping herself safe e) All necessary documentation is recorded in medical records in case of prosecution

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Sexual Assault A. Refers to variety of types of unwanted sexual touching or penetration without consent 1. From unwanted sexual contact or touching of an intimate part of another person 2. To forced anal, oral, or genital penetration 3. Rape → forced sexual intercourse including both psychologic coercion as well as physical force a) Includes penetration by offender or foreign object 4. One of most underreported crimes in United States a) Reporting varies by type of rape or sexual assault b) 9 out of 10 victims female

B. Common Myths about Rape 1. Only certain types of women are raped 2. Men rape women because that is men’s nature, biologic role 3. Women who party hard, drink, and do drugs are setting themselves up for sexual assault 4. If woman just relaxes, it will all be over with soon, might even find it isn’t so bad after all 5. Rapist is easy to spot in crowd 6. Women lie about rape as an act of revenge or guilt 7. Fighting back incites rapist to violence

C. Characteristics of Perpetrators 1. All ethnic, racial, religious, socioeconomic, educational, professional backgrounds 2. Attitudes toward women 3. Impulsive, antisocial tendencies 4. Male, alcohol, drug use 5. Emotionally unsupportive family environment 6. Beliefs that support male entitlement and sexual violence

D. Types of Rape 1. Power rape → purpose is control or mastery a) Vast majority of rapes

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Anger rape → used to express feelings of rage a) Brutality and degradation characterize this type of rape 3. Sadistic rape → antisocial personality, delights in torture, mutilation a) Cause the most injuries, including homicide 4. Stranger rape → sudden, unexpected 5. Acquaintance rape → assailant is someone the victim has had previous nonviolent interaction a) Nonstranger rape b) Marital rape c) Date rape 6. Gang rape → reinforcing mechanism for membership in particular group of men a) Provides means for demonstrating power → prove status in group

E. Role of Substances in Sexual Assault 1. Used to sedate intended victim a) Alcohol most common b) Flunitrazepam (Rohypnol) c) Gamma hydroxybutyrate (GHB) d) Ketamine e) MDMA (Ecstasy) f) Clonazepam g) Scopolamine 2. See Table 8–1: Indicators of Possible Drug-Facilitated Sexual Assault, p. 150 a) Becoming intoxicated very rapidly b) Having just one or two drinks, then suddenly feeling very drunk c) Feeling drowsy, dizzy, agitated weak, confused, nauseous, increased heart rate or blood pressure, slurred speech, lack of motor coordination d) Waking up suspecting she may have been raped because of vaginal soreness, finding self in unfamiliar place, other indicators e) Being told she suddenly appeared drunk, drowsy, dizzy, confused with impaired motor skills, judgment, amnesia or partial amnesia

F. Date Rape and Violence on College Campuses 1. 23.1% of all undergraduate females experience sexual assault or rape 2. Increased awareness of rape and violence has occurred in the wake of high-profile cases 3. Title IX Legislation a) Best known for its requirement that all colleges and universities that receive federal funding provide equal opportunities for women in athletic programs, facilities, educational programs, etc. 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Also addresses the issue of sexual harassment and violence against women. c) Campuses now have Title IX officers who actively work to provide education to students, faculty, and staff about these issues.

G. Rape Trauma Syndrome 1. Four phases a) Acute (disorganization) phase (1) Begins during rape → few days, up to 3 weeks (2) Shock, disbelief, denial (3) May feel humiliated, guilty, unclean (4) May suppress emotions or reveal them (5) Alterations in sleep patterns b) Outward adjustment (denial) phase (1) After acute stage passed → may appear adjusted (2) Means of regaining control of life (3) May move, institute security measures c) Reorganization (1) As denial and suppression deteriorate → depression, anxiety, urge to talk about rape (2) Alters self-concept, resolve feelings (3) May develop phobias (4) Frequently report menstrual, GYN disorders, sexual dysfunction (5) Long-term physical, psychologic health consequences (a) Pregnancy (b) Chronic pain (c) Gastrointestinal disorders (d) Headaches (e) Sexually transmitted infections (f) Depression (g) Fear and anxiety (h) Sleep disorders (i) Difficulty trusting others (j) Eating disorders (k) Attempted or completed suicide (l) Postraumatic stress disorder (m) Unhealthy behaviors d) Integration and recovery (1) Resolution (2) Blame lies with assailant e) Silent reaction (1) Women who do not report (2) May seek help for injuries without disclosing rape

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

H. Sexual Assault as a Cause of Posttraumatic Stress Disorder 1. Diagnosis a) Must have been exposed to traumatic event that triggered feelings of intense fear, horror, helplessness b) Reexperience event in recurrent, intrusive thoughts, images, perceptions, flashback c) Persistently avoid stimuli associated with the trauma, demonstrate generalized numbness of responsiveness d) Demonstrate persistent signs of increased arousal 2. Marked by varying degrees of intensity a) Prior mental health issues b) Woman’s own resiliency 3. Difficult to treat

I. Physical Care of the Sexual Assault Survivor 1. Primary purpose of care to meet needs of survivor a) Evaluate and treat injuries b) Conduct prompt examinations c) Provide support, crisis intervention, advocacy d) Provide prophylaxis against STIs e) Assess for pregnancy risk, discuss treatment options f) Provide follow-up care (1) Medical and emotional needs 2. Secondary purpose of care a) Collect and preserve legal evidence for use in prosecuting assailant b) Even though evidence collected → survivor does not have to prosecute c) Respect rights of survivor 3. Secondary victimization a) Victim blaming, insensitive and prying care b) Forensic nurse examiner (FNE) and sexual assault response team (SART) → multidisciplinary community programs c) Advocacy in the emergency department 4. Detailed history a) Essential first step in acquiring medical and forensic data b) Caring and sensitive → therapeutic tool 5. Collection of evidence a) May be traumatic for the woman b) Thorough explanation → informed consent form c) Chain of evidence (1) Physical evidence and specimens in hands of professional and then police officer

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Vaginal and rectal examinations (3) Complete physical examination for trauma d) Clothing (1) Clothing marked, placed in individual paper bag, sealed, labeled e) Swabs of stains and secretions (1) Analyzed for semen or sperm (2) Cultures f) Hair and scrapings (1) Clippings or scrapings of woman’s fingernails (2) Hairs pulled from woman’s head, pubic area (3) Pubic hair combed to check for loose hairs g) Blood samples h) Urine samples (1) If drug-facilitated sexual assault suspected (2) Drug ingested within 96 hours of evidentiary exam i) Photographs (1) Of injured areas (2) Informed consent form 6. Prevention of sexually transmitted infections a) Common → trichomoniasis, bacterial vaginosis, gonorrhea, chlamydia b) Preventative therapy recommended (1) Centers for Disease Control (CDC) → single-dose intramuscularly (IM) ceftriaxone, single-oral dose metronidazole, single-oral dose azithromycin (2) Instruct to see caregiver in 2 weeks for assessment c) Hepatitis B risk → hepatitis B vaccination if never immunized 7. Prevention of pregnancy a) Questioned about menstrual cycle, contraception b) Receive information about treatment options

J. Nursing Management for the Woman Who Has Been Sexually Assaulted 1. Often access healthcare system through ED a) Nurses must examine own attitudes and beliefs about sexual assault and survivors b) Mindful of potential for increased complexity of treatment → cultural backgrounds 2. Nursing Assessment and Diagnosis a) Create safe, secure environment b) Full mental status examination c) Scrupulous documentation d) Diagnoses may include (1) Fear (2) Powerlessness

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing Plan and Implementation a) See Table 8–3: Nursing Actions Appropriate to Phases of Recovery Following Rape, p. 154 (1) Acute phase (a) Create safe environment (b) Explain sequence of events in healthcare facility (c) Allow woman to grieve and express feelings (d) Provide care for significant others (2) Outward adjustment phase (a) Provide advocacy, support at level requested by the woman (b) Provide assistance to significant others (3) Reorganizational phase (a) Establish a trusting relationship (b) Assist woman in understanding her role in the assault (c) Clarify and enhance woman’s feelings (d) Assist the woman in planning for her future (4) Integration and recovery (a) Acknowledge victim’s success in overcoming trauma (b) Support advocacy efforts 4. Community-based nursing care a) Reorganization phase → urge to discuss, resolve feelings (1) Specially trained sexual assault advocate, counselor (2) Information and support to explore, identify feelings b) Health promotion education (1) Preventive strategies (2) What to do during and after an attack c) See Table 8–4: General Guidelines for Helping Victims of Sexual Assault, p. 155 (1) Believe the victim (2) Listen and be patient (3) Reinforce that sexual assault was not victim’s fault (4) For recent assaults, encourage reporting, and preservation of evidence (5) Encourage person to seek medical attention (6) Suggest seeking counseling, other support services (7) Help victim to organize thoughts, let survivor make own decisions (8) Take care of yourself (9) Acknowledge limits, realistically identify abilities to assist survivor 5. Sexual assault advocacy and information a) Sexual assault crisis centers → 24 hours/day, 7 days/week 6. Evaluation a) Woman receives prompt, compassionate, respectful individualized medical attention b) Woman recovers from physical effects of sexual assault c) Woman able to verbalize recognition that sexual assault is crime of violence expressed sexually 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Woman able to identify culturally appropriate community resources available to her e) Woman able to make decision about whether to prosecute assailant f) If victim decides to prosecute, all necessary forensic evidence collected

K. Prosecution of the Assailant 1. Considered crime against state rather than victim a) Victim must initiate process 2. Second rape: victim must identify assailant, repeat details of assault 3. Cross-examination by defendant’s attorney can be degrading, intimidating 4. Rape shield laws 5. Nurse needs to be aware of judicial sequence a) Anticipate rising tension, frustration in the victim and support system

L. Responding to Violence Against Women: Vicarious Trauma 1. Gradual internal transformation a) Negatively affect commitment to one’s work b) Reduce sense of accomplishment c) Lead to questioning of personal belief system 2. Burnout 3. Similar to vicarious trauma, more severe

Sex Trafficking 1. Refers to “the recruitment, harboring, transportation, provision, or obtaining of a person, through force, fraud, or coercion, for the purpose of commercial sex” (Nurse Practitioner’s in Women’s Health [NPWH], 2017, p.8). 2. Domestic minor sex trafficking (DMST) is a subset of the problem. a) Refers to the specific engagement of minors less than 18 years of age. b) Refers to sexual acts in which the child is the victim of sexual exploitation for remuneration to survive (1) i.e., money, shelter, food, or clothing 3. In 2000 the U.S. Trafficking Victims Protection Act (TVPA) was passed to address this issue. a) Updated the post-Civil War slavery statutes b) Narrow in scope and only provides assistance to undocumented immigrant women who are victims of severe forms of trafficking and to girls under age 18. 4. Females who are at highest risk for sex trafficking: a) Young b) Limited education c) Engage in drug use 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Live in extreme poverty e) History of abuse in their family f) Adolescent runaways at greatest risk 5. Long-term health issues for victims of sex trafficking: a) Unintended pregnancies b) Poor dentitian due to malnutrition c) Sexually transmitted infections d) Depression e) PTSD 6. Nursing assessment for signs an individual may be in an exploitive situation: a) Similar to signs of domestic violence b) Submissive behavior and evidence of being controlled c) Vague answers to questions about history d) Discrepancies between clinical injury and the client’s explanation of how the injury occurred e) Delay in seeking treatment for an injury f) Signs of physical abuse g) Depression, substance abuse, or PTSD h) Recurrent STI’s i) Genital or rectal trauma j) History of repeat miscarriages or abortion

VI.

Focus Your Study

VII.

Activities 1. Individual For a major city in the state or for a specific state, have each student develop a resource list for the survivors of domestic violence and rape that can be submitted electronically for compiling. 2. Small Group Divide the class in small groups of three to five students. Assign each group an ethnic group or culture in their local area. Have each group research the views and customs regarding domestic violence and rape and prepare a short presentation for the class. 3. Large Group Invite a domestic abuse counselor or rape counselor (nurse if available) to discuss the care of victims with the entire class.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 9 Reproductive Physiology, Conception, and Fetal Development Female Reproductive System...........................................................................

Female Reproductive Cycle..............................................................................

Male Reproductive System…………………………………………………………………………

Gametogenesis…………………………………………………………………………………………..

The Process of Fertilization………………………………………………………………………..

Preembryonic Stage…………………………………………………………………………………..

Twins………………………………………………………………………………………………………....

Development and Functions of the Placenta………………………………………………

Development of the Fetal Circulatory System…………………………………………….

Embryonic and Fetal Development…………………………………………………………….

Factors Influencing Embryonic and Fetal Development……………………………..

Focus Your Study.............................................................................................

Activities...........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Female Reproductive System

A. External Genitals 1. Vulva a) Mons pubis (1) Softly rounded mound of subcutaneous fatty tissue (2) Covered with pubic hair b) Labia majora (1) Longitudinal raised folds of pigmented skin on either side of vulvar cleft (2) Extensive venous network → varicosities may occur during pregnancy (3) Trauma (sexual or birth) → hematoma (4) Lymphatic supply c) Labia minora (1) Soft folds of skin within labia majora converge near anus (2) Many sebaceous glands, tactile nerve endings d) Clitoris (1) Between labia minora (2) Tissue erectile (3) Covered by fold of skin → prepuce or clitoral hood (4) Rich blood and nerve supply (5) Primary erogenous organ of women e) Urethral meatus and opening of paraurethral glands (1) 1 to 2.5 cm beneath clitoris (2) Difficult to visualize (3) Skene glands open into posterior wall of urethra to close opening f) Vaginal vestibule (1) Boat-shaped depression enclosed by labia majora → visible when separated (2) Hymen → thin, elastic collar of tissue surrounding vaginal opening (a) Essentially avascular (3) Vulvovaginal (Bartholin) glands under constrictor muscles of vagina (4) Secretions enhance viability and motility of sperm deposited in vaginal vestibule (5) Innervated by perineal nerve from sacral plexus g) Perineal body (1) Wedge-shaped mass of fibromuscular tissue (2) Found between lower part of the vagina and anus (3) Superficial area referred to as perineum (4) External sphinctor ani, levator ani, bulbocavernosus 2. See Figure 9–1: Female external genitals, longitudinal view, p. 158

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Birth canal b) Cervix of uterus projects into upper part of anterior wall c) Upper part of vagina → vaginal vault (1) Recess around cervix → vaginal fornix d) Space in fornix permits pooling of semen e) Walls of vagina covered with ridges → rugae (1) Stretch for childbirth and coitus f) Vaginal environment normally acidic during reproductive life (1) Lactic acid–producing bacilli and vaginal epithelial cells maintain environment g) Distinct vascular, lymphatic pattern in each third of vagina (1) Vaginal lymphatics → drain to external and internal iliac, hypogastric, and inguinal nodes (2) Posterior wall → nodes in rectovaginal system h) Pudendal nerve → lower third i) Functions (1) Serve as passage for sperm, fetus (2) Provide passage for menstrual blood flow (3) Protect against trauma and infection 2. Uterus a) Hollow muscular thick-walled organ b) Upside-down pear shape c) Center of pelvic cavity d) One fourth of women exposed to diethylstilbestrol (DES) in utero have structural variations of the cervix, uterus, and vagina e) Divided into two major parts (1) Corpus → uterine body (a) Myometrium (b) Fundus (c) Cornua (2) Lower segment → isthmus (a) Between cervical os and endometrial cavity f) Extensive blood and lymphatic supply (1) See Figure 9–4: Blood supply to the vagina, ovary, uterus, and fallopian tube, p. 160 g) Autonomic nervous system (1) Vasoconstriction, muscular contraction h) Pain of contractions → 11th and 12th thoracic nerve roots i) Motor fibers → 7th and 8th thoracic vertebrae j) Function (1) Safe environment for fetal development (2) Nidation k) Body of uterus, cervix → permanently changed by pregnancy l) Uterine corpus (1) Three layers 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Serosal layer → perimetrium (b) Muscular layer → myometrium (i) Smooth involuntary muscle (ii) Longitudinal muscle fibers (iii) Interlacing muscle fibers (iv) Circular fibers (v) See Figure 9–5: Myometrium uterine muscle layers placement and function, p. 160 (c) Mucosal layer → endometrium (i) Monthly renewal and degeneration (ii) Glands produce secretion → keeps cavity moist, facilitates sperm travel to fallopian tubes (iii) Blood supply unique → differing responses to hormone cycle 3. Cervix a) Distal end of uterus (1) Internal os to external os → approximately 2.5 cm (2) Protective portal for body of uterus b) Vaginal cervix → pink, ends at external os c) Supravaginal cervix → surrounded by ligaments that give uterus main support (1) Uterosacral, transverse, and pubocervical d) Cervical canal e) Elastic f) Three functions (1) Provide lubrication for vaginal canal (2) Act as bacteriostatic agent (3) Provide alkaline environment to shelter deposited sperm from acidic vaginal secretions (a) Cervical mucus clearer, thinner, more alkaline at ovulation g) See Figure 9–2: Female internal reproductive organs, p. 159 h) See Figure 9–3: Structures of the uterus, p. 159 4. Uterine ligaments a) Broad ligament → keeps uterus centrally placed, provides stability b) Round ligaments → keep uterus in place c) Ovarian ligaments → anchor lower pole of ovary to cornua of uterus d) Cardinal ligaments → chief uterine supports, suspending uterus from side walls of true pelvis → Mackenrodt ligaments, transverse cervical ligaments e) Infundibulopelvic ligament → suspends and supports ovaries f) Uterosacral ligaments → provide support for uterus, cervix at level of ischial spines g) See Figure 9–7: Uterine ligaments, p. 162 5. Fallopian tubes a) Oviducts, uterine tubes → arise from each side of uterus (1) 8 to 13.5 cm long 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Short section inside uterus b) Divided into three parts (1) Isthmus (2) Ampulla (3) Fimbria c) Wall of fallopian tube four layers (1) Peritoneal (serous) (2) Subserous (adventitial) (3) Muscular (4) Mucous d) Tubal transport system e) Rich blood, lymph supply f) Three functions (1) Provide transport for ovum from the ovary to the uterus (2) Provide a site for fertilization (3) Serve as warm, moist, nourishing environment for ovum, zygote 6. Ovaries a) Two almond-shaped glandular structures just below pelvic brim b) Each side of pelvic cavity c) 6 to 10 g, 1.5 to 3 cm wide, 2 to 5 cm long, 1 to 1.5 cm thick d) Enlarge after puberty → decrease in size after menopause e) No peritoneal covering (1) Assists mature ovum to erupt (2) Also allows easier spread of malignant cells from cancer of ovaries f) Primary source of estrogens (characteristics of femaleness) and progesterone (hormone of pregnancy) g) Interplay between ovarian hormones and FSH, LH responsible for cyclic changes → allow pregnancy to occur 7. See Figure 9–6: Fallopian tube and ovaries, p. 161

C. Bony pelvis 1. Two unique functions a) Support and protect pelvic contents b) Form relatively fixed axis of birth passage

D. Breasts 1. Mammary glands a) Accessories of reproductive system b) Specialized sebaceous glands c) Conical, symmetrically placed on sides of chest d) Cooper ligaments suspend fibrous tissue

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nipple → center of each mature breast a) Erectile tissue b) Surrounded by heavily pigmented areola c) Small papillae → tubercles of Montgomery → secrete fatty substance that helps lubricate and protect the breasts 3. Composed of glandular, fibrous, and adipose tissue a) Alveoli arranged in series of 15 to 24 lobes b) Grapelike clusters around tiny ducts c) Cyclic hormonal control is complex 4. Biologic function a) Provide nourishment and protective antibodies to infants through lactation process b) Source of pleasurable sexual sensation c) See Figure 9–8: Anatomy of the breast, p. 163

II.

Female Reproductive Cycle

A. Ovarian cycle and menstrual cycle B. Effects of Female Hormones 1. Cyclic pattern of ovulation and menstruation from menarche through menopause a) Menstruation under neurohormonal control b) Ovaries → mature gametes, secrete hormones → estrogens, progesterone, testosterone (1) Sensitive to FSH and LH c) Uterus → sensitive to estrogen and progesterone 2. Estrogens a) Hormones that control development of female secondary sex characteristics b) Assist in maturation of ovarian follicles c) Cause endometrial mucosa to proliferate following menstruation d) Have effects on many hormones, other carrier proteins 3. Progesterone a) Secreted by corpus luteum b) Hormone of pregnancy → allows pregnancy to be maintained (1) Vaginal epithelium proliferates (2) Cervix secretes thick, viscous mucus (3) Breast glandular tissue increases in size and complexity (4) Breasts prepare for lactation (5) Temperature rise that accompanies ovulation, secretory phase of menstrual cycle 4. Prostaglandins a) Oxygenated fatty acids produced by cells of endometrium b) Prostaglandin E (PGE) relaxes smooth muscle, vasodilator c) Prostaglandin F (PGF) increases contractility of muscles, arteries vasoconstrictor 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Prostaglandin production increases during follicular maturation 5. See Figure 9–9: Female reproductive cycle: interrelationships of hormones with the three phases of the uterine cycle, and the two phases of the ovarian cycle in an ideal 28-day cycle, p. 164

C. Neurohormonal Basis of the Female Reproductive Cycle 1. Hypothalamus secretes gonadotropin-releasing hormone (GnRH) → pituitary gland → anterior pituitary secretes FSH and LH 2. FSH responsible for maturation of ovarian follicle a) Final maturation requires action of LH → peak production precedes ovulation by as much as 12 hours to 24 hours b) LH increases production of progesterone by granulose cells of follicle (1) Estrogen production declines, progesterone secretion continues (2) Ovulation → following rapid growth of follicle (3) Ruptured follicle → rapid change → complete luteinization accomplished → cells become corpus luteum 3. Ovarian cycle a) Follicular phase → days 1 to 14 b) Luteal phase → days 15 to 28 c) Graafian follicle → day 14 → dual control of FSH and LH (1) Produces estrogen (2) Mature graafian follicles surrounded by granulose cells (3) Zona pellucida develops around oocyte (4) Two cells form → polar body, secondary oocyte d) Travels to surface of ovary e) Mid-cycle pain → mittelschmerz caused by local peritoneal reaction to expelling of follicular contents f) Body temperature increases 24 to 48 hours after ovulation g) Ovum travels through ruptured follicle to fallopian tube opening h) Luteal phase begins when ovum leaves follicle i) Under influence of LH → corpus luteum develops j) If fertilized → implants → begins to secrete human chorionic gonadotropin (hCG) k) If no fertilization → degenerates → connective tissue scar called corpus albicans → decrease in estrogen, progesterone

D. Uterine (Menstrual) Cycle 1. Menstruation → cyclic uterine bleeding in response to cyclic hormonal changes a) Menses → blood mixed with cervical vaginal secretions, bacteria, mucus, leukocytes, cellular debris b) Menstrual parameters vary greatly c) Arterial blood supply

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) See Figure 9–11: Blood supply to the endometrium (cross-sectional view of the uterus), p. 166 2. Three phases a) Menstrual phase (1) Menstruation occurs b) Proliferative phase (1) Endometrial glands enlarge (2) Blood vessels become prominent, dilated → endometrium increases thickness (3) Cervical mucus thin, clear, watery, alkaline (4) Cervical mucus increased elasticity (5) Ferning c) Secretory phase (1) Follows ovulation (2) Endometrium → estrogen causes slight cellular growth (3) Progesterone causes swelling and growth (4) Vascularity increases → nourishing bed for a fertilized ovum d) Ischemic phase (1) If fertilization does not occur (2) Estrogen and progesterone levels fall (3) Vascular changes (4) Escape of blood into stromal cells

III.

Male Reproductive System

A. External Genitals 1. See Figure 9–13: Male reproductive system, sagittal view, p. 168 a) Penis (1) Elongated, cylindrical structure → body → shaft, cone-shaped end → glans (2) Lies in front of scrotum b) Shaft → three longitudinal columns of erectile tissue (1) Corpora cavernosa (2) (2) Corpus spongiosum (a) Contains urethra (b) Ends at tip of glans → urethral meatus c) Prepuce → foreskin d) Hypospadias or epispadias e) Innervated by pudendal nerve (1) Sexual stimulation causes erection (2) Parasympathetic nerve stimulation → engorgement (3) Ejaculation → intense stimulation f) Urinary and reproductive systems 2. Scrotum a) Pouchlike structure → hangs in front of anus, behind penis 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Skin and dartos muscle (2) Sebaceous glands open directly onto scrotal surface → distinctive odor b) Two lateral compartments inside (1) Testis in each (2) Function → protect testes, sperm (a) Maintain temperature lower than body temperature

B. Male Internal Reproductive Organs 1. Gonads → testes 2. See Figure 9–14: The testes. A. External view. B. Sagittal view showing interior anatomy, p. 169 a) Pair of oval, compound glandular organs (1) Site of spermatozoa production, secretion of male sex hormones → in sexually mature male (2) 4 to 6 cm long, 2 to 3 cm wide, 3 to 4 cm deep b) Seminiferous tubules in each lobule in testes (1) Contain sperm cells in all stages of development (2) Interstitial cells produce testosterone (3) Sertoli cells → nourish, protect spermatocytes (4) Come together → rete testis → forms ducts → empty into duct of epididymis (5) Cells lining seminiferous tubules → spermatogenesis c) Process of spermatogenesis → result of complex neural and hormonal controls (1) Hypothalamus → releasing factors → anterior pituitary → release gonadotropins → cause testes to produce testosterone → maintains spermatogenesis, increase sperm production, stimulate production of seminal fluid d) Testosterone → most prevalent, potent of testicular hormones (1) Secondary male characteristics, behavioral patterns (2) Action is constant, not cyclic (3) Production not limited to certain number of years e) Functions (1) Serve as site of spermatogenesis (2) Produce testosterone 3. Epididymis a) Duct behind each testis → 5.6 m long b) Provides reservoir where spermatozoa can survive (1) As sperm transported along course of epididymis → become motile, fertile 4. Vas deferens and ejaculatory ducts a) 40 cm long → connects epididymis with prostate b) One from posterior border of each testis c) Unites with seminal vesicle → form ejaculatory duct → enter prostate gland d) Function → rapidly squeeze sperm from storage sites into urethra e) Vasectomy → scrotal portion of vas deferens incised or cauterized 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Sperm can be produced but can no longer reach outside of body 5. Urethra a) Male urethra → passageway for urine and semen 6. Accessory glands a) Seminal vesicles (1) Many lobules (2) Between bladder and rectum, above base of prostate (3) Secretes fluid → helps provide environment favorable to sperm motility, metabolism b) Prostate gland (1) Many lobules (2) Encircles upper part of urethra, below neck of bladder (3) Secretes fluid → protects sperm from acidic environment of vagina, male urethra c) Bulbourethral glands (Cowper glands) (1) On either side of membranous urethra (2) Secrete fluid that becomes part of semen (3) Lubricates penile urethra, neutralizes acid in male urethra, vagina d) Urethra glands (Littre glands) (1) Mucus-secreting glands throughout membranous lining of penile urethra 7. Semen a) Male ejaculate, seminal fluid → spermatozoa and secretions of accessory glands (1) Transports viable, motile sperm (2) Nutrients, pH about 7.5, concentration of sperm to fluid, osmolarity b) Spermatozoa (1) Made up of head and tail (2) Head → carries male’s haploid number of chromosomes (3) Tail (flagellum) → specialized for motility (4) Stored in male genital system up to 42 days (5) Average volume → 2 to 5 mL (6) Sperm lives 2 to 3 days once ejaculated into female genital tract

IV.

Gametogenesis A. Process by which germ cells (gametes) produced 1. Haploid genetic material

B. Oogenesis → process that produces female gamete 1. Ovaries begin to develop early in fetal life a) All ova present at birth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. First meiotic division → produces two cells of unequal size 3. Second meiotic division begins at ovulation → continues as oocyte moves down fallopian tube a) Division not equal 4. Second oocyte completes second meiotic division after fertilization → mature ovum with haploid number a) Second polar body forms b) Both divide → four haploid cells → three small polar bodies, one ovum 5. See Figure 9–15: Gametogenesis involves meiosis within the ovary and testis, p. 171

C. Spermatogenesis 1. Germinal epithelium in seminiferous tubules of testes a) Begins spermatogenesis during puberty b) Diploid spermatogonium replicate before first meiotic division (1) Primary spermatocyte c) First meiotic division → replicates → two haploid cells → secondary spermatocytes d) Second meiotic division → four spermatids → haploid e) Series of changes → nucleus compacted, lose most of cytoplasm

The Process of Fertilization A. Process by which sperm fuses with ovum → form new diploid cell (zygote) 1. Zygote → single cell → complete set of genetic material

B. Preparation for fertilization 1. Brief time to unite 2. Ovum’s cell membrane surrounded by two layers of tissue a) Zona pellucida, corona radiata 3. Ovulation → estrogen levels increase peristalsis in fallopian tubes 4. Fertilization usually takes place in ampulla of fallopian tube 5. Single ejaculation → 200 to 500 million spermatozoa in vagina a) Only about 1000 reach ampulla b) Flagellar movement of tails propel spermatozoa c) 5 minutes to 2 to7 hours from cervix into fallopian tube 6. Prostaglandins in semen → help transport sperm 7. Sperm undergoes two processes a) Capacitation → removal of plasma membrane, glycoprotein coat b) Acrosomal reaction → follows capacitation 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Acrosome caps of sperm surrounding ovum → release enzymes → break down hyaluronic acid that holds corona radiata together (2) Thousands of caps for one sperm to penetrate c) At moment of penetration by fertilizing sperm → zona pellucida reacts (1) Prevents additional sperm from entering single ovum

C. The moment of fertilization 1. After sperm enters ovum → chemical signal prompts secondary oocyte → complete second meiotic division → forms nucleus of ovum → ejects second polar body 2. Sex of zygote determined a) XX → female → mature ovum → only one type of sex chromosome b) XY → male → spermatogenesis yields two X and two Y sperm

VI.

Preembryonic Stage

A. First 14 days of human development B. Cellular multiplication → begins as zygote moves through fallopian tube 1. Rapid mitotic divisions → cleavage a) Divides → 2 cells → 4 cells → 8 cells → etc. b) Blastomeres → eventually form solid ball of 12 to 32 cells → morula 2. Morula enters uterus → intracellular fluid increases, central cavity forms a) Inside cavity → mass of cells → blastocyst b) Outer layer of cells → trophoblast → develops into chorion c) Blastocyst → embryonic disc 3. Early pregnancy factor (EPF) → secreted by trophoblastic cells a) Appears in maternal serum → 24 to 48 hours after fertilization

C. Implantation (nidation) 1. While floating in uterine cavity → blastocyst nourished by uterine glands a) Trophoblast attaches to surface of endometrium b) Upper part of posterior uterine wall c) Between days 7 to10 → blastocyst implants d) Lining of uterus thickens below implanted blastocyst 2. Endometrium increases in thickness, vascularity → influence of progesterone a) After implantation → endometrium called decidua b) Covers blastocyst → decidua capsularis c) Directly under blastocyst → decidua basalis → maternal part of placenta develops from decidua basalis d) Lines rest of uterine cavity → decidua vera

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Cellular differentiation 1. Primary germ layers a) 10 to 14 days after conception → homogenous blastocyst cells differentiate b) Ectoderm, mesoderm, endoderm → formed at same time as embryonic membranes c) All tissues develop from these primary germ cell layers d) See Table 9–1: Derivation of Body Structures from Primary Cell Layers, p. 175 e) From ectoderm (1) Epidermis (2) Sweat glands (3) Sebaceous glands (4) Nails (5) Hair follicles (6) Lens of eye (7) Sensory epithelium of internal and external ear, nasal cavity, sinuses, mouth, anal canal (8) Central and peripheral nervous system (9) Oral glands and tooth enamel (10) Pituitary gland (11) Mammary glands f) From mesoderm (1) Dermis (2) Wall of digestive tract (3) Kidneys and ureter (suprarenal cortex) (4) Reproductive organs (gonads, genital ducts) (5) Connective tissue (cartilage, bone, joint cavities) (6) Skeleton (7) Muscles (all types) (8) Cardiovascular system (heart, arteries, veins, blood, bone marrow) (9) Pleura (10) Lymphatic tissue and cells (11) Spleen g) From endoderm (1) Respiratory tract epithelium (2) Epithelium (except nasal) (3) Lining of digestive tract (4) Primary tissue of liver and pancreas (5) Urethra and associated glands (6) Urinary bladder (except trigone) (7) Vagina (parts) 2. Embryonic membranes → begin to form at time of implantation a) Chorion → first, outermost membrane (1) Fingerlike projections → chorionic villi

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Early genetic testing (3) Villi degenerate → except those just under embryo (4) By fourth month of pregnancy → surface smooth, except at place of attachment to uterine wall b) Amnion → second membrane, from ectoderm (1) Contains amniotic fluid (2) Space between membrane and embryo → amniotic cavity (3) Expands until comes in contact with chorion (4) Form fluid-filled amniotic sac (bag of waters) → protects 3. Amniotic fluid a) Functions (1) Acts as cushion against mechanical injury (2) Helps control embryo’s temperature (3) Permits symmetric external growth and development of embryo (4) Acts as extension of fetal extracellular space (5) Prevents adherence of embryo-fetus to amnion to allow freedom of movement (6) Allows umbilical cord to be relatively free of compression (7) Acts as wedge during labor (8) Provides fluid for analysis to determine fetal health and maturity b) Slightly alkaline → contains albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fat, fructose, leukocytes, proteins, epithelial cells, enzymes, lanugo (1) Amount of fluid at 10 weeks → about 30 mL → 210 mL at 16 weeks (2) Constantly changing (3) Fluid contributes to volume → excretes urine (4) After 23 to 25 weeks → thickening of fetal skin inhibits diffusion (5) Fetal kidneys source of fluid (6) Abnormalities of fetal urine production (a) Potter syndrome (b) Bartter syndrome (7) Fluid removed in last half of pregnancy → fetal swallowing c) Abnormal variations (1) Oligohydramnios → <500 mL (2) Hydramnios (polyhydramnios) → >2000 mL 4. Yolk sac a) In humans → small, functions only in early embryonic life b) Develops as a second cavity about day 8 or 9 c) Forms primitive red blood cells 5. Umbilical cord a) Formed from mesoderm and covered by amnion b) Contains blood vessels c) Body stalk fuses with embryonic portion of placenta → elongates → vessels decrease → one large vein, two small arteries 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Wharton’s jelly surrounds blood vessels e) Prevents compression of the umbilical cord in utero f) Central insertion into placenta considered normal g) Appear twisted spiraled → likely caused by fetal movement (1) True knot rare

VII.

Twins

A. Twinning → 33 in 1000 births B. Fraternal → dizygotic → two placentas, two chorions, two amnions 1. Placentas sometimes fuse 2. Increases with maternal age up to about 35 years → decreases abruptly 3. Tends to occur in certain families 4. Reported more often among black than white → more often in white than Asian

C. Identical → monozygotic → single fertilized ovum 1. Same sex, same appearance 2. Usually have common placenta 3. Originate from division of fertilized ovum at different stages of early development a) Within 4 days of fertilization → 2 embryos, 2 amnions, 2 chorions → dichorionicdiamniotic b) Division about 4 to 8 days after fertilization → 2 embryos, 2 amnion sacs, common chorion → monochorionic-diamniotic placenta c) Division about 8 to 12 days after fertilization → 2 embryos, common sac and chorion → rare 4. Monozygotic twinning random event → 3 to 4 per 1000 live births a) Survival rate 10% lower than of dizygotic twins b) Congenital anomalies more prevalent

VIII.

Development and Functions of the Placenta

A. Placenta → means of metabolic and nutrient exchange between embryonic and maternal circulations 1. Begins about third week of embryonic development 2. Expansion until about 20 weeks → covers about half of inside of uterus a) After 20 weeks → thicker, not wider 3. Maternal portion → decidua basalis and circulation a) Surface red, fleshlike → Dirty Duncan 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Fetal portion → covered by amnion → shiny, gray appearance → Shiny Schultze 5. See Figure 9–23: Maternal side of placenta (Dirty Duncan) and Figure 9–24: Fetal side of placenta (Shiny Schultze), p. 178 6. Begins to form at implantation → chorionic villi grow into spaces in tissue of decidua basalis 7. Two trophoblastic layers a) Syncytium → direct contact with maternal blood → functional layer of placenta b) Cytotrophoblast 8. Anchoring villi → third inner layer → eventually form septa of placenta a) 15 to 20 cotyledons → complex vascular system (1) Exchange of gases and nutrients b) Exchange of substances across placenta minimal first 3 to 5 months (1) Membrane initially too thick (2) Permeability increases as membrane thins until last month of pregnancy

B. Placental circulation 1. After implantation → cells differentiate into fetal cells, trophoblastic cells a) Trophoblast invades endometrium → opens uterine capillaries, then larger uterine vessels b) Completion of maternal-placental-fetal circulation → about 17 days after conception → embryonic heart begins functioning c) End of fourth week embryonic blood circulating d) 14 weeks → placenta is discrete organ e) Cotyledons of maternal surface → branches of single placental mainstream villus (1) Compartmentalization of uteroplacental circulation 2. Fully developed placenta’s umbilical cord → fetal blood flow through two umbilical arteries to capillaries of villi a) Oxygen-enriched blood flow back through umbilical vein to fetus b) See Figure 9–25: Vascular arrangement of the placenta, p. 179 3. Maternal blood moves from actuate artery → radial artery → uterine spiral arteries → spurts into intervillous spaces a) Circulation within intervillous spaces → depends on maternal blood pressure b) Fresh blood continually enters, exerts pressure → pushing blood toward exits in basal plate c) Blood drained through uterine, other pelvic veins (1) Uterine souffle

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Braxton Hicks contractions → believed to facilitate placental circulation → enhances movement of blood from center of cotyledon through intervillous space

C. Placental functions 1. Placental exchange functions a) Only in fetal vessels in intimate contact with syncytial membrane 2. Metabolic activities a) Provides glycogen, cholesterol, fatty acids continuously b) Provides numerous enzymes required for fetoplacental transfer c) Breaks down certain substances, such as epinephrine and histamine d) Stores glycogen and iron 3. Transport functions a) Simple diffusion b) Facilitated transport c) Active transport d) Pinocytosis 4. Reduction of placental surface → less is functional for exchange 5. Blood flow alteration changes transfer rate of substances 6. Maternal blood → picks up fetal waste products and carbon dioxide → drains back into maternal circulation

D. Endocrine functions 1. Produces hormones vital to survival of fetus 2. Human chorionic gonadotropin (hCG) → similar to luteinizing hormone (LH) → prevents normal involution of corpus luteum at end of menstrual cycle a) Causes corpus luteum to secrete increased amounts of estrogen and progesterone b) After 11th week → placenta produces enough progesterone, estrogen to maintain pregnancy c) In male fetus → hCG exerts cell stimulating effect on testes → produces testosterone d) hCG present in maternal blood serum → 8 to10 days after fertilization → as soon as implantation has occurred 3. Progesterone → hormone essential for pregnancy a) Increases secretion to provide for nutrition of morula and blastocyst b) Must be present in high levels for implantation c) Implantation occurs at time of peak production of progesterone by corpus luteum → 7 to 10 days after ovulation d) After 11 weeks → placenta takes over production of progesterone → more than 250 mg/day late in pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Estrogens production → 50% by placenta by 7 weeks a) Cause enlargement of uterus, breasts, breast glandular disuse b) Increasing vascularity, vasodilation c) Placenta → estriol d) Ovaries → estradiol e) Placenta → needs dehydroepiandrosterone sulfate (DHEA-S) to synthesize estriol 5. Human placental lactogen (hPL) → similar to human pituitary growth hormone

E. Immunologic properties 1. Placenta, embryo → homografts a) Exempt from immunologic reaction by host b) Chorionic villi may not evoke rejection responses

IX.

Development of the Fetal Circulatory System A. Most of blood supply bypasses fetal lungs → no respiratory gas exchange 1. Placenta assumes function of fetal lungs

B. See Figure 9–26: Fetal circulation, p. 181 C. Blood from placenta → umbilical vein → enters abdominal wall → some blood through portal circulation, most through ductus venosus → inferior vena cava → right atrium → foramen ovale → left atrium → left ventricle → aorta 1. Some blood from head, upper extremities → superior vena cava → right atrium → tricuspid valve into right ventricle → pulmonary artery → small amount to lungs for nourishment only 2. Larger portion of blood → pulmonary artery through ductus arteriosus → descending aorta (bypassing lungs) → umbilical arteries to placenta 3. Fetus receives oxygen via diffusion → gradient difference of PO2 in maternal blood → 50 mmHg to 30 mmHg (fetus) a) Highest available oxygen concentration → head, neck, brain, heart (1) Cephalocaudal development of fetus

D. Fetal heart 1. Under control of own pacemaker → sinoatrial (SA) node, atrioventricular (AV) node 2. When fetus stressed → sympathetic nervous system causes release of norepinephrine → increases fetal heart rate a) Baroreceptors counteract increase in blood pressure b) Chemoreceptors in fetal PNS and CNS → respond to decreased oxygen tensions, increased carbon dioxide tensions → fetal tachycardia, increase blood pressure

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Increased activity of fetus → increase in beat-to-beat variability of fetal heart baseline

Embryonic and Fetal Development A. Pregnancy → average 10 lunar months 1. 40 weeks, 280 days a) From beginning of last normal menstrual period to birth b) Estimated date of birth (EDB) (estimated date of delivery [EDD]) calculated by this method c) Most fetuses born within 10 to14 days of calculated date of birth

B. Organ development 1. Up to 8 weeks → embryonic period → ninth week until birth → fetal period 2. See Table 9–2: Timeline of Organ System Development in the Embryo and Fetus, pp. 182– 184 a) Age: 2–3 weeks (1) Length: 2 mm C–R (crown to rump) (2) Nervous system: Groove forms along middle back as cells thicken; neural tube forms from closure of neural groove (3) Cardiovascular system: Beginning of blood circulation; tubular heart begins to form during third week (4) Gastrointestinal system: Liver function begins (5) Genitourinary system: Kidneys formation begins (6) Respiratory system: Nasal pits forming (7) Endocrine system: Thyroid tissue appears (8) Eyes: Optic cup, lens pit formed; pigment in eyes (9) Ears: Auditory pit now enclosed structure b) Age: 4 weeks (1) Length: 4–6 mm C–R (2) Weight: 0.4 g (3) Nervous system: Anterior portion of neural tube closes, forms brain; closure of posterior end forms spinal cord (4) Musculoskeletal system: Noticeable limb buds (5) Cardiovascular system: Tubular heart beats at 28 days, primitive red blood cells circulate through fetus, chorionic villi (6) Gastrointestinal system: Mouth—oral cavity forms; primitive jaws present; esophagotracheal septum begins division of esophagus, trachea. Digestive tract— stomach forms; esophagus, intestine become tubular; ducts of pancreas, liver forming c) Age: 5 weeks (1) Length: 8 mm C–R (2) Weight: Only 0.5% of total body weight = fat (to 20 weeks) (3) Nervous system: Brain differentiated, and cranial nerves present 19 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Musculoskeletal system: Developing muscles innervated (5) Cardiovascular system: Atrial division occurred d) Age: 6 weeks (1) Length: 12 mm C–R (2) Musculoskeletal system: Bone rudiments present; primitive skeletal shape forming; muscle mass develops; skull, jaw ossification begins (3) Cardiovascular system: Chambers present in heart; groups of blood cells identifiable (4) Gastrointestinal system: Oral, nasal cavities, upper lip formed; liver begins to form red blood cells (5) Respiratory system: Trachea, bronchi, lung buds present (6) Ears: Formation of external, middle, inner ear continues (7) Sexual development: Embryonic sex glands appear e) Age: 7 weeks (1) Length: 18 mm C–R (2) Cardiovascular system: Fetal heartbeat detectable (3) Gastrointestinal system: Mouth—tongue separates; palate folds. Digestive tract— stomach attains final form (4) Genitourinary system: Separation of bladder, urethra from rectum (5) Respiratory system: Diaphragm separates abdominal, thoracic cavities (6) Eyes: Optic nerve formed; eyelids appear, thickening of lens (7) Sexual development: Begin differentiation of sex glands into ovaries, testes f) Age: 8 weeks (1) Length: 2.5–3 cm C–R (2) Weight: 2 g. (3) Musculoskeletal system: Digits formed; further differentiation of cells in primitive skeleton; cartilaginous bones show first signs of ossification; development of muscles in trunk, limbs, and head; some movement of fetus now possible (4) Cardiovascular system: Development of heart essentially complete; fetal circulation follows two circuits—four extraembryonic and two intraembryonic. Heartbeat can be heard with Doppler at 8 to12 weeks (5) Gastrointestinal system: Mouth: completion of lip fusion. Digestive tract: rotation in midgut; anal membrane has perforated (6) Ears: External, middle, and inner ear assuming final forms (7) Sexual development: Male and female external genitals appear similar until end of ninth week g) Age: 10 weeks (1) Length: 5–6 cm C–R (2) Weight: 14 g (3) Nervous system: Neurons appear at caudal end of spinal cord; basic divisions of brain present (4) Musculoskeletal system: Fingers and toes begin nail growth (5) Gastrointestinal system: Mouth: separation of lips from jaw; fusion of palate folds. Digestive tract: developing intestines enclosed in abdomen (6) Genitourinary system: Bladder sac formed 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(7) Endocrine system: Islets of Langerhans differentiated (8) Eyes: Eyelids fused closed; development of lacrimal duct (9) Sexual development: Males: production of testosterone and physical characteristics between 8 and 12 weeks h) Age: 12 weeks (1) Length: 8 cm C–R; 11.5 cm C–H (crown to heel) (2) Weight: 45 g (3) Musculoskeletal system: Clear outlining of miniature bones (12 to 20 weeks); process of ossification is established throughout fetal body; appearance of involuntary muscles in viscera (4) Gastrointestinal system: Mouth: completion of palate. Digestive tract: appearance of muscles in gut; bile secretion begins; liver is major producer of red blood cells (5) Respiratory system: Lungs acquire definitive shape (6) Skin: Pink and delicate (7) Endocrine system: Hormonal secretion from thyroid; insulin present in pancreas (8) Immunologic system: Appearance of lymphoid tissue in fetal thymus gland i) Age: 16 weeks (1) Length: 13.5 cm C–R; 15 cm C–H (2) Weight: 200 g (3) Musculoskeletal system: Teeth beginning to form hard tissue that will become central incisors (4) Gastrointestinal system: Mouth: differentiation of hard and soft palate. Digestive tract: development of gastric and intestinal glands; intestines begin to collect meconium (5) Genitourinary system: Kidneys assume typical shape and organization (6) Skin: Appearance of scalp hair; lanugo present on body; transparent skin with visible blood vessels; sweat glands developing (7) Eyes, ears, and nose: Formed (8) Sexual development: Sex determination possible j) Age: 18 weeks (1) Musculoskeletal system: Teeth beginning to form hard tissue (enamel and dentine) that will become lateral incisors (2) Cardiovascular system: Fetal heart tones audible with fetoscope at 16 to 20 weeks k) Age: 20 weeks (1) Length: 19 cm C–R; 25 cm C–H (2) Weight: 435 g (6% of total body weight is fat) (3) Nervous system: Myelination of spinal cord begins (4) Musculoskeletal system: Teeth beginning to form hard tissue that will become canine and first molar. Lower limbs are of final relative proportions (5) Gastrointestinal system: Fetus actively sucks and swallows amniotic fluid; peristaltic movements begin (6) Skin: Lanugo covers entire body; brown fat begins to form; vernix caseosa begins to form

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(7) Immunologic system: Detectable levels of fetal antibodies (immunoglobin G [IgG] type) (8) Blood formation: Iron is stored and bone marrow is increasingly important l) Age: 24 weeks (1) Length: 23 cm C–R; 28 cm C–H (2) Weight: 780 g (3) Nervous system: Brain looks like mature brain (4) Musculoskeletal system: Teeth are beginning to form hard tissue that will become the second molars (5) Respiratory system: Respiratory movements may occur (24 to 40 weeks). Nostrils reopen. Alveoli appear in lungs and begin production of surfactant; gas exchange possible (6) Skin: Reddish and wrinkled, vernix caseosa present (7) Immunologic system: IgG levels reach maternal levels m) Age: 28 weeks (1) Length: 27 cm C–R; 35 C–H (2) Weight: 1200–1250 g (3) Nervous system: Begins regulation of some body functions (4) Skin: Adipose tissue accumulates rapidly; nails appear; eyebrows and eyelashes present (5) Eyes: Eyelids open (26 to 29 weeks) (6) Sexual development: Males: testes descend into inguinal canal and upper scrotum n) Age: 32 weeks (1) Length: 31 cm C–R; 38–43 cm C–H (2) Weight: 2000 g (3) Nervous system: More reflexes present o) Age: 36 weeks (1) Length: 35 cm C–R; 42–48 cm C–H (2) Weight: 2500–2750 g (3) Musculoskeletal system: Distal femoral ossification centers present (4) Skin: Pale; body rounded, lanugo disappearing, hair fuzzy or woolly; few sole creases; sebaceous glands active and helping to produce vernix caseosa (36 to 40 weeks) (5) Ears: Earlobes soft with little cartilage (6) Sexual development: Males: scrotum small and few rugae present; descent of testes into upper scrotum to stay (36 to 40 weeks). Females: labia majora and minora equally prominent p) Age: 38–40 weeks (1) Length: 40 cm C–R; 48–52 C–H (2) Weight: 3200+ g (16% of total body weight is fat) (3) Respiratory system: At 38 weeks, lecithin-sphingomyelin (L/S) ratio approaches 2:1 (indicates decreased risk of respiratory distress from inadequate surfactant production if born now)

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Skin: Smooth and pink; vernix present in skin folds; moderate to profuse silky hair; lanugo on shoulders and upper back; nails extend over tips or digits; creases cover sole (5) Ears: Earlobes firmer due to increased cartilage (6) Sexual development: Males: rugous scrotum. Females: labia majora well developed and minora small or completely covered 3. Human development follows three stages

C. Embryonic stage 1. Day 15 → 8 weeks (C-R length of 3 cm) a) Tissues differentiate into essential organs → most vulnerable to teratogens b) 3 weeks → most advanced organ is heart c) 4 to 5 weeks → somites (vertebra develop from somites) tail bud (1) Tubular heart beating regular rhythm d) 5 weeks → optic cups, lens vesicles of eye, nasal pits develop (1) Partitioning of heart (2) Brain differentiated, 10 pairs cranial nerves recognizable e) 6 weeks → head structure more developed, trunk straighter f) 7 weeks → head rounded, nearly erect (1) GI, GU tracts changing g) 8 weeks → 3 cm C–R, resembles human being (1) External genitals appear h) See Figure 9–27: The human conceptus from fertilization to the early fetal stage; Figure 9–28: The embryo at 4 weeks; Figure 9–29: The embryo at 5 weeks; Figure 9–30: The embryo at 7 weeks; Figure 9–31: The embryo at 8 weeks, pp. 185–186

D. Fetal stage 1. 9 weeks → birth a) 9 weeks → fetus → every organ system, external structure present (1) Refining and perfecting b) 9 to 12 weeks → C–R 5cm, 14 g → 8 cm C–R, 45 g (1) Face well formed, spontaneous movement, fetal heart tones c) 13 to 16 weeks → rapid growth, lanugo develops, active movements, skeletal ossification identifiable d) 20 weeks → doubles C–R to 19 cm, 435 to 465 g (1) Lanugo covers body, brown fat, muscles well developed, nails and hair e) 24 weeks → C–R 28 cm, 780 g (1) Hair longer, eyes complete, grasp reflex, startle reflex (2) Vernix caseosa f) 25 to 28 weeks → skin red, brain developing rapidly, testes begin to descend (1) C–R 35 to 38 cm, 1200 to 1250 g (2) Viable → lungs sufficiently developed to provide gas exchange g) 29 to 32 weeks → pupillary light reflex at 30 weeks 23 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) C–R 31 cm, 2000 g (2) CNS direct breathing, partially control body temperature h) 35 to 36 weeks → plump, less wrinkled, lanugo disappears, nails to edge of fingertips (1) 2500 to 2750 g, C–R 42 to 48 cm i) 38 to 40 weeks → full term at 38 weeks up to 40 weeks after conception (1) C–R 48 to 52 cm, 3000 to 3600 g (2) Males usually weigh more than females (3) Lanugo on upper arms and shoulders, hair coarse (4) Vernix caseosa in skin folds, creases 2. As fetus enlarges → amniotic fluid diminishes a) Assumes position of comfort → lie (1) Head generally down

E. What parents want to know 1. See Key Facts to Remember: Embryonic and Fetal Development: What Parents Want to Know, p. 188 2. 4 weeks: fetal heart begins to beat 3. 8 weeks: all body organs are formed 4. 8 to 12 weeks → fetal heart tones can be heard by Doppler device 5. 16 weeks → baby’s sex can be seen, fetus looks like a baby 6. 20 weeks → heartbeat can be heard with fetoscope a) Mother feels movement (quickening) b) Baby develops a regular schedule of sleeping, sucking, kicking c) Hands can grasp d) Baby assumes a favorite position in utero e) Vernix protects body, lanugo keeps oil on skin f) Head hair, eyebrows, eyelashes present 7. 24 weeks → weighs 780 g (1 lb 10 oz) a) Activity is increasing b) Fetal respiratory movements begin 8. 28 weeks → eyes begin to open and close a) Baby can breathe at this time b) Surfactant needed for breathing at birth is formed c) Baby is two-thirds final size 9. 32 weeks → has fingernails and toenails a) Subcutaneous fat being laid down b) Baby appears less red and wrinkled

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

10. 38+ weeks → baby fills total uterus a) Baby gets antibodies from mother

XI.

Factors Influencing Embryonic and Fetal Development

A. Include 1. Quality of sperm or ovum 2. Genetic code established at fertilization 3. Adequacy of intrauterine environment 4. Time of injury critical in development of anomalies

B. Organs formed primarily during embryonic development 1. Vulnerable to hazardous agents during first months of pregnancy 2. Teratogen → any agent that can cause development of abnormal structures in an embryo 3. Developmental vulnerability a) Weeks since conception → potential teratogen-induced malformation (1) 3 → ectromelia, ectopia cordis (2) 4 → omphalocele, tracheoesophageal fistula, hemivertbra (3) 5 → nuclear cataract, micropthalmia, facial clefts, carpal or pedal ablation (4) 6 → gross septal or aortic abnormalities, cleft lip, agnathia (5) 7 → interventricular septal defects, pulmonary stenosis, cleft palate, micrognathia, epicanthus, brachycephalism, mixed sexual characteristics (6) 8 → persistent ostium primum, digital stunting 4. Adequacy of maternal environment important a) Maternal nutrition affects brain and neural tube development b) Maternal hyperthermia → spontaneous abortion, CNS defects, failure of neural tube closure c) First trimester use of prescription medications d) Cigarette smoking → intrauterine growth restriction (UGR)

XII.

Focus Your Study

XIII.

Activities 1. Individual Assign each student a potential teratogen-induced malformation to research. The rubric should include the following: the week of gestation at risk, the germ layer involved, and the teratogen suspected. Have students write a two-page paper summarizing their research and instruct the students to use APA format and citation style.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the expectant parent. For each group, assign the gestational age by weeks of gestation. Instruct the groups to included printed material in their plans and remind them to use APA style for their citations. 3. Large Group Show an appropriate video related to fetal development. Some possible choices include: • National Geographic, In the Womb, DVD, Dilly Barlow • From Conception to Birth, DVD, Mark Petersson • National Geographic, Inside the Living Body, DVD, Kate Burton • In the Womb, Collection, DVD • NOVA, The Miracle of Life, DVD, Michael Agaton

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 10 Reproductive Genetics Genetic Disorders………………….…………….…………………………………………………….

Modes of Inheritance…………….…………….…………………………………………………….

Prenatal Diagnostic Tests…………….…………….………………………………………………

Genetic Evaluation…………….…………….………………………………………………………..

Focus Your Study.............................................................................................

Activities..........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Genetic Disorders

A. Desired outcome of pregnancy → birth of healthy, perfect baby 1. Grief, fear, anger → baby born with defect, genetic disease 2. Many questions → nurse to anticipate questions, concerns, direct to appropriate resources, support family

B. Chromosomes and Chromosomal Analysis 1. All hereditary material → carried on strands of DNA 2. Chromosomes carry genes → smallest unit of inheritance 3. Somatic cells → 46 chromosomes → diploid 4. Sperm and egg → 23 chromosomes, haploid a) 22 pairs → autosomes (non-sex chromosomes) b) 1 pair → sex chromosome (1) See Figure 10–1: Normal female karyotype and Figure 10–2: Normal male karyotype, p. 192 (2) See Figure 10–5 A. Karyotype of a male who has trisomy 18. B. Infant girl with trisomy 18, pp. 192, 193 5. Karyotype → pictorial analysis of individual’s chromosomes a) Chromosomal abnormalities → autosomes, or sex chromosomes (1) Small alterations can cause problems 6. Abnormalities of chromosome number a) See Table 10–1: Chromosomal Syndromes, p. 194 b) Most commonly seen as trisomies, monosomies, mosaicism (1) Nondisjunction (a) In either sperm or egg → abnormal chromosome makeup in all cells (b) After fertilization → cells with two or more different chromosome makeup c) Trisomies → product of union of normal gamete with gamete that contains extra chromosome (1) 47 chromosomes → trisomic (2) Down syndrome most common (a) Distinctive clinical features (b) See Figure 10–4: A boy with Down syndrome, p. 193 (3) Trisomy 18, trisomy 13 (a) Prognosis poor → 70% die within first 3 months of life d) Monosomies → normal gamete unites with gamete missing a chromosome (1) Monosomy generally incompatible with life e) Mosaicism → after fertilization → two different cell lines, each having different chromosomal number f) Most common with Down syndrome 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Abnormalities of chromosome structure a) Involve parts of chromosomes → translocations, deletions, duplications (1) Most Down syndrome children have trisomy 21 → some have abnormal rearrangement of chromosomal material → translocation b) Translocation → transfer of segment of one chromosome to another chromosome (1) Nonhomologous → reciprocal translocation relatively common (2) Balanced → no deletion or duplication of material (a) Individual may not have health concern → offspring may have unbalanced translocation (3) Unbalanced → chromosome material deleted or duplicated (a) Pregnancy loss, congenital anomalies, intellectual disability, other health concerns (4) Robertsonian translocations → individual has 45 chromosomes (a) See Figure 10–8: Diagram of various types of offspring …, p. 195 c) Duplication or deletions (1) Structural abnormality (2) Any portion of chromosome may be lost or added resulting in some adverse effect 8. Abnormalities of the sex chromosome a) Early embryonic stage → females: one of two normal X chromosomes becomes inactive (1) Forms dark-staining area known as the Barr body (2) Female has one, male has no Barr bodies → he has only one X chromosome b) Common abnormalities (1) Turner syndrome in females → 45, X with no Barr bodies present (2) Klinefelter syndrome in males → 47, XXY, with one Barr body present

C. Modes of Inheritance 1. Two major categories: Mendelian (single-gene) inheritance and non-Mendelian (multifactorial) inheritance a) Phenotype → responsible for observable expression of traits → single gene trait b) Genotype → pattern of genes on chromosomes c) One of genes for trait from mother, one from father d) Two identical → homozygous for trait e) Two different alleles → heterozygous 2. Autosomal dominant inheritance a) Disease trait is heterozygous, individual inherits disorder (1) May be familial (2) De novo mutation b) Family pedigree may show multiple generations c) Affected individuals have 50% chance of passing abnormal gene d) Males and females equally affected e) Autosomal dominant inherited disorders have varying degrees of presentation (1) May be difficult to diagnose 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Penetrance → individual with genetic trait fails to express features of disorder → reduced penetrance (b) Expressivity → severity of expression of phenotype (c) Pleiotropic → single abnormal gene produces diverse phenotypic effects f) See Figure 10–9: Autosomal dominant pedigree, p. 196 3. Autosomal recessive inheritance a) Individual must have two abnormal genes to be affected (1) Carrier → individual is heterozygous for abnormal gene, clinically normal (2) Two carriers mate → pass on abnormal gene (a) Affected individual can have clinically normal parents → both carriers (b) 25% chance abnormal gene passed to any offspring (c) Each pregnancy 25% chance resulting in affected child (d) Child or two carrier parents clinically normal → two-thirds chance child is carrier (e) Both males and females equally affected (f) Increased history of consanguineous matings b) Common disorders (1) Cystic fibrosis (2) Phenylketonuria (PKU) (3) Galactosemia (4) Sickle cell disease (5) Tay-Sachs disease (a) See Figure 10–10: Autosomal recessive pedigree, p. 196 4. X-linked recessive inheritance a) Sex-linked disorders → abnormal gene carried on X chromosome (1) Manifested in male who carries abnormal gene on his only X chromosome → hemizygous (2) Two thirds of the time → mother carrier (3) Most carrier females do not have symptoms b) Characteristics (1) No male–male transmission (2) 50% chance that carrier mother will pass abnormal gene to each of her sons → affected (3) 50% chance that carrier mother will pass normal gene to each of her sons → unaffected (4) 50% chance that carrier mother will pass abnormal gene to each of her daughters → become carriers (5) Father affected cannot pass disorder to sons → all daughters become carriers c) Common disorders (1) Hemophilia (2) Duchenne muscular dystrophy (3) Some forms of color blindness

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. X-linked dominant inheritance a) Rare (1) Most common → vitamin D–resistant rickets b) Pattern similar to X-linked recessive inheritance except heterozygous females can also be affected (1) No male-to-male transmission c) Some so severe → lethal in utero or newborn period in hemizygous males (1) Rett syndrome (2) Severe form of otopalataldigital 6. Trinucleotide repeat disorders a) Anticipation → trinucleotide repeats during meiosis → gene passed from generation to generation with a larger and larger number of triplet repeats b) Associated with phenotypic expression condition c) Diseases (1) Huntington disease (2) Myotonic dystrophy (3) Fragile X syndrome 7. Multifactorial inheritance a) Many common malformations → do not follow clear pattern of Mendelian inheritance (1) Interaction of many genes (2) Cleft palate (3) Heart defect (4) Spina bifida (5) Dislocated hips (6) Clubfoot (7) Pyloric stenosis b) Characteristics (1) Malformations may range from mild to severe (2) Often a sex bias (a) Pyloric stenosis more common in males, cleft palate more common in females (b) Greater number of genes present if less commonly affected sex shows condition (3) Increased risk among closest relatives, multiple family members affected c) Careful family history (1) Other disorders within multifactorial inheritance group (a) Diabetes (b) Hypertension (c) Some heart diseases (d) Mental illness

D. Prenatal Diagnostic Tests 1. Parent–child, family-planning counseling → responsibility of nurses a) Counseling before prenatal screening, diagnostic testing 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Include conditions detectable (2) Diagnostic test available if screen positive (3) Risk to mother and pregnancy of test (4) Accuracy of test (5) Limitations of test b) Should be available to all women regardless of maternal age c) Women counseled on difference between screening and invasive diagnostic testing 2. Genetic ultrasound a) Visualize (1) Fetal head for abnormalities (2) Craniospinal defects (3) Gastrointestinal malformations (4) Renal malformations (5) Skeletal malformations b) Best done at 16 to 20 weeks c) Nuchal translucency measurement at 10 and 13 weeks → chromosomal abnormalities 3. Maternal serum screening a) Specific hormones, proteins → risk for Down syndrome, trisomy 18, open spina bifida b) Nuchal translucency measurement → often added in first trimester 4. Noninvasive prenatal testing (NIPT) through cell-free fetal DNA a) Measuring circulating cell-free DNA in maternal serum b) Not meant to replace diagnostic testing such as CVS or amniocentesis c) Recommended for women of advanced age and women with abnormal fetal ultrasound findings 5. Genetic amniocentesis a) Risks (1) Infection (2) Miscarriage (3) < 0.1 to 0.3% b) Indications (1) Maternal age 35 or older (2) Previous child born with a chromosomal abnormality (3) Parent carrying a chromosomal abnormality (balanced translocation) (4) Mother carrying an X-linked disease (5) Both parents carrying an autosomal recessive disease (6) Family history of neural tube defects (7) Fetus with major or minor abnormalities on ultrasound (8) Women with positive serum screening results, including NIPT c) See Figure 10–12: A. Genetic amniocentesis for prenatal diagnosis …, p. 199 6. Percutaneous umbilical cord sampling and chorionic villus sampling (CVS) a) Percutaneous umbilical cord sampling (PUBS) 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Blood obtained from umbilical cord during pregnancy (2) More rapid chromosome diagnosis (3) Transfusion for Rh alloimmunization or hydrops fetalis (4) Risk of pregnancy complication higher then CVS b) Chorionic villus sampling (CVS) (1) Obtains chorionic villi tissue either transabdominally or transcervically (2) Diagnostic capability similar to amniocenteses (3) Advantage → information available at 10 to 12 weeks’ gestation c) Risks (1) Infection (2) Pregnancy loss (3) Estimated 1% 7. Nursing Management for the Woman with Possible Risk Factors for Genetic Disorders a) See Key Facts to Remember: Couples Who May Benefit from Preconceptual or Prenatal Genetic Counseling, p. 201 (1) Women age 35 or older at time of birth (2) Couples with a balanced translocation (3) Family history of known or suspected single-gene disorder (4) Couples with a previous pregnancy or child with chromosomal abnormality (5) Couples in which either partner or a previous child is affected with or in which both partners are carriers for a diagnosable metabolic disorder (6) Family history of birth defects and/or intellectual disability (7) Ethnic groups at increased risk for specific disorders (8) Couples with a history of three or more first trimester spontaneous abortions (9) Women with an abnormal maternal serum screening test (10) Women with a teratogenic risk secondary to an exposure or maternal health condition b) Counseling precedes any procedure for prenatal diagnosis c) Couple may decide to interrupt pregnancy d) Can give parents opportunity to prepare for a child with special needs e) Every pregnancy 3% to 5% risk of infant with birth defect 8. Newborn screening a) Hearing loss, congenital heart disease, hemoglobinopathies, certain endocrine diseases, and other inherited genetic diseases b) State-level program 9. Postnatal diagnosis a) Genetic disorders often discussed in newborn period (1) Anomalies, does not progress → genetic evaluation b) Incorporate: (1) Complete and detailed histories → determine if problem prenatal, postnatal, familial in origin (2) Thorough physical and dysmorphology examination by trained clinical geneticist 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Laboratory analysis → includes chromosome analysis, enzyme assay for inborn errors of metabolism, DNA studies, antibody titers for infectious teratogens c) Human Genome Project → implications for identification, management of inherited diseases (1) Ethical considerations

E. Genetic Evaluation 1. Communication → a) Helps family, individual → understand, adapt to implications of genetic contributions to disease 2. Referral advised for a) Congenital abnormalities, including intellectual disability b) Familial disorders c) Known inherited diseases d) Metabolic disorders e) Chromosomal abnormalities 3. Process a) Form for family pedigree (1) See Figure 10–13: Screening pedigree, p. 201 b) Initial session (1) Counselor gathers additional information (a) Affected child’s growth and development (b) Family’s understanding of problem (c) Ethnic background (i) See Developing Cultural Competence: Genetic Screening Recommendations for Various Ethnic Groups, p. 203 (2) Child given physical examination (3) Other family members may be examined (4) Laboratory studies, if any, done at this time c) Follow-up counseling (1) After data examined and analyzed (2) Parents given all information available (3) Discuss course of action appropriate for the family (4) See Key Facts to Remember: Nursing Responsibilities in Genetic Evaluation and Counseling, p. 204 (a) Identify families at risk for genetic problems (b) Determine how the genetic problem is perceived and what information is desired before proceeding (c) Assist families in acquiring information about the specific problem (d) Act as liaison between family and genetic counselor (e) Assist the family in understanding dealing with information received (f) Provide information on support groups 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(g) Aid families in coping with this crisis (h) Provide information about known genetic factors (i) Ensure continuity of nursing care to the family 4. Nursing Management for the Family Undergoing Genetic Evaluation a) Key role in preventing recurrence b) Inform parents genetic counseling is available c) Answer additional questions d) Attend counseling sessions e) Act as liaison between family and genetic counselor

II.

Focus Your Study

III.

Activities 1. Individual Have students prepare a screening pedigree for a patient. Instruct students to include two preceding generations. 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a patient teaching plan for one of the following: a. Following basal body temperature (BBT) b. Hysterosalpingography c. Therapeutic insemination d. Transvaginal ultrasound e. Amniocentesis f. Maternal serum alpha-fetoprotein g. In vitro fertilization 3. Large Group Invite a nurse from a fertility clinic or a genetic counselor to talk to the students about specific nursing care of their patients.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 11 Physical and Psychologic Changes of Pregnancy Anatomy and Physiology of Pregnancy.........................................................

Signs of Pregnancy.........................................................................................

Psychologic Response of the Expectant Family to Pregnancy......................

Cultural Values and Pregnancy......................................................................

Focus Your Study....................................................................................... …..

Activities.........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Anatomy and Physiology of Pregnancy

A. Reproductive System 1. Uterus a) Size → 7.5 × 5 × 2.5 cm → 28 ×24 × 21 cm b) Weight → 70 g → 1100 g c) Capacity → 10 mL → 5000 mL d) Hypertrophy of preexisting myometrial cells (1) Uterine walls get thicker → stimulated by increased estrogen, progesterone levels (2) Enlarges more around fundus and placental insertion site (3) Myometrial hypertrophy continues first few months → musculature begins to distend e) Braxton Hicks contractions → irregular contractions of uterus 2. Cervix a) Major component of cervical tissue → connective tissue b) Estrogen stimulates glandular tissue → increases in cell number, hyperactive c) Thick mucus plug seals endocervical canal → expelled when cervical dilation begins d) Goodell sign e) Chadwick sign 3. Ovaries a) Cease ovum production during pregnancy b) Human chorionic gonadotropin (hCG) maintains corpus luteum → persists until about 6 to 8 weeks of pregnancy (1) Secretes progesterone to maintain endometrium until placenta produces enough to maintain pregnancy 4. Vagina a) Estrogen-induced changes → hypertrophy, increased vascularization, hyperplasia (1) Increased secretions → thick, white, acidic → pH plays role in preventing infections, except yeast organisms b) Smooth muscle cells hypertrophy → accompanying loosening of supportive connective tissue c) Increased blood flow → may show same blue-purple color seen in cervix 5. Breasts a) Changes occur soon after first missed menstrual period b) Estrogen- and progesterone-induced changes (1) Increases in breast size, nodularity → result of glandular hyperplasia, hypertrophy (2) End of second month → superficial veins prominent, nipples more erectile, pigmentation of areola obvious (3) Hypertrophy of Montgomery follicles (4) Striae may develop

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Colostrum → antibody-rich yellow secretion (1) May be expressed manually by 12th week (2) Gradually converts to mature milk during first few days following childbirth

B. Respiratory System 1. Pulmonary function modified throughout pregnancy 2. Small degree of hyperventilation → tidal volume increases steadily throughout pregnancy 3. Oxygen consumption increases → meet increased needs of mother, fetus, placenta a) Progesterone-induced marked decrease of airway resistance 4. Chest circumference may increase → elevated diaphragm 5. Lung disease may be aggravated 6. Rhinitis of pregnancy a) Epistaxis b) Estrogen-induced edema and vascular congestion of nasal mucosa

C. Cardiovascular System 1. Uterus exerts pressure on diaphragm → pushes heart upward, to left, rotating forward a) May appear somewhat enlarged on x-ray 2. Blood volume progressively increases throughout pregnancy a) No increase in pulmonary capillary wedge pressure or central venous pressure → decrease in systemic vascular resistance, pulmonary vascular resistance b) Cardiac output begins to increase in early pregnancy → peaks at 25 to 30 weeks 3. Pulse frequently increases during pregnancy → 10 to 15 beats/min 4. Blood pressure decreases slightly → second trimester then rises to near prepregnant by term 5. Femoral venous pressure slowly rises → uterus exerts increasing pressure on return blood flow → edema 6. Enlarging uterus may put pressure on vena cava when supine → supine hypotensive syndrome a) Marked decrease in BP, with dizziness, pallor, clamminess → lie on left side to correct b) See Figure 11–1: Vena cava syndrome, p. 209 7. Total erythrocyte volume increases about 25% a) Supports additional oxygen transport b) Physiologic anemia of pregnancy c) Iron necessary for hemoglobin formation → recommended to add supplemental iron to diet

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

8. Leukocyte production equal or slightly greater than increased blood volume a) Occasional physiologic leukocytosis of 15,000/mm3 b) During normal labor → may reach 25,000/mm3 9. Platelet count does not change much in pregnancy 10. Plasma fibrinogen known to increase by as much as 50% a) Clotting time does not differ significantly b) Blood factors VII, VIII, IX, X increased → pregnancy somewhat hypercoagulable c) Pregnant woman at increased risk of developing venous thrombosis

D. Gastrointestinal System 1. Nausea and vomiting during first trimester → sometimes associated with hCG, change in carbohydrate metabolism a) Gum tissues hyperemic, softened b) Increased secretion of saliva 2. Second half of pregnancy → numerous symptoms attributable to pressure of growing uterus, smooth muscle relaxation due to elevated progesterone levels a) Heartburn b) Bloating, constipation c) Hemorrhoids 3. Mild liver changes 4. Gallbladder emptying may be slow

E. Urinary Tract 1. First trimester → urinary frequency 2. Second trimester → uterus becomes abdominal organ → no pressure on bladder 3. Near term → pressure on bladder a) Susceptible to infection, trauma b) Capacity reduced 4. Dilation of kidneys, ureter → right side, due to lie of uterus 5. Glomerular filtration rate (GFR), renal plasma flow (RPF) increase early in pregnancy a) GFR elevated until birth b) Increased renal tubular reabsorption → compensates for increased glomerular activity

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Glycosuria not uncommon, not necessarily pathogenic

F. Skin and Hair 1. Changes in skin pigmentation common → increased estrogen, progesterone, α-melanocytestimulating hormone levels a) Increased pigmentation primarily in areas already hyperpigmented b) Linea nigra (1) See Figure 11–2: Linea nigra, p. 211 c) Chloasma 2. Striae → stretch marks 3. Vascular spider nevi → disappear after pregnancy ends 4. Rate of hair growth may decrease during pregnancy a) After birth → number of hair follicles in resting phase increases → increased shedding of hair for 1 to 4 months 5. Sweat and sebaceous glands → frequently hyperactive

G. Musculoskeletal System 1. Teeth → no demonstrable changes 2. Sacroiliac, sacrococcygeal, pubic joints of pelvis relax in later part of pregnancy → hormonal changes a) Waddling gait 3. Lumbodorsal spinal curve accentuated as pregnant woman’s center of gravity changes a) Late in pregnancy → aches in shoulder, neck, upper extremities 4. Diastasis recti

H. Eyes 1. Intraocular pressure decreases 2. Slight thickening of cornea 3. May affect fit of contacts

I. Central Nervous System 1. Many describe decreased attention, concentration, memory during and after pregnancy 2. Sleep problems common in pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Maternal reserves 2. Recommended total weight gain a) 11.5 to 16 kg (25 to 35 lb) → normal prepregnancy weight b) to 11.5 kg (15 to 25 lb) → overweight prepregnancy c) 5 to 9 kg (11 to 20 1b) → obese prepregnancy d) 12.7 to 18.1 kg (28 to 40 1b) → underweight prepregnancy e) 0.5 to 2.0 kg first trimester f) 0.45 kg per week during last two trimesters 3. Water metabolism a) Increased water retention → basic chemical alteration of pregnancy b) Increased level of steroid sex hormones c) Lowered serum protein d) Extra water needed for products of conception, increased blood volume, interstitial fluids; enlarged organs 4. Nutrient metabolism a) Fetal demands greatest during second half of gestation (1) Doubles in weight in last 6 to 8 weeks b) Increased protein retention → hyperplasia, hypertrophy of maternal tissues c) Fats more completely absorbed during pregnancy (1) Marked increase in serum lipids, lipoproteins, cholesterol d) Fat deposits increase from 2% midpregnancy to 12% at term e) Woman’s body switches from glucose metabolism to lipid metabolism once glucose from food intake has been used up f) Demand for carbohydrate increases g) Intermittent glucosuria not uncommon h) Diabetes → plasma levels of insulin increase during pregnancy (1) Rapid destruction of insulin within placenta (2) Insulin production must be increased by mother during second trimester i) Demand for iron accelerated (1) Iron transfer at placenta toward fetus (a) Stored in fetal liver (b) Compensates for inadequate amounts of iron in breast milk j) Progressive absorption, retention of calcium

K. Endocrine System 1. Thyroid gland a) Often palpable change → increase in vascularity, hyperplasia of glandular tissue b) Serum thyroxine (T4) increases early in pregnancy, thyroid-stimulating hormone (TSH) decreases c) Basal metabolic rate (BMR) increases by as much as 20% to 25% during pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Parathyroid gland a) Concentration of parathyroid hormone, size of glands increase b) Paralleling fetal calcium requirements 3. Pituitary gland a) Enlarges somewhat → returns to normal size after birth b) Pregnancy possible by hypothalamic stimulation of follicle-stimulating hormone (FSH) → stimulates follicle growth; luteinizing hormone (LH) → effects ovulation c) Thyroid-stimulating hormone and adrenotropin → alter maternal metabolism to support pregnancy d) Prolactin responsible for initial lactation e) Posterior pituitary contains mechanism for release of oxytocin, vasopressin 4. Adrenal glands a) Little structural change in adrenal glands b) Circulating cortisol levels regulate carbohydrate and protein metabolism c) Increased secretion of aldosterone by early part of second trimester 5. Pancreas a) Increased insulin needs b) Latent deficiency → symptoms of gestational diabetes 6. Hormones in pregnancy a) hCG → from trophoblast early in pregnancy b) Human placental lactogen → antagonist of insulin (1) Decreases maternal metabolism of glucose to favor fetal growth c) Estrogen → originally by corpus luteum, primarily produced by placenta d) Progesterone → originally by corpus luteum, then placenta → greatest role in maintaining pregnancy e) Relaxin → inhibits uterine activity, believed to be produced by placenta, uterine decidua throughout pregnancy 7. Prostaglandins (PGs) in pregnancy a) PGs → lipid substance that can arise from most body tissues b) May be responsible for maintaining reduced placental vascular resistance

II.

Signs of Pregnancy

A. Subjective (Presumptive) Changes 1. Amenorrhea 2. Nausea and vomiting of pregnancy (NVP) a) Changed carbohydrate metabolism b) Morning sickness c) Usually disappears spontaneously 6 to 12 weeks after it starts

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Women who experience NVP → have more favorable pregnancy outcome than those who do not 3. Excessive fatigue 4. Urinary frequency 5. Change in breasts 6. Quickening → about 18 to 20 weeks after last menstrual period (LMP)

B. Objective (Probable) Changes 1. Changes in pelvic organs a) Goodell sign b) Chadwick sign c) Hegar sign d) Ladin sign e) McDonald sign f) Braun von Fernwald sign g) Piskacek sign 2. Enlargement of abdomen 3. Braxton Hicks contractions 4. Uterine souffle 5. Changes in pigmentation of skin 6. Appearance of abdominal striae 7. Fetal outline may be identified by palpation after 24 weeks’ gestation a) Ballottement 8. Pregnancy tests → analysis of maternal blood or urine for detection of hCG a) Clinical pregnancy tests (1) β-Subunit radioimmunoassay (RIA) → very accurate (2) Enzyme-linked immunosorbent assay (ELISA) → sensitive, quick → 7 to 9 days after ovulation and conception (3) Fluoroimmunoassay (FIA) → 2 to 3 hours to perform, extremely sensitive b) Over-the-counter pregnancy tests (1) Home pregnancy tests (HPTs) → convenient, private (a) Multiple brands (b) Many variables that affect accuracy of home pregnancy tests (c) False-positive rate low → false negatives more common

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Diagnostic (Positive) Changes 1. Fetal heartbeat can be detected with electronic Doppler device as early as 10 to 12 weeks 2. Fetal movement → after about 20 weeks’ gestation 3. Visualization of the fetus by ultrasound → confirms pregnancy a) Gestational sac → 4 to 5 weeks’ gestation b) Fetal parts, fetal heart movement → as early as 8 weeks c) Transvaginal ultrasound → gestational sac as early as 10 days after implantation

III.

Psychologic Response of the Expectant Family to Pregnancy

A. Developmental challenge 1. Stress, anxiety → whether desired or not a) Transition period 2. Couple may be unaware → physical, emotional, cognitive states peculiar to pregnancy 3. Roles a) Mate → adds mother, parent role b) Career goals, mobility → altered c) Without stable partner (1) Role changes, maturation → alone or seek support (2) Face future as single parent 4. Financial considerations a) Breadwinners → impact b) Decisions to be made 5. Labor and birth a) Must face realities → childbirth classes can address lack of information, misinformation b) Threats for woman → pain, disfigurement, disruption of bodily function, death c) Partner → woman’s disfigurement, impairment of her health, her death d) Both → fear baby may be ill, disfigured 6. Developmental tasks a) Support or conflict for couple b) Plan for first child’s arrival → collect information on how to be parents (1) Social support c) Other family members also adjust to pregnancy d) Major psychosocial adjustments (1) See Table 11–3: Parental Reactions to Pregnancy, p. 218 (2) First trimester (a) Mother’s reactions (i) Informs father (ii) Feels ambivalent 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(iii) Aware of physical changes, daydreams of possible miscarriage (iv) Develops special feeling for, renewed interest in own mother (b) Father’s reactions (i) Differ according to age, parity, desire for child, economic stability (ii) Acceptance of pregnant woman’s attitude or complete rejection, lack of communication (iii) Aware of sexual feelings, may develop more or less sexual arousal (iv) Accepts, rejects, or resents mother-in-law (v) May develop new hobby outside of family as sign of stress (3) Second trimester (a) Mother’s reactions (i) Remains regressive, introspective; projects problems with authority figures onto partner (ii) Continues to deal with feelings as mother, shops for nursery furniture as concrete action (iii) May experience anxiety or be lackadaisical and wait until ninth month to shop for baby (iv) Feels movement, aware of fetus (v) Dreams that partner will be killed, telephones him often for reassurance (vi) Experiences more distinct physical changes, sexual desires may increase or decrease (b) Father’s reactions (i) If he can cope → will give her extra attention; if cannot cope → develop new time-consuming interest outside home (ii) May develop creative feeling, closeness to nature (iii) May become involved in pregnancy, buy or make furniture (iv) Feels for movement of baby, listens to heartbeat or remains aloof, no physical contact (v) May have fears and fantasies about himself being pregnant (vi) May react negatively if partner too demanding, may become jealous of physician, and physician’s importance to partner and pregnancy (4) Third trimester (a) Mother’s reactions (i) More anxiety and tension, physical awkwardness (ii) Feels much discomfort, insomnia (iii) Prepares for birth (iv) Dreams about misplacing baby, not being able to give birth, fears birth of deformed baby (v) Feels ecstasy and excitement (b) Father’s reactions (i) Adapts to alternative methods of sexual contact (ii) Becomes concerned over financial responsibility (iii) May show new sense of tenderness, concern, treat partner like doll (iv) Dreams about child as if older, dreams of losing partner 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(v) Renewed sexual attraction to partner (vi) Feels he is ultimately responsible for whatever happens e) Late pregnancy (1) Focus mostly on unborn child, safety of mother (2) Couples typically agree on primary concern → health of unborn child f) May be crisis → disturbance or conflict in which the individual cannot maintain state of equilibrium (1) Maturational crisis (2) Disequilibrium, disorganization (3) If not resolved → maladaptive behaviors, possible disintegration of family

B. Mother 1. Alters body image, reorders social relationships, changes roles of family members 2. Intendedness a) Unintended pregnancy not necessarily unwanted b) May be risk factor for depression 3. Ambivalence a) Surprise → conception actually occurred b) Individuals who do not view parenthood as being important c) Higher perceived cost of having children d) Lack of positive attitude toward the partner e) Lower socioeconomic variables f) May be more pronounced if pregnancy unwanted, unintended g) Financial and emotional support from partner → essential to positive attitude h) May have negative thoughts → feel guilty for negative thoughts 4. Acceptance a) Influenced by many factors → planned/unplanned b) First trimester → evidence of pregnancy amenorrhea, word of caregiver c) Second trimester → begins to accept reality of pregnancy → primigravida may wear maternity clothing (1) Quickening → about week 20 (2) Adjusts to idea of change → prepares for new role, new set of relationships (3) “Glow” d) Third trimester → pride with anxiety (1) Accepts help due to advanced pregnancy or rejects (2) Physical discomforts increase, needs rest (3) Worries (4) Vulnerable to rejection, loss, insult 5. Introversion a) Turning in on oneself → common b) More concerned with needs for rest, time alone 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Partner may feel she is being overly sensitive d) Fantasies about unborn child common 6. Mood swings a) Great joy to deep despair b) Tearful with little cause c) Unsettling to partner → may withdraw → feels confused and inadequate 7. Changes in body image a) Marked changes in body → short period of time b) Explanation and discussion may help 8. Psychologic tasks of mother a) Ensuring safe passage through pregnancy, labor, and birth b) Seeking of acceptance of this child by others c) Seeking of commitment, acceptance of self as mother to infant (binding-in) d) Learning to give of oneself on behalf of one’s child

C. Father 1. View of role changed from bystander → nurturing, caring involved parent, provider a) Many of same feelings, conflicts of expectant mothers b) Psychologic stress → transition of roles c) Must establish fatherhood role d) Role of father is crucial both prenatally and postnatally 2. First trimester a) After initial excitement, announcement → may feel left out of pregnancy b) Confused by mood changes, his responses to her changing body 3. Second trimester a) Role still vague, involvement increasing (1) Can hear fetal heartbeat b) Needs to confront, resolve own conflicts about fathering they received c) Anxiety may be lessened → both parents agree on role man to assume d) Woman’s appearance begins to alter → men react differently 4. Third trimester a) Communicated concerns to one another → special, rewarding time b) Involved in childbirth education classes c) Concrete preparations d) Concerns, fears may recur → fear of injuring baby during intercourse e) Couvade → unintentional development of physical symptoms that pregnant woman experiencing

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Partners of Lesbian Mothers 1. More obstacles to overcome including the basic decision as to which woman will become the biological parent. 2. Legal barriers as to legal parents

E. Siblings 1. Introduction of new baby → may be beginning of sibling rivalry a) Fear of change in security of relationships with parents 2. Preparation of young child → several weeks before a) Feel baby moving in uterus → “special place where babies grow” 3. Consistency with people, places, things a) Crib or cosleeping b) Toilet training → several months before or after baby’s arrival (1) May regress 4. Introduce older children to new baby → not playmate yet 5. Pregnancy a family affair → school-age children a) Teaching based on level of understanding, interest 6. Older children → discuss concerns, involve in preparation a) Dispel misconceptions 7. After birth → program at hospital

F. Grandparents 1. Usually first relatives told about a pregnancy 2. Response can vary considerably → interest or seeming disinterest 3. Signal change in grandparents’ own lives 4. Childbearing, childrearing practices very different → advice comes because they care 5. Too much advice → perceived as criticism 6. Classes for grandparents

IV.

Cultural Values and Pregnancy A. Ceremonial rituals and rites around important life events 1. Identification of cultural values useful in planning, providing culturally sensitive care 2. Generalizations difficult a) Not every individual in a culture may display characteristics 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Related to social, economic factors 3. Cultural assessment important aspect of prenatal care a) Identify main beliefs, values, behaviors that relate to pregnancy, childbearing

Focus Your Study

VI.

Activities 1. Individual Ask students to identify cultural values, beliefs, and behaviors in their personal cultural and/or ethnic group. Alternatively, ask students to pick a group to research. Instruct students to include in their rubrics: an outline of common values, beliefs, and behaviors and subgroup differences, if identified. Students should use APA format for their reference citations. 2. Small Group Divide the class into small groups of three to five students. Assign each group a body system that is altered in some way during pregnancy. The groups should prepare a visual presentation of some type with a short (two to four pages) written report with references in APA format. 3. Large Group Invite a childbirth educator to speak to the class specifically about grandparent, sibling, and partner preparation in light of the physical and psychological changes of pregnancy.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 12 Antepartum Nursing Assessment Initial Patient History.....................................................................................

Initial Prenatal Assessment...........................................................................

Subsequent Patient History..........................................................................

Subsequent Prenatal Assessment.................................................................

Focus Your Study...........................................................................................

Activities........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Initial Patient History

A. Factors that influence pregnancy course B. Definition of Terms 1. Antepartum 2. Intrapartum 3. Postpartum 4. Gestation 5. Abortion 6. Term a) Early term b) Full term c) Late term d) Postterm 7. Preterm labor 8. Postterm labor 9. Gravida 10. Nulligravida 11. Primigravida 12. Multigravida 13. Para 14. Nullipara 15. Primipara 16. Multipara 17. Stillbirth 18. TPAL a) Gravida, para → refer to total number of pregnancies b) T → number of term births c) P → number of preterm births d) A → number of pregnancies ending in spontaneous or therapeutic abortions e) L → number of currently living children to whom the woman has given birth f) Examples g) Five-digit system → multiple births 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Patient Profile 1. Current pregnancy a) First day of last menstrual period (LMP) b) Cramping or bleeding since LMP c) Opinion about conception, due date d) Attitude toward pregnancy e) Date of positive/negative pregnancy test f) Any pregnancy discomforts since LMP g) Spontaneous conception? Infertifility treatments? 2. Past pregnancies a) Number of pregnancies b) Number of abortions, spontaneous or therapeutic c) Number of living children d) History of previous pregnancies (1) Length of pregnancy (2) Length of labor and birth (3) Type of birth (4) Location of birth (5) Type of anesthesia/medication used (6) Perception of the experience (7) Complications e) Neonatal status of previous children (1) Apgar scores (2) Birth weights (3) General development (4) Complications (5) Feeding method f) Loss of child g) Blood type, Rh factor h) Prenatal education classes, resources, knowledge about pregnancy, childbirth and parenting 3. Gynecologic history a) Date of last Pap smear? Results? b) Previous infections c) Previous surgery d) Age of menarche e) Regularity, frequency, duration of menstrual flow f) History of dysmenorrheal g) History of infertility h) Sexual history i) Contraceptive history

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Current medical history a) Weight, height, body mass index (BMI) b) Blood type, Rh factor c) General health: nutrition, regular exercise program, monthly breast exams, eye exam, dental exam d) Any medication use, any medications taken since LMP e) Previous or present use of alcohol, tobacco, caffeine (1) Amount (2) Planning cessation f) Illicit drug use (1) Specific drugs (2) Planning cessation g) Drug or food allergies, latex allergy or sensitivities, what type of reaction h) Potential teratogenic insults to this pregnancy (1) Viral infections, medications, x-ray examinations, surgery, cats in the home i) Presence of chronic disease conditions (diabetes, hypertension, asthma, cardiovascular disease, renal problems, or thyroid disease) j) Infections or illnesses since LMP k) Record of immunizations l) Presence of any abnormal signs/symptoms 5. Past medical history a) Childhood diseases (varicella) b) Past treatment for any disease condition; hospitalizations; major accidents? c) Surgical procedures d) Presence of bleeding disorders or tendencies e) Blood transfusion history; will she accept blood transfusions? 6. Family medical history a) Presence of diabetes, cardiovascular disease, hypertension, hematologic disorders, tuberculosis, thyroid disease, cancer b) Occurrence of multiple births c) History of congenital diseases or deformities d) History of mental illness e) Occurrence of cesarean births and cause, if known f) Cause of death of deceased parents or siblings 7. Genetic history a) Thalassemia, neural tube defect, congenital heart defect, Down syndrome, Tay-Sachs disease, Canavann disease, sickle cell disease or trait, hemophilia or other blood disorder, cystic fibrosis, Huntington chorea, intellectual disability/autism, other genetic disorder b) Recurrent pregnancy loss or stillbirth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

8. Religious/cultural history a) Does woman wish to specify religious preference on her chart? Any beliefs or practices that might influence her healthcare or that of child? b) What practices are important to maintain her spiritual well-being? c) Are there practices in her culture or that of her partner that might influence her care or that of her child? 9. Occupational history a) Occupation b) Physical demands c) Exposure to lead, chemicals, or other harmful substances d) Opportunity for regular meals and break for nutritious snacks e) Provision for maternity or family leave 10. Birth father’s physical history a) Presence of genetic conditions or diseases in him, or in family history b) Age c) Significant health problems d) Blood type, Rh factor e) Immunizations up to date 11. Father’s/partner’s social history a) Occupation b) Educational level; methods by which he or she learns best c) Current tobacco use, drug use, and alcohol intake d) Thoughts/feelings regarding pregnancy 12. Personal information about the woman (social history) a) Age b) Relationship status c) Educational level; methods by which she learns best d) Race or ethnic group e) Housing, stability of living conditions f) Economic level g) Intimate partner violence (IPV): Any history of emotional or physical deprivation or abuse of herself or children (1) Abuse in current relationship (2) Has she been hit, slapped, kicked, or hurt within the past year or since she has been pregnant? (3) Afraid of her partner or anyone else h) History of emotional/mental health disorder i) Support systems/postpartum support j) Personal preferences about the birth k) Plans for care of child following birth l) Feeding method for the baby

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Obtaining Data 1. American College of Obstetricians and Gynecologists (ACOG) questionnaire a) Filled out by woman b) Nurse review, obtain further information

E. Prenatal Risk-Factor Screening 1. Any findings shown to have negative effect on pregnancy outcomes a) Woman or unborn child 2. See Table 12–1: Prenatal High-Risk Factors, p. 231 a) Social-personal (1) Low income level or low educational level (2) Poor diet (3) Living at high altitude (4) Multiparity greater than 3 (5) Weight <45.5 kg (100 lb) (6) Weight >91 kg (200 lb) (7) Age <16 years (8) Age >35 years (9) Smoking one pack/day or more (10) Use of illicit drugs (11) Excessive alcohol consumption b) Preexisting medical disorders (1) Diabetes mellitus (2) Cardiac disease (3) Anemia: hemoglobin less than 11 g/dL, hematocrit (Hct) <32% (4) Hypertension (5) Thyroid disorder (6) Hypothyroidism (7) Hyperthyroidism (8) Renal disease (moderate to severe) (9) Diethylstilbestrol (DES) exposure 3. Obstetric considerations a) Previous pregnancy (1) Stillborn (2) Recurrent abortion (3) Cesarean birth (4) Rh or blood group sensitization b) Current pregnancy (1) Large for gestational age (LGA) (2) Gestational diabetes mellitus (3) Rubella (first trimester) (4) Rubella (second trimester) 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Toxoplasmosis (6) Cytomegalovirus (7) Herpesvirus type 2 (8) Syphilis (9) Urinary tract infection (10) Abruptio placentae; placenta previa (11) Preeclampsia/eclampsia (12) Multiple gestation (13) Elevated hematocrit (> 41%) (14) Spontaneous premature rupture of membranes

II.

Initial Prenatal Assessment

A. Focuses on woman holistically → physical, cultural, psychosocial factors 1. Establishment of nurse–patient relationship 2. Discuss factors that may influence woman’s expectations of childbearing experience 3. Be familiar with common practices of groups in the community

B. Prepare woman for physical examination 1. Vital signs 2. Head-to-toe examination with pelvic exam last a) Give anticipatory guidance and reassurance → may be first gynecologic examination b) Thorough, systematic antepartal examination 3. Clean urine specimen for screening prior to pelvic exam a) Disrobe → gown and sheet for modesty, comfort, warmth

C. See Assessment Guide: Initial Prenatal Assessment, p. 234 D. Vital signs 1. Physical assessment/normal findings a) Blood pressure (BP) less than or equal to 120/80 mmHg b) Pulse 60 to 100 beats/min c) Respiration 12 to 22 breaths/min d) Temperature 36.2°C to 37.6°C (97°F to 99.6°F) 2. Alterations and possible causes a) High BP → essential hypertension, renal disease, apprehension, preeclampsia b) Increased pulse rate → excitement, anxiety, dehydration, infection, cardiac disorders c) Marked tachypnea, abnormal patterns d) Elevated temperature

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing responses to data a) BP of 120 to 139/80 to 89 mmHg considered prehypertensive b) BP greater than 140/90 mmHg requires immediate consideration (1) Establish woman’s BP (2) Refer to healthcare provider if necessary (3) Assess woman’s knowledge about high BP (4) Counsel on self-care and medical management c) Count pulse for 1 full minute (1) Note irregularities (2) Evaluate temperature, increase fluids d) Assess for respiratory disease e) Assess for infection process (1) Refer to healthcare provider

E. Height and weight → normal findings 1. Physical assessment/normal findings a) Depends on body build 2. Alterations and possible causes a) >91 kg (200 lb) b) <45 kg (100 lb) c) Rapid sudden weight gain → preeclampsia 3. Nursing responses to data a) Evaluate need for nutritional counseling (1) Obtain information on eating habits (2) Income limitations, need for food supplements (3) Food allergies, pica, other abnormal food habits (4) Note initial weight → establish baseline for weight gain throughout pregnancy (5) Determine BMI, recommended weight gain for pregnancy

F. Skin 1. Physical assessment/normal findings a) Color → consistent with racial background; pink nail beds b) Condition → absence of edema c) Lesions → absence of lesions (1) Spider nevi common d) Moles e) Pigmentation changes of pregnancy f) Café-au-lait spots 2. Alterations and possible causes a) Pallor b) Bronze, yellow c) Bluish, reddish, mottled 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Dusky appearance, pallor of palms and nail beds in dark-skinned women e) Edema→ preeclampsia, normal pregnancy changes f) Rashes, dermatitis→ allergic response g) Ulceration→ varicose veins, decreased circulation h) Petechiae, multiple bruises, ecchymosis→ hemorrhagic disorders, abuse i) Change in size or color→ carcinoma j) Six or more→ Albright syndrome or neurofibromatosis 3. Nursing responses to data a) Tests to perform b) Refer to healthcare provider (1) For preeclampsia, if severe lesion, suspect bleeding disorder, allergic reaction c) Counsel on relief measures d) Assess for preeclampsia, circulatory status e) Counsel on normal manifestations of pregnancy and physiologic basis for changes

G. Nose 1. Physical assessment/normal findings a) Character of mucosa → redder than oral mucosa, edematous 2. Alterations and possible causes a) Olfactory loss 3. Nursing responses to data a) Counsel about possible relief measures

H. Mouth 1. Physical assessment/normal findings a) May note hypertrophy of tissues because of estrogen 2. Alterations and possible causes a) Edema, inflammation, pale in color 3. Nursing responses to data a) Assess hematocrit for anemia b) Counsel regarding dental hygiene habits c) Refer to healthcare provider or dentist d) Routine dental care appropriate during pregnancy

I. Neck 1. Physical assessment/normal findings a) Nodes → small, mobile, nontender b) Thyroid → small, smooth, lateral lobes palpable on either side of trachea (1) Slight hyperplasia by third month of pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Alterations and possible causes a) Tender, hard, fixed, or prominent nodes b) Enlargement or nodule tenderness 3. Nursing responses to data a) Examine for local infection b) Refer to healthcare provider c) Tests d) Question about dietary habits

J. Chest and lungs 1. Physical assessment/normal findings a) Chest → symmetric, elliptic, smaller anteroposterior than transverse diameter b) Ribs → slope downward from nipple line c) Inspection and palpation → no retraction of bulging of intercostal spaces (ICS) during inspiration or expiration, symmetric expansion d) Percussion → bilateral symmetry in tone (1) Low-pitched resonance of moderate intensity e) Auscultation → upper lobes → bronchovesicular sounds above sternum and scapulas; equal expiratory, inspiratory phases f) Remainder of chest → vesicular breath sounds heard; inspiratory phase longer 2. Alterations and possible causes a) Increased anteroposterior (AP) diameter, funnel chest, pigeon chest b) More horizontal c) Angular bumps d) Rachitic rosary e) ICS retractions with inspirations, bulging, with expiration; unequal expansion→ respiratory disease f) Tachypnea or hyperpnea→ respiratory disease g) Flatness of percussion (1) May be affected by chest wall thickness h) High diaphragm (atelectasis or paralysis)→ pleural effusion i) Abnormal breath sounds (if heard on any area) (1) Rales, rhonchi, wheezes, pleural friction rub j) Absence of breath sounds (1) bronchophony, egophony, whispered pectoriloquy 3. Nursing responses to data a) Evaluate for emphysema, asthma, pulmonary disease b) Evaluate for fractures c) Consult nutritionist d) Refer to healthcare provider e) Evaluate for pleural effusions, consolidations, tumor

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

K. Breasts 1. Physical assessment/normal findings a) Supple → symmetric, darker pigmentation of nipple, areola b) Axillary nodes nonpalpable, or pellet size c) Pregnancy changes (1) Size increase primarily in first 20 weeks (2) Become nodular (3) Tingling sensation, feeling of heaviness (4) Pigmentation darkens (5) Superficial veins dilate, more prominent (6) Striae seen in multiparas (7) Tubercles of Montgomery enlarge (8) Colostrum may be present after 12 weeks (9) Secondary areola → 20 weeks (10) Breasts less firm, old striae in multiparas 2. Alterations and possible causes a) Pigskin or orange-peel appearance b) Nipple retractions c) Swelling d) Hardness (carcinoma) e) Redness f) Heat g) Tenderness h) Cracked or fissured nipple i) Tender, enlarged, or hard axillary node 3. Nursing responses to data a) Encourage regular self-examination b) Instruct woman how to examine own breasts c) Refer to healthcare provider for evaluation of abnormal findings d) Discuss normalcy of changes, meaning with woman e) Teach/institute appropriate relief measures f) Encourage use of supportive well-fitting brassiere

L. Heart 1. Physical assessment/normal findings a) Normal rate, rhythm, heart sounds b) Pregnancy changes (1) Palpitations may occur due to sympathetic nervous system disturbance (2) Short systolic murmurs that increase in held expiration → normal due to increased volume

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Alterations and possible causes a) Enlargement b) Thrills, thrusts c) Gross irregularity or skipped beats d) Gallop rhythm or extra sounds 3. Nursing responses to data a) Complete initial assessment b) Explain normalcy c) Refer to healthcare provider if indicated

M. Abdomen 1. Physical assessment/normal findings a) Normal appearance, skin texture, hair distribution b) Liver nonpalpable c) Abdomen nontender d) Pregnancy changes (1) Purple striae, linea nigra (2) Diastasis of rectus muscles late in pregnancy (3) Size flat or rotund, progressive enlargement of uterus (4) Fetal heart rate with Doppler 110 to 160 beats/min (10 to 12 weeks) (a) Fetoscope at 17 to 20 weeks (5) Fetal movement palpable by trained examiner after 18th week (6) Ballottement 2. Alterations and possible causes a) Muscle guarding, tenderness, mass b) Size of uterus inconsistent with length of gestation (1) Intrauterine growth restriction (IUGR) or multiple pregnancy (2) Fetal demise (3) Incorrect estimated date of birth (EDB) (4) Abnormal amniotic fluid (5) Hydatidiform mole c) Failure to hear fetal heartbeat with Doppler → fetal demise, hydatidiform mole d) Failure to feel fetal movements after 20 weeks’ gestation → fetal demise, hydatidiform mole e) No ballottement → oligohydramnios 3. Nursing responses to data a) Assure woman of normalcy of diastasis b) Provide initial information about appropriate prenatal, postpartum exercises c) Evaluate anxiety level d) Refer to healthcare provider e) Reassess menstrual history regarding dating f) Evaluate increase in size using McDonald method 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

g) Ultrasound to establish diagnosis

N. Extremities 1. Physical assessment/normal findings a) Skin warm, pulses palpable, full range of motion b) May be some edema of hands, ankles in late pregnancy c) Varicose veins may become more pronounced d) Palmar erythema may be present 2. Alterations and possible causes a) Nonpalpable or diminished pulses b) Marked edema → preeclampsia 3. Nursing responses to data a) Evaluate for other symptoms of heart disease b) Initiate follow-up if woman mentions rings are tight c) Discuss prevention/self-treatment for varicose veins d) Refer to healthcare provider

O. Spine 1. Physical assessment/normal findings a) Concave cervical, convex thoracic, concave lumbar b) In pregnancy (1) Lumbar spinal curve may be accentuated c) Shoulders, iliac crests should be even 2. Alterations and possible causes a) Abnormal spinal curves → flatness, hypnosis, lordosis, scoliosis b) Backache c) Uneven shoulders and iliac crests 3. Nursing responses to data a) Refer to healthcare provider if indicated b) May have implications for spinal anesthesics c) Refer very young women to healthcare provider; back-stretching exercise with older women

P. Reflexes 1. Physical assessment/normal findings a) Normal, symmetric 2. Alterations and possible causes a) Hyperactivity, clonus → preeclampsia 3. Nursing responses to data a) Evaluate for other symptoms of preeclampsia 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Q. Pelvic area: external female genitalia 1. Physical assessment/normal findings a) Normally formed, female hair distribution b) In multiparas, labia majora loose, pigmented c) Urinary, vaginal orifices visible, appropriately located 2. Alterations and possible causes a) Lesions, genital warts b) Hematomas, varicosities c) Inflammation of Bartholin’s glands d) Clitoral hypertrophy (masculinization) 3. Nursing responses to data a) Explain pelvic examination procedure b) Encourage woman to minimize discomfort by relaxing hips c) Provide privacy

R. Vagina 1. Physical assessment/normal findings a) Pink or dark pink b) Vaginal discharge odorless, nonirritating c) In multiparas, vaginal folds smooth, flattened d) May have episiotomy scar 2. Alterations and possible causes a) Abnormal discharge associated with vaginal infections 3. Nursing responses to data a) Obtain vaginal smear b) Provide understandable verbal, written instructions about treatment for woman and partner, if indicated

S. Cervix 1. Physical assessment/normal findings a) Pink color b) Os closed except in multiparas → os admits fingertip c) Pregnancy changes (1) 1 to 4 weeks’ gestation: enlargement in anteroposterior diameter (2) 4 to 6 weeks’ gestation: softening of cervix (Goodell sign); softening of isthmus of uterus (Hegar sign); cervix takes on bluish coloring (Chadwick sign) (3) 8 to 12 weeks’ gestation: Vagina and cervix appear bluish violet in color (Chadwick sign) 2. Alterations and possible causes a) Eversion, reddish erosion, nabothian or retention cysts, cervical polyp 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Bleeding granular area (carcinoma of cervix) c) Lesions (herpes, human papilloma virus [HPV]) d) Presence of string or plastic tip from cervix (intrauterine device [IUD] in uterus e) Absence of Goodell sign → inflammatory conditions, carcinoma f) Fixed → pelvic inflammatory disease (PID) g) Nodular surface → fibroma 3. Nursing responses to data a) Provide woman with a hand mirror and identify genital structures for her b) Encourage her to view cervix if she wishes c) Refer to healthcare provider if indicated d) Advise woman of potential serious risks of leaving an IUD in place during pregnancy e) Refer to healthcare provider for removal

T. Uterus 1. Physical assessment/normal findings a) Pear shaped, mobile, smooth surface

U. Ovaries 1. Physical assessment/normal findings a) Small walnut shaped, nontender 2. Alterations and possible causes a) Pain on movement of cervix → PID b) Enlarged or nodular ovaries → cyst, tumor, tubal pregnancy, corpus luteum of pregnancy 3. Nursing responses to data a) Evaluate adnexal areas b) Refer to healthcare provider c) Ultrasound

V. Pelvic measurements: internal measurements 1. Physical assessment/normal findings a) Diagonal conjugate at least 11.5 cm b) Obstetric conjugate estimated by subtracting 1.5 cm from diagonal conjugate c) Inclination of sacrum d) Motility of coccyx; external intertuberosity diameter > 8 cm 2. Alterations and possible causes a) Measurement below normal b) Disproportion of pubic arch c) Abnormal curvature of sacrum d) Fixed or malposition of coccyx

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing responses to data a) Vaginal birth may not be possible if deviations are present

W. Anus and rectum 1. Physical assessment/normal findings a) No lumps, rashes, excoriation, tenderness; cervix may be felt through rectal wall 2. Alterations and possible causes a) Hemorrhoids, rectal prolapse; warts; nodular lesion (carcinoma) 3. Nursing responses to data a) Counsel about appropriate prevention and relief measures b) Refer to healthcare provider for further evaluation

X. Laboratory evaluation 1. Physical assessment/normal findings a) Hemoglobin 12 to 16 g/dL b) ABO, Rh typing c) Complete blood count (CBC) (1) Hematocrit 38% to 47% (2) Red blood cells (RBC) 4.2 to 5.4 million/microliter (3) White blood cells (WBC) 5000 to 12,000/microliter (4) Differential (5) First trimester aneuploidy screening (6) Integrated screening (7) Syphilis tests negative → serologic test for syphilis (STS), venereal disease research laboratory (VDRL) test (8) Gonorrhea culture → negative (9) Urinalysis → normal color, specific gravity, pH 4.6 to 8 (a) Negative for protein, RBCs, WBCs, casts (b) Glucose negative (small degree of glucosuria may occur) (10) Rubella titer → 1:10 or above indicates immune (11) Hepatitis B screen negative (12) HIV screen → offered to all → negative (13) Illicit drug screen → offered to all → negative (14) Sickle-cell screen for African American patients → negative (15) Pap smear negative 2. Alterations and possible causes a) Hgb <11 g/dL → anemia b) Rh negative c) Marked anemia, blood dyscrasias d) Presence of infection e) Increased nuchal translucency, elevated β-HCG, reduced PAPP-A f) Positive STS → false positive, acute infection 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

g) Positive culture h) Cloudy, abnormal color of urine i) HAI titer less than 1:10 j) Positive hepatitis B or HIV k) Positive l) Positive m) Abnormal cells, with negative or positive high-risk HPV 3. Nursing responses to data a) Nutritional counseling, iron supplementation b) Rh negative → check for antibodies, partner blood type (1) Discuss need for Rh immune globulin at 28 weeks c) CBC, Schilling differential cell count d) Evaluate for other signs of infection e) If findings positive, genetic and diagnostic testing offered f) Positive results confirmed with fluorescent treponemal antibody-absorption (FTA-ABS) test (1) Antibiotics (2) Refer for treatment g) Refer for treatment h) Repeat urinalysis, refer to healthcare provider i) Assess blood glucose, test urine for ketones j) Immunization postpartum k) Positive Hep B/HIV refer to physician (1) Infants born to HepB positive → HepB immune globulin soon after birth followed by first dose of hepatitis B vaccine l) Refer to healthcare provider

Y. Cultural assessment 1. Physical assessment/normal findings a) Determine fluency in written/oral English b) How does she prefer to be addressed? c) Customs and practices regarding prenatal care (1) To be followed or avoided d) Activities to avoid e) Foods to eat or avoid f) Caregiver gender g) Partner/family involvement preferred h) Type of support and counseling available 2. Variations to consider a) May be fluent in language other than English b) Formal or informal c) Acts related to sleep, activity, clothing 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Sexual activity, work d) Lactose intolerance e) Female only? f) Partner or female family member g) Family members, tribal healers, religious leaders 3. Nursing responses to data a) Work with translator b) Address woman according to preference c) Honor practices unless contraindicated because of safety (1) Have information printed in language she understands d) Respect food preferences (1) Help to plan adequate prenatal diet (2) Refer to dietitian if necessary e) Arrange for female caregiver if preference f) Respect preferences about partner involvement g) Respect sources of support

Z. Psychologic status 1. Physical assessment/normal findings a) Excitement and/or apprehension, ambivalence 2. Alterations and possible causes a) Marked anxiety, fear b) Apathy, display of anger with pregnancy diagnosis 3. Nursing responses to data a) Establish lines of communication b) Establish trusting relationship c) Encourage woman to take active part in care d) Begin counseling

AA. Educational needs 1. Physical assessment/normal findings a) May have questions about pregnancy b) May need time to adjust to reality of pregnancy 2. Nursing responses to data a) Establish educational, supporting environment that can be expanded throughout pregnancy

BB. Support system 1. Physical assessment/normal findings a) Can identify at least two to three individuals with whom is emotionally intimate

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Alterations and possible causes a) Isolated b) Cannot name neighbor or friend whom she can call on in an emergency c) Does not perceive parents as part of her support system 3. Nursing responses to data a) Institutes support system through community groups b) Help woman to develop trusting relationship with healthcare professionals

CC. Family functioning 1. Physical assessment/normal findings a) Emotionally supportive b) Communications adequate c) Mutually satisfying d) Cohesiveness in times of trouble 2. Alterations and possible causes a) Long-term problems of specific problems related to the pregnancy b) Potential stressors within the family c) Pessimistic attitudes d) Unilateral decision making e) Unrealistic expectations of the pregnancy or child 3. Nursing responses to data a) Help identify the problems and stressors b) Encourage communication c) Discuss role changes and adaptations d) Refer to counseling as indicated

DD. Economic status 1. Physical assessment/normal findings a) Source of income is stable and sufficient to meet basic needs of daily living and medical needs 2. Alterations and possible causes a) Limited prenatal care b) Poor physical health c) Limited use of healthcare system d) Unstable economic status 3. Nursing responses to data a) Discuss available resources for health maintenance and the birth b) Institute appropriate referral for meeting expanding family’s needs

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

EE. Stability of living conditions 1. Physical assessment/normal findings a) Adequate, stable housing for expanding family’s needs 2. Alterations and possible causes a) Crowded living conditions b) Questionable supportive environment for newborn 3. Nursing responses to data a) Refer to appropriate community agency b) Work with family on self-help ways to improve situation

FF. Determination of Due Date 1. Families eager to know due date a) EDB = estimated date of confinement (EDC) = estimated date birth (EDB) (1) Need LMP (2) If precise LMP not available → early ultrasound (US) 2. Nägele’s rule a) First day of LMP – 3 months + 7 days b) Gestational calculator or wheel (1) See Figure 12–1: The EDB wheel can be used to calculate the due date, p. 242 c) Fairly accurate if (1) Menses every 28 days (2) Accurate LMP (3) Not using hormonal contraception d) Not useful if (1) Irregular periods that include amenorrhea (2) Amenorrhea but ovulating and conceive while breastfeeding (3) Conceive before regular menstruation established following discontinuation of oral contraceptives or termination of a pregnancy

GG. Uterine Assessment 1. Physical examination a) At first prenatal visit 2. Fundal height a) Indicator of uterine size b) Not used for dating late in pregnancy c) McDonald method (1) Distance in centimeters from top of symphysis pubis over curve of the abdomen to top of uterine fundus (2) See Figure 12–2: A cross-sectional view of fetal position when McDonald method is used to assess fundal height, p. 243 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) In centimeters correlates well with weeks of gestation (1) 22 to 34 weeks e) Accuracy → same examiner each time f) Maternal position g) Inaccurate in following situations (1) Obese women (2) Women with uterine fibroids (3) Women who develop hydramnios h) Empty bladder before measuring i) Measurements may yield other information (1) Lag from month to month → may indicate IUGR (2) Sudden increase → twins, hydramnios, LGA fetus

HH. Assessment of Fetal Development 1. Quickening → fetal movements felt by mother a) May be experienced between 16 to 22 weeks b) May be described as feeling butterfly movements, gas, flicking sensations, bubbles 2. Fetal heartbeat a) Doppler device → primary tool (1) 10 to 12 weeks’ gestation (2) Normal range →110 to 160 beats/min b) Ultrasound if unable to auscultate between 10 and 12 weeks 3. Ultrasound a) First trimester → transabdominal ultrasound can detect gestational sac as early as 4 to 5 weeks after LMP (1) Fetal heart activity by 6 to 7 weeks (2) Fetal breathing movements by 10 to 11 weeks (3) Crown-to-rump measurements → can be used for gestational age from 4 days to 12 weeks b) Biparietal diameter (BPD) by approximately 12 to 13 weeks, most accurate 14–26 weeks (1) Predicts EDB within 7 to 10 days

II. Assessment of Pelvic Adequacy 1. Clinical pelvimetry → series of assessments and measurements to determine whether size and shape adequate for a vaginal birth 2. Pelvic cavity a) False pelvis b) True pelvis 3. Pelvic inlet a) Diagonal conjugate (1) Distance from lower border of symphysis pubis to sacral promontory 21 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Typically 12.5 cm b) Obstetric conjugate (1) Smallest and most important anteroposterior diameter (2) Extends from middle of sacral promontory to the upper inner point on symphysis (a) Estimated by subtracting 1.5 cm from length of diagonal conjugate (3) Should measure 10 cm or more c) Conjugata vera (true conjugate) d) See Figure 12–6: Manual measurement of inlet and outlet, p. 245 e) Midplane → anteroposterior diameter, posterior sagittal diameter, transferse diameter (1) Cannot be accurately measured by clinical examination f) Evaluation made based on prominence of ischial spines (1) Locate sacrospinous ligament → run fingers along it laterally (2) Toward anterior portion of pelvis g) Sacrosciatic notch should admit two fingers (1) Wide → sacrum curves posteriorly (2) Narrow → decreased diameter h) Capacity of cavity assessed by sweeping fingers down side walls bilaterally (1) Convergent (2) Divergent (3) Straight → normal finding 4. Pelvic outlet a) Anteroposterior diameter of pelvic outlet (1) Lower border of symphysis pubis to tip of sacrum (2) Measured digitally, should be 9.5 to 11.5 cm (3) See Figure 12–6: Manual measurement of inlet and outlet, p. 245 b) Transverse diameter (1) Measured by placing fist between ischial tuberosities (2) Should be 8 to 10 cm (3) See Figure 12–7: Use of a closed fist to measure the outlet, p. 246 c) Mobility of coccyx → determined by pressing down on it during initial vaginal exam d) Subpubic angle (1) Estimated by palpating bony structure externally (2) See Figure 12–8A: Evaluation of the outlet. Estimation of the subpubic angle, p.247 e) Length and shape of pubic rami f) Height and inclination of symphysis pubis measured (1) Contour of pubic arch estimated (2) Posterior inclination with lower border of pubis slanting inward decreases anteroposterior diameter g) See Figure 12–8C: Evaluation of the outlet. Estimation of the depth and inclination of the pubis, p. 247

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

JJ. Screening Tests 1. Initial prenatal visit a) Pap smear b) Complete blood count c) HIV screening d) Rubella titer e) ABO and Rh typing f) Urine culture g) Hepatitis B h) Sexually transmitted infections (STIs) i) Hemoglobin electrophoresis (1) Women of African, Southeast Asian, Mediterranean descent (a) Evaluate for sickle cell disease and thalassemias j) Tuberculin test (PPD) for high risk (1) Cystic fibrosis (CF) k) Women who have not received varicella immunization, negative disease history (1) Evaluate varicella immunity (2) Immunize after pregnancy 2. Throughout pregnancy a) Gestational diabetes mellitus (GDM) (1) Between 24 and 28 weeks (2) 2 approaches (a) 1 step 75-g oral glucose tolerance test (OGTT) (b) 2 step: initial nonfasting test using 50-g 1-hr glucose followed by a 3-hr 100mg OGTT if initial results are positive b) Group B streptococcus (GBS) testing (1) Between 35 and 37 weeks (2) Women with positive GBS in urine do not get cultured, considered positive 3. Testing for fetal aneuploidy (trisomy) and neural tube defects a) All women, regardless of age, should be offered screening b) Nuchal translucency: ultrasound assessment of thickness of fetal nuchal fold c) Combined with serum screening for free β-hCG and pregnancy-associated plasma protein A (PAPP-A) d) Genetic counseling e) Chorion villus sampling; amniocentesis f) Quadruple screen (Quad screen): performed on mother’s serum between 15 and 20 weeks

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

III.

Subsequent Patient History

A. Continue to gather data 1. Over course of pregnancy 2. Adjustment of support person and family 3. Preparations made for new baby 4. Discomfort 5. Physical changes 6. Exposure to contagious illnesses 7. Medical treatments and therapies 8. Over-the-counter or prescription medications, herbal supplements, alcohol, nicotine, illicit drugs use 9. Use of complementary or alternative therapies 10. Danger signs of pregnancy and preterm labor a) Discussed at initial prenatal visit b) Reviewed each subsequent visit c) Printed information (1) See Table 12–2: Danger Signs of Pregnancy, p. 249 (2) Danger sign → possible cause (3) Sudden gush of fluid from vagina → premature rupture of membranes (PROM) (4) Vaginal bleeding → abruptio placentae, placenta previa, lesions of cervix or vagina, bloody show, cervical or vaginal infection, irritation of cervix from intercourse (5) Abdominal pain → premature labor, abruptio placentae (6) Temperature above 38.3°C (101°F) → infection (7) Dizziness, blurring of vision, double vision, spots before eyes → hypertension, preeclampsia (8) Persistent nausea and vomiting → hyperemesis gravidarum (9) Severe headache → hypertension, preeclampsia (10) Edema of hands or face → preeclampsia (11) Seizures or convulsions → preeclampsia, eclampsia (12) Epigastric pain → preeclampsia, ischemia in major abdominal vessel (13) Dysuria→ urinary tract infection (14) Absent or decreased fetal movement → maternal medication, obesity, fetal death, fetal distress (15) Signs of Preterm Labor, p. 248 (a) Painful menstrual-like cramps (b) Dull low backache (c) Suprapubic pain or pressure 24 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(d) Pelvic pressure or heaviness (e) Change in character or amount of vaginal discharge (bloody, thinner, thicker) (f) Diarrhea (g) Uterine contractions felt every 10 minutes for 1 hour (h) Leaking of water from vagina 11. Provide time to ask questions, voice concerns a) Encourage woman and partner to bring list of questions, concerns to visits b) Be sensitive to religious, spiritual, cultural and socioeconomic factors that may influence response to pregnancy 12. Begin assessing developing readiness to take on responsibilities of parenthood a) See Table 12–3: Guide to Prenatal Assessment of Parenting, p. 250 b) Areas assessed (1) Perception of complexities of mothering (a) Desires for baby itself (b) Expresses concern about impact of mothering role on other roles (c) Gives up routine habits because “not good for baby” (2) Attachment (a) Strong feelings regarding sex of baby (b) Interested in data regarding fetus (c) Fantasies about baby (3) Acceptance of child by significant others (a) Acknowledges acceptance by significant other of the new responsibility inherent in child (b) Concrete demonstration of acceptance of pregnancy/baby by significant others (4) Ensures physical well-being (5) Family/patient decisions reflect concern for health of mother and baby

IV.

Subsequent Prenatal Assessment A. Depression during and after pregnancy common 1. Challenges can be overwhelming 2. Infants of depressed women at increased risk a) Social-emotional development, cognitive development, behavioral development, and physical health negatively impacted

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Signs of psychologic problems 1. Increasing anxiety 2. Depression or feelings of sadness (common in pregnancy and should be screened regularly for it) 3. Inability to establish communication 4. Inappropriate responses or actions 5. Denial of pregnancy 6. Inability to cope with stress 7. Intense preoccupation with the sex of the baby 8. Failure to acknowledge quickening 9. Failure to plan and prepare for the baby 10. Indications of substance abuse

C. Refer as appropriate D. Frequency of subsequent visits 1. Every 4 weeks for the first 28 weeks’ of gestation 2. Every 2 weeks until 36 weeks’ gestation 3. After week 36 → every week until childbirth

E. Assessment Guide: Subsequent Prenatal Assessment, pp. 251–255 F. Vital signs 1. Physical assessment/normal findings a) Temperature 36.2°C to 37.6°C (97°F 99.6°F) b) Pulse 60 to 100 beats/min c) Respirations 12 to 20 breaths/min d) Blood pressure less than or equal to 120/80 mmHg 2. Alterations and possible causes a) Elevated temperature → infection b) Increased pulse rate → anxiety, cardiac disorders c) Marked tachypnea or abnormal patterns → respiratory disease d) BP greater than 120 to 139/80 to 89 mmHg considered prehypertensive e) Greater than 140/90 mmHg or increase of 30 mm systolic and 15 mm diastolic → preeclampsia

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing responses to data a) Evaluate for signs of infection (1) Refer to healthcare provider b) Note irregularities (1) Assess for anxiety and stress c) Refer to healthcare provider d) Assess for edema, proteinuria, hyperreflexia (1) Refer to healthcare provider (2) Schedule appointments more frequently

G. Weight gain 1. Physical assessment/normal findings a) Total 11.5 to 16 kg (25 to 35 lb) b) First trimester → 1.6 to 2.3 kg (3.5 to 5 lb) c) Second trimester → 5.5 to 6.8 kg (12 to 15 lb) d) Third trimester → 5.5 to 6.8 kg (12 to 15 lb) 2. Alterations and possible causes a) Inadequate weight gain → poor nutrition, nausea, IUGR b) Excessive weight gain → excessive caloric intake, edema, preeclampsia 3. Nursing responses to data a) Discuss appropriate weight gain b) Provide nutritional counseling c) Assess for presence of edema or anemia d) Refer to dietitian as needed

H. Edema 1. Physical assessment/normal findings a) Small amount of dependent edema, especially last weeks of pregnancy 2. Alterations and possible causes a) Edema in hands, face, legs, feet → preeclampsia 3. Nursing responses to data a) Identify correlation between edema and activities, BP or proteinuria b) Refer to healthcare provider if indicated

I. Uterine size 1. Physical assessment/normal findings a) See Assessment Guide: Initial Prenatal Assessment 2. Alterations and possible causes a) Unusually rapid growth → multiple gestation, hydatidiform mole, hydramnios, miscalculation of EDB 27 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing responses to data a) Evaluate fetal status b) Determine height of fundus c) Use diagnostic ultrasound

J. Fetal heartbeat 1. Physical assessment/normal findings a) 110 to 160 beats/min, funic souffle 2. Alterations and possible causes a) Absence of fetal heartbeat after 20 weeks’ gestation → maternal obesity, fetal demise 3. Nursing responses to data a) Evaluate fetal status

K. Laboratory evaluation 1. Physical assessment/normal findings a) Hgb →12 to 16 g/dL, pseudoanemia of pregnancy b) Quad marker screen c) Indirect coombs test → Rh negative women → negative (at 28 weeks) d) 50-g 1-hour glucose screen at 24 to 28 weeks’ gestation e) Urinalysis (UA) (1) Protein negative (2) Glucose negative, glycosuria may be present due to physiologic alterations in glomerular filtration rate and renal threshold. (3) GBS negative 2. Alterations and possible causes a) Less than 11 g/dL → anemia b) Elevated maternal serum alpha-fetoprotein (MSAFP) → neural tube defect, underestimated gestational age, multiple gestation (1) Lower than normal MSAFP → Down syndrome, trisomy 18 (2) Higher than normal hCG and inhibin-A → Down syndrome (3) Lower than normal UE → Down syndrome c) Rh antibodies present → maternal sensitization occurred d) Plasma glucose >140 → abnormal e) See Assessment Guide: Initial Prenatal Assessment for deviations (1) Proteinuria, albuminuria → contamination by vaginal discharge, urinary tract infection, preeclampsia (2) Persistent glycosuria → diabetes mellitus (3) Positive culture → maternal infection 3. Nursing responses to data a) Provide nutritional counseling (1) Hgb repeated at 7 months gestation 28 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Women of Mediterranean heritage → possibility of thalassemia b) Offered to all pregnant women (1) Abnormal → further testing → ultrasound or amniocentesis c) Rh negative and unsensitized → Rh immune globulin given (1) Rh antibodies present → Rh immune globulin not given → fetus monitored closely for isoimmune hemolytic disease d) Refer for diagnostic 100-g oral glucose tolerance test (1) Discuss implications of GDM if diagnosis made (2) Refer to healthcare provider e) Urinalysis and culture at initial visit, as indicated (1) Dipstick urine sample (2) Refer to healthcare provider if deviations are present f) Explain maternal and fetal/neonatal risks (1) Refer to healthcare provider for therapy

L. Cultural assessment 1. Physical assessment/normal findings a) Determine mother’s, family’s attitudes about sex of unborn child b) Ask about woman’s expectations of childbirth (1) Someone with her? Who? Role of partner? c) Ask about preparations for baby 2. Variations to consider a) Some women have no preference, some do (1) Some cultures value boys as firstborn b) Some women want partner present for labor, birth (1) Others prefer female relative or friend (2) Some women expect to be separated from partner once labor begins c) Some women have fully prepared nursery (1) Others may not have separate room 3. Nursing responses to data a) Provide opportunities to discuss preferences, expectations (1) Avoid judgmental attitude b) Provide information on birth options but accept woman’s decision c) Explore reasons for not preparing for baby d) Support preferences, provide information about sources of assistance if decision related to lack of resources

M. Expectant mother: psychologic status 1. Physical assessment/normal findings a) First trimester/period of adjustment b) Second trimester/period of radiant health c) Third trimester/period of watchful waiting 29 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Alterations and possible causes a) Increased stress and anxiety b) Inability to establish communication c) Inability to accept pregnancy d) Inappropriate response or actions e) Denial of pregnancy f) Inability to cope 3. Nursing responses to data a) Encourage woman to take active part in care b) Establish lines of communication c) Provide anticipatory guidance regarding normalcy of feelings as necessary

N. Educational needs: self-care measures and knowledge 1. Physical assessment/normal findings a) Health promotion b) Breast care c) Hygiene d) Rest e) Exercise f) Nutrition g) Relief measures for common discomforts of pregnancy h) Danger signs in pregnancy i) Signs of preterm labor j) Sexual activity k) Preparation for parenting l) Preparation for childbirth m) Patient aware of (1) Prepared childbirth techniques (2) Normal processes, changes during childbirth (3) Problems that may occur due to drug, alcohol use, smoking n) Woman met other physician or nurse-midwife who may be attending in absence of primary caregiver o) Impending labor (1) Patient knows signs of impending labor (a) Uterine contractions that increase in frequency, duration, and intensity (b) Bloody show (c) Expulsion of mucous plug (d) Rupture of membranes 2. Alterations and possible causes a) Inadequate information b) Lack of information about effects of pregnancy and/or alternative positions during sexual intercourse 30 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Lack of preparation d) Continued abuse of drugs, alcohol e) Denial of possible effect on self, baby f) Introduction of new individual at birth may increase stress, anxiety for woman and partner g) Lack of information 3. Nursing responses to data a) Provide information and counseling b) Refer to classes for childbirth preparation c) Encourage prenatal class attendance d) Review danger signs e) Introduce woman to all members of group practice f) Provide appropriate teaching, stressing importance of seeking appropriate medical assistance

O. Expectant partner: psychologic status 1. Physical assessment/normal findings a) First trimester (1) Excitement (2) Financial concerns b) Second trimester (1) More confident (2) Less concerned with financial matters (3) Concerns about wife’s changing size and shape, increasing introspection c) Third trimester (1) Feelings of rivalry with fetus (2) Energetic (3) More interest in self (4) Fantasize about child, usually older child (5) Fears mutilation, death of woman and child 2. Alterations and possible causes a) Increasing stress and anxiety b) Inability to establish communication c) Inability to accept pregnancy diagnosis d) Withdrawal of support e) Abandonment of the mother 3. Nursing responses to data a) Encourage expectant partner to come to prenatal visits b) Establish line of communication c) Establish trusting relationship d) Counsel e) Include expectant partner in pregnancy activities as he desires 31 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Provide education, information and support

Focus Your Study

VI.

Activities 1. Individual Have students interview an older family member or a neighbor focusing on his or her traditions, beliefs, and practices related to pregnancy and childbirth. Students should prepare a short (one- to two-page) narrative describing these cultural practices. 2. Small Group Divide the class into small groups of three to five students. Have each group practice collecting and completing a complete history on each other. Instruct groups to include cultural and psychosocial assessments to identify variations and potential risk factors.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 13 The Expectant Family: Needs and Care Nursing Care During the Prenatal Period........................................................

Care of the Pregnant Woman’s Family...........................................................

Cultural Considerations in Pregnancy.............................................................

Childbearing Decisions……………………………………………………………………………….

Classes for Family Members During Pregnancy…………..................................

Relief of the Common Discomforts of Pregnancy..........................................

Health Promotion During Pregnancy..............................................................

Focus Your Study.............................................................................................

Activities..........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Nursing Care During the Prenatal Period

A. Nursing Diagnoses 1. Written care plan that anticipates certain diagnoses a) Constipation b) Sexuality Pattern, Ineffective c) Nausea 2. Nursing Plan and Implementation a) Prioritize (1) Results of findings during a prenatal visit (2) Interventions most used by nurses common → communication and teaching– learning strategies b) Community-based nursing care (1) Typically clinic or private office c) Health maintenance organization (HMO) or clinic d) Wealth of community services and resources to assist families e) Home care (1) Assessments vary according to scope of practice (2) Home care visit or phone contact (3) Health promotion (4) Informal and formal teaching (5) Used with complicated and uncomplicated pregnancies (6) See Table 13–-1: Topics for Patient Teaching During Pregnancy, p. 259 f) All three trimesters (1) Discomforts of pregnancy (2) Nutrition and weight gain (3) Sexual activity (4) Sibling preparation g) First trimester (1) Attitude toward pregnancy (2) Exercise and rest (3) Smoking; use of alcohol and other drugs (4) Traveling (5) Fetal growth and development (6) Danger signals associated with spontaneous abortion (7) Employment (8) Early pregnancy classes h) Second trimester (1) Concerns related to changes in body (2) Fetal growth and development (3) Fetal movement (4) Clothing 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Care of the skin and breasts (6) Beginning preparation for care of the infant (7) Decisions about infant feeding i) Third trimester (1) Exercise and rest (2) Traveling (3) Danger signals (4) Preparation for labor and birth (5) Completion of preparation in home for new baby (6) Decisions about the infant (7) Decision making for the early postpartum period (8) Education about psychologic and physical expectations in the early postpartum period

II.

Care of the Pregnant Woman’s Family

A. Care of the Father or Partner 1. Father generally present, but don’t assume presence 2. May not be part of family structure 3. Assess support system to determine which significant persons will play a role in childbearing experience 4. Provide anticipatory guidance a) Information about changes related to pregnancy b) Culturally acceptable → refer to expectant parent classes c) See Figure 13–1: The Empathy Belly..., p. 259 d) Assess intended degree of participation during labor and birth, knowledge of what to expect

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Support decision

B. Care of Siblings and Other Family Members 1. Consider effect of pregnancy on other children 2. Discussion about ambivalence 3. Encourage bringing children to antepartum visits 4. Grandparent participation

III.

Cultural Considerations in Pregnancy

A. Include cultural backgrounds in care → cultural humility 1. Intercultural exchange → adapt to specific needs of each perinatal patient 2. Goal → understand and assist people of diverse cultural groups

B. Should be patient specific → have conversation with each patient to develop a transcultural nursing diagnosis and care plan C. Pregnancy, childbirth → special, transitional event in virtually all cultures D. Beliefs 1. Prescriptive beliefs or requirements that describe expected behaviors 2. Restrictive beliefs → stated negatively, limit behaviors 3. Taboo beliefs → refer to specific supernatural consequences 4. See Table 13–2: Cultural Beliefs and Practices During Pregnancy, p. 261 a) Home remedies b) Nutrition c) Alternative healthcare providers d) Exercise e) Spirituality f) Birth rituals

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Be open to other beliefs if not harmful 6. See Nursing Care Plan: Language Barriers at First Prenatal Visit, p. 263

IV.

Childbearing Decisions A. Decisions parents face about childbirth experiences and preferences → birth plan B. See Figure 13–4, Birth plan for childbirth choices, p. 264 1. Identify options 2. Set priorities 3. Clarify requests as needed 4. Discuss need for change if unexpected complications occur 5. See Table 13–3: Benefits and Risk of Some Consumer and Medical Decisions During Pregnancy, Labor, and Birth, p. 265 a) Breastfeeding b) Ambulation during labor c) Electronic fetal monitoring d) Whirlpool (jet hydrotherapy) e) Analgesic f) Episiotomy

C. Healthcare Provider 1. Nurse explains options and what can be expected from each 2. General philosophy and characteristics of certified nurse-midwives, obstetricians, family practice physician, lay midwives 3. Help the woman/couple develop interview questions 4. Discuss qualities of care provider for the newborn

D. Prenatal Care Services 1. Individual prenatal care services 2. Centering or group prenatal care 3. Centering pregnancy a) Health assessment, education, and support b) Unified program c) Replaces one-on-one visits d) Patients meet in small groups at 12 to 16 weeks and meet monthly for first 4 months then biweekly until due date e) Increased investment in pregnancy and self-care after attending group sessions 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Birth Setting 1. Tour facilities 2. Nurse describes options available 3. Concept of individuality 4. Encourage personalizing the birth setting

F. Labor Support Person 1. Coaches or support person during childbirth classes, labor, and birth 2. Some men welcome the role; others do not 3. Nurse provides encouragement and support to both woman and support person 4. Role of the nurse cannot be overestimated 5. Doula → companion who provides support, but does not perform any clinical tasks a) Provides labor support → emotional, physical, informational, does not perform clinical tasks b) Acts as advocate for woman and her family c) May be trained to provide support and care during postpartum period d) May or may not be paid a fee 6. Monitrice a) Specially trained nurse who provides assessment, nursing care, and support b) Not common in United States

G. Siblings at Birth 1. Prepared through books, audiovisual materials, models, discussion, and sibling classes 2. Imperative child has own support person or coach 3. Child should have option of relating to the birth in manner they choose as long as not disruptive

Classes for Family Members During Pregnancy A. Taught by certified childbirth educators (CBEs or CCEs) 1. Many CBEs also registered nurses, but nursing education is not required 2. Coalition for Improving Maternity Services (CIMS) → mother-friendly care a) Normalcy of the birthing process b) Empowerment c) Autonomy d) Do no harm 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Responsibility

B. Parental education 1. Labor and birth 2. Pain relief 3. Obstetric complications and procedures 4. Breastfeeding 5. Normal newborn care 6. Postpartum adjustment 7. Content of each class directed by overall goals of the program a) Gestational changes and fetal development b) Childbirth choices available today c) Preparation of the mother d) Preparation for cesarean or vaginal birth e) Preparation for couples who desire an unmedicated birth f) Preparation of grandparents or siblings g) Newborn care and safety h) Self-care during postpartum period i) Identify parents’ needs, goals, and learning styles j) By end of classes, parents should be able to make appropriate and informed decisions k) Nurses can help direct parents to programs 8. Education of the Family Having a Cesarean Birth a) 32% of births in the United States b) Need for cesarean birth not often known in advance c) Many birthing units provide preparation classes if known in advance d) Woman concerned about postoperative pain 9. Preparation for Parents Desiring Trial of Labor After Cesarean Birth a) TOLAC → previously termed vaginal birth after cesarean (VBAC) b) Nurse can supply information on criteria necessary to attempt TOLAC c) Parents may want to develop two birth plans to prepare 10. Breastfeeding Programs a) La Leche League, lactation consultants b) Healthy People 2020 objective is 81.9%, but rates are well below c) Classes & support groups can include information on: (1) Advantages and challenges (2) Techniques and positioning (3) Methods of breast pumping and milk storage (4) How to involve the father or partner (5) Successfully breastfeeding and returning to work 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

11. Sibling Preparation: Adjustment to the Newborn a) Formal sibling preparation classes (1) Children 3 to 12 years (2) Help children feel part of the birthing process (3) Reducing anxiety (4) Express feelings and concerns (5) Realistic expectations (6) Active participant in baby’s care (7) Parent and child attend class together 12. Classes for Grandparents a) Current roles b) Transitioning to new role c) Beliefs regarding childbirth d) Ways to support the new family

VI.

Relief of the Common Discomforts of Pregnancy

A. First Trimester 1. Nausea and vomiting of pregnancy (NVP) a) Very common (50–80%) b) Exact cause unknown → multifactorial c) Health promotion (1) Assess onset, frequency, duration, severity, nutritional intake (2) Decrease potential development of hyperemesis gravidarum (3) Avoid odors, causative factors (4) Dry crackers, toast before arising (5) Small frequent meals (6) Avoid greasy, highly seasoned foods (7) Carbonated beverages (8) Complementary and alternative medicine therapies → acupressure, ginger (9) Medications (10) Extreme nausea and vomiting → antiemetics 2. Urinary frequency a) Common early in pregnancy, third trimester b) Health promotion (1) Empty bladder frequently, reduce incidence of UTIs (2) Maintain adequate fluid intake (2000 mL per day) 3. Fatigue a) So common → presumptive sign b) Health promotion (1) Plan nap, rest period (2) Go to bed earlier 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Seek family support, assistance 4. Breast tenderness a) Occurs early, continues throughout pregnancy b) Increased estrogen and progesterone cause soreness and tingling of breasts and increased sensitivity of nipples c) Health promotion d) Wear well-fitting supportive bra 5. Increased vaginal discharge (leukorrhea) a) Common → hyperplasia of vaginal mucosa b) Health promotion (1) Promote cleanliness by daily bathing (2) Avoid douching, nylon underpants (3) Cotton underpants 6. Nasal stuffiness, nosebleed (epistaxis) a) Health promotion (1) Cool-air vaporizer 7. Ptyalism a) Rare discomfort where excessive, bitter saliva is made b) Health promotion (1) Astringent mouthwashes, chew gum, candy (2) Carry tissues or small towel to spit when necessary

B. Second and Third Trimesters 1. Heartburn (pyrosis) a) Displacement of stomach by enlarging uterus b) Health promotion (1) Eat small, frequent meals (2) Use low-sodium antacids (3) Avoid overeating, fatty and fried foods, lying down after eating, sodium bicarbonate (4) Sit upright after eating 2. Ankle edema a) Difficulty of venous return from lower extremities b) Health promotion (1) Practice frequent dorsiflexion of feet when prolonged sitting or standing necessary (2) Elevate legs (3) Avoid tight garters, constrictive bands around legs 3. Varicose veins a) Result of weakening of walls of veins, faulty functioning of the valves b) Weight of gravid uterus on pelvic veins aggravates condition c) Health promotion 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Regular exercise, such as swimming, cycling, walking (2) Elevate legs frequently (3) Wear supportive hose (4) Avoid crossing legs at the knees, standing for long periods, garters, hosiery with constrictive bands (5) Commercial product to provide support for vulvar varicosities (6) Pillows under hips to elevate pelvic area (Figure 13–9) 4. Flatulence a) Decreased gastrointestinal motility b) Health promotion (1) Avoid gas-forming foods (2) Regular bowel habits (3) Exercise 5. Hemorrhoids a) Varicosities of veins in lower end of rectum, anus (1) May appear in second stage of labor (2) Bleeding, itching, swelling, pain b) Health promotion (1) Avoid constipation (2) Apply ice packs, topical ointments, anesthetic agents, warm soaks, (3) Gently reinsert into rectum if necessary (4) Contact healthcare provider → hardened, noticeably tender to touch 6. Constipation a) Bowel sluggishness → hormonal, displacement of intestines, oral iron supplements b) Health promotion (1) Increase fluid intake, fiber in diet, exercise (2) Develop regular bowel habits (3) Use stool softeners as recommended by caregiver (4) Drink warm beverages or glass of prune juice 7. Backache a) Common, 70% of women experience it b) Increased curvature of lumbosacral vertebrae c) Health promotion (1) Use proper body mechanics (Figure 13–10) (2) Practice pelvic tilt exercise (3) Avoid uncomfortable working heights, high-heeled shoes, heavy lifting 8. Leg cramps a) Painful muscle spasms, often at night b) Extension of foot can trigger cramps c) Health promotion (1) Stretches (Figure 13–11) 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Massage and warm packs (1) Stretching exercises before bedtime 9. Faintness a) Caused by a combination of changes in blood volume and postural hypotension b) Health promotion (1) Avoid prolonged standing in warm or stuffy environments c) Arise slowly from resting position (1) If continues, go assisted to area to lie down or get fresh air 10. Shortness of breath a) Occurs as uterus rises into abdomen and causes pressure on diaphragm b) Worse in final weeks of pregnancy, improves after lightening occurs c) Health promotion (1) Use proper posture when sitting and standing (2) Sleep propped up with pillows if problem occurs at night 11. Difficulty sleeping a) Common into postpartum period after 12 weeks b) Enlarged uterus, active fetus, other discomforts of pregnancy contributing factors c) Health promotion (1) Thorough assessment about habits, activities (2) Warm caffeine-free beverage before bed (3) Back rub from partner (4) Pillows (5) Relaxation techniques 12. Restless leg syndrome (RLS) a) More common in second half of pregnancy, effects 15 to 25% of women b) Also called Willis-Ekborn Disease (WED) c) Health promotion (1) Has been associated with iron deficiency anemia and inactivity (2) Moderate intensity, low impact exercise (3) In severe cases carbidopa/levodopa may be prescribed for use at bedtime 13. Round ligament pain a) Stretch, hypertrophy and lengthen as uterus rises in abdomen b) Causes intense “grabbing” sensation in lower abdomen and inguinal area c) Health promotion (1) Warn women of possible discomfort (2) Heating pad may bring some relief (3) Bring knees up on her abdomen 14. Carpal tunnel syndrome (CTS) a) Numbness and tingling of hand near thumb caused by compression of median nerve in carpal tunnel of wrist

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Health promotion c) Avoid aggravating activities and repetitive motions (1) Use splint as prescribed (2) Can resolve after pregnancy (3) Severe cases may require injecting steroids or surgery

VII.

Health Promotion During Pregnancy

A. Fetal Activity Monitoring 1. Encourage to monitor fetal well-being a) Vigorous fetal activity provides reassurance of fetal well-being b) Mothers should monitor regularly after 28 weeks’ gestation c) Marked decrease in activity or cessation of movement may indicate possible fetal compromise

B. Breast Care 1. Proper support of breasts important a) Retain shape, prevent back strain, promote comfort b) Well-fitting, supportive bra has following qualities (1) Straps wide, do not stretch (2) Cup holds all breast tissue comfortably (3) Bra has tucks, other devices → allow it to expand (4) Bra supports nipple line approximately midway between elbow and shoulder c) Cleanliness of breasts (1) Colostrum can crust → remove with warm water d) Inverted or flat nipples (1) Diagnoses with pressure on areola → nipple retracts (2) See Figure 13–12: Normal and inverted nipples A, B, and C, p. 277 (3) Breast shields may be effective e) Resources (1) La Leche League (2) American Academy of Pediatrics (3) National Organization of Mothers of Twins Club

C. Clothing 1. Traditionally fuller lines → allow increase in abdominal size a) Soft, elastic waistbands, stretchable panel over abdominal area 2. Now includes more fitted styles 3. Loose, nonconstricting 4. Large pendulous abdomen → well-fitting supportive girdle a) Tight bands should be avoided

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. High heel shoes can aggravate back discomfort

D. Bathing 1. Daily bathing → increased perspiration, mucoid vaginal discharge a) Practices influenced by cultural norms 2. Caution with tub baths → balance becomes a problem as pregnancy advances a) Vasodilation due to warm water b) Contraindicated with vaginal bleeding, rupture of membranes 3. Avoid hyperthermia associated with hot tub, whirlpool 4. Limit time to 10 minute a) Avoid submerging head, arms, shoulders, and upper chest

E. Employment 1. With no complications → work until women go into labor a) Jobs that require prolonged standing, strenuous physical activity, and/or use of industrial machines → higher incidence of poor pregnancy outcomes 2. Major deterrents a) Fetotoxic hazards b) Excessive physical strain c) Overfatigue d) Medical- or pregnancy-related complications e) Occupations involving balance need adjusted for the pregnant mother 3. Contact company physician or nurse about possible work-environment hazards

F. Travel 1. If medical or pregnancy complication not present → no restrictions on travel 2. Travel by automobile can be especially fatiguing a) Frequent opportunities to get out of car and walk b) Limit to 6 hours per day c) Every 2 hours for 10 minutes d) Three-point seat belt 3. As pregnancy progresses → airplane or train recommended for long distances a) Medical or obstetric complications → avoid flying b) Check with airlines → may restrict travel after 36 weeks’ gestation

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Avoid dehydration, hemoconcentration 5. Carry copy of medical records 6. Consider availability of medical care

G. Activity and Rest 1. Exercise during pregnancy helps maintain maternal fitness and muscle tone a) Improved self-image b) Increases energy c) Improves sleep d) Relieves tension e) Helps control weight gain f) Promotes regular bowel function g) Associated with improved postpartum recovery 2. Prevention of maternal and fetal complications a) May assist in prevention of gestational diabetes 3. Should be examined by certified nurse-midwife or physician prior to beginning exercise program a) Seek opinion of healthcare provider before taking part in part in contact sports 4. Certain conditions do not contraindicate exercise 5. Rupture of membranes a) Preeclampsia-eclampsia b) Cervical insufficiency (cerclage) c) Persistent vaginal bleeding in second or third trimesters d) Multiple gestation at risk for preterm labor e) Preterm labor in the current pregnancy f) Placenta previa after 26 weeks’ gestation g) Chronic medical conditions might be negatively impacted by vigorous exercise such as significant heart disease, restrictive lung disease h) Warning signs (1) Chest pain (2) Vaginal bleeding (3) Regular uterine contractions (4) Decreased or absent fetal movement (5) Leakage of amniotic fluid (6) Calf pain or swelling (7) Dizziness (8) Headache (9) Dyspnea before exertion (10) Muscle weakness (11) Adequate rest important for physical and emotional health 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Find time to rest during day (b) Sleeping more difficult during last trimester

H. Exercises to Prepare for Childbirth 1. Pelvic tilt, or pelvic rocking a) Strengthens abdominal muscle tone b) See Figure 13–14: Pelvic tilt on hands and knees, p. 280 c) Body alignment when pelvic tilt correctly done → maintained throughout the day 2. Abdominal exercises a) Tightening abdominal muscles with each breath b) Partial sit-ups 3. Perineal exercises → Kegel exercises (Figure 13–15) a) Feel specific muscle group by stopping urination midstream (1) Discourage Kegel exercises while urinating b) Technique for teaching Kegel exercises → perineal muscles as an elevator (2) Should not contract muscles of buttocks or thighs c) Can be done at almost any time 4. Inner-thigh exercise a) Assume cross-legged sitting position whenever possible b) Stretches muscles of inner thighs (Figure 13–16)

I. Sexual Activity 1. Many changes of pregnancy → brings up questions and concerns about sexual activity 2. No medical reason to limit sexual activity 3. Intercourse contraindicated if threatened spontaneous abortion, placenta previa diagnosis, or risk of preterm labor 4. Changes in sexual desire and response a) Related to discomforts b) Increased vascular congestion of pelvis → greater sexual satisfaction c) Third trimester → decreased interest in coitus 5. Sexual activity does not have to include intercourse 6. Sexual desires of men affected by many factors a) Previous relationship with partner b) Acceptance of pregnancy c) Attitudes toward the partner’s change of appearance (1) Concern about hurting expectant mother or baby d) Couple should be aware of changes, normality of changes, communication e) See Teaching Highlights: Sexual Activity During Pregnancy, p. 282

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

J. Dental Care 1. Important to maintain regular oral hygiene a) Have extensive dental work done before becoming pregnant if possible b) Inform dentist so not exposed to teratogenic substances c) Dental x-rays permitted as long as abdomen shielded by lead apron

K. Immunizations 1. Ideally prior to becoming pregnant 2. Attenuated live viruses → should NOT be given in pregnancy 3. See Table 13–4: Recommendations for Immunization Before, During, and After Pregnancy, p. 283

L. Complementary Health Therapies 1. Part of integral approach to their healthcare a) Herbal medicine (1) Categorized as dietary supplements (a) Not regulated as prescription or over-the-counter drugs (2) Advise pregnant women not to ingest any herbs during first trimester (a) National Center for Complementary and Alternative Medicine (b) Office of Dietary Supplements b) Acupuncture, acupressure, ginger root, vitamin B6 for nausea c) Chiropractic manipulation for backache

M. Teratogenic Substances 1. Teratogen → adversely affects normal growth and development of fetus 2. Medications a) Greatest risk is during first trimester b) FDA → classification system for medications administered during pregnancy (1) Category A → no associated risk → few drugs (2) Category B → animal studies show no risk, no studies in women or animal studies indicate a risk, but controlled human studies fail to demonstrate risk (3) Category C → no adequate studies or animal studies show teratogenic effects, but no controlled studies in women available (4) Category D → evidence of human fetal risk does exist, but benefits of drug in certain situations thought to outweigh risk (5) Category X → demonstrated fetal risks clearly outweigh any possible benefit (6) Lactation → consider medication risk for lactating mothers (7) Females and males of reproductive potential → medications have potential effect on fertility (8) If woman has taken drug in category D or X → inform of risks associated, alternatives 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Avoid all medication if possible (b) Woman has right to most comprehensive information available concerning medications (c) Remind woman to check with caregiver about medications being taken when pregnancy occurred 3. Tobacco a) Modifiable cause of poor pregnancy outcomes (1) Spontaneous abortion (2) Intrauterine growth restriction (IUGR) (3) Low birth weight infants (4) Preterm birth (5) Perinatal mortality (6) Placenta previa (7) Abruptio placentae (8) Premature rupture of membranes (PROM) (9) Increased risk of sudden infant death syndrome (SIDS) b) Public health education → decreased smoking during pregnancy (1) Five As (a) Ask about tobacco use (b) Advise to quits smoking (c) Assess willingness to quit (d) Assist in attempt to quit (e) Arrange for follow-up care (2) More than 20 cigarettes/day → provider may consider nicotine replacement therapy (3) Educational resources (4) American Lung Association (5) March of Dimes (6) American Cancer Society (a) Healthy Mothers, Healthy Babies 4. Alcohol a) One of primary teratogens in Western world b) Fetal alcohol syndrome (FAS) (1) Growth restriction (2) Behavioral disturbances (3) Craniofacial abnormalities (4) Brain, cardiac, spinal defects (5) Major preventable cause of intellectual disability in the United States c) Moderate consumption of alcohol during pregnancy unclear (1) Passes placental barrier within minutes after consumption → fetal blood alcohol levels becoming equivalent to maternal blood alcohol levels (2) Risk of neurologic damage decreases with cessation of heavy drinking (3) Assessment of alcohol intake chief part of each woman’s medical history

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Caffeine a) No evidence that moderate levels of caffeine are linked to birth defects, spontaneous abortions, or preterm birth 6. Evaluation a) Essential part of effective nursing care b) Recognize situations that require referral for further evaluation c) Ongoing and cyclic nature of nursing process → effective if (1) Common discomforts of pregnancy quickly identified, relieved or lessened effectively (2) Woman able to discuss physiologic, psychologic changes of pregnancy (3) Woman implements appropriate self-care measures, if indicated, during pregnancy (4) Woman avoids substances, situations that pose risk to her well-being or that of child (5) Woman seeks regular prenatal care

VIII.

Focus Your Study

IX.

Activities 1. Individual Have students compile a list of the medications in their households. Instruct students to research the medications in the Physician’s Drug Handbook, or to use another resource such as a pharmacotherapy textbook, for the FDA pregnancy classification of each medication. Have students present their findings to the class. 2. Small Group Divide the class into small groups of three to five students. Have each group prepare one teaching plan regarding the common discomforts of pregnancy. Have groups present their teaching plans to the class. 3. Large Group Have all the students practice the abdominal, perineal, and inner-thigh exercises described in this chapter. As a class, develop strategies for discussing the need to exercise with the pregnant woman who is resistant to exercising.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 14 Maternal Nutrition Maternal Nutrition…………………………………………………………………………………….

Maternal Weight.............................................................................................

Nutritional Requirements...............................................................................

Vegetarianism.................................................................................................

Factors Influencing Nutrition..........................................................................

Nutritional Care of the Pregnant Adolescent.................................................

Postpartum Nutrition......................................................................................

Focus Your Study.............................................................................................

Activities..........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Maternal Nutrition

A. General Nutritional Status Before Pregnancy 1. Prepregnancy nutrition status important 2. Nutritional deficits at conception and during prenatal period influence pregnancy

B. Maternal Age 1. Expectant adolescent must meet the nutritional needs for her own growth in addition to the nutritional needs of pregnancy

C. Maternal Parity 1. Number of pregnancies and interval between them influence nutritional needs

D. Maternal Nutritional Status Affects the Fetus E. Fetal Growth Occurs in Three Phases 1. Increase cell number 2. Increase cell number and size 3. Increase in cell size alone

II.

Maternal Weight

A. Prepregnancy Weight 1. Important for mothers and babies a) Risks for underweight and obesity 2. Maternal weight gain a) Adequate weight gain indicates adequate caloric intake (1) Tends to be variable b) Optimal weight gain depends on woman’s pre-pregnant BMI, pre-pregnant nutritional state (1) Recommendations for total weight gain (a) BMI < 18.5 = 12.5–18 kg (28–40 lb) (b) BMI 18.5–24.9 = 11.5–16 kg (25–35 lb) (c) BMI 25–29.9 = 7–11.5 kg (15–25 lb) (d) BMI > 30 = 5–9.1 kg (11–20lb) c) Pattern of weight gain important (1) Normal weight → 0.5 to 2 kg in first trimester (a) Average 0.45 kg/week during last two trimesters (b) Slightly higher → underweight (c) Slightly lower → overweight 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(d) Twin pregnancy → 1.5 kg/week during second half of twin pregnancy d) Average weight gain distribution (1) 5 kg (11 lb) → Fetus, placenta, amniotic fluid (2) 0.9 kg (2 lb) → Uterus (3) 1.8 kg (4 lb) → Increased blood volume (4) 1.4 kg (3 lb) → Breast tissue (5) 2.3–4.5 kg (5–10 lb) → Maternal stores 3. Obesity in pregnancy a) Association between maternal weight gain and outcome 4. Weight gain alone → not guarantee of adequate nutrition 5. Eating a well-balanced diet a) See Table 14–1: Dietary Reference Intakes for Nonpregnant, Pregnant, and Lactating Females, p. 288 6. U.S. Department of Agriculture online website: choosemyplate.gov a) See Figure 14–2: MyPlate, p. 290

III.

Nutritional Requirements

A. Calories 1. Dietary reference intakes for total energy a) Unchanged during first trimester b) Second, third trimester → additional 300 kcal/day

B. Carbohydrates 1. Primary source of energy, fiber 2. Promotes weight gain, growth → fetus, placenta, maternal tissues 3. Dairy, fruits, vegetables, whole-grain cereals, breads

C. Protein 1. Increased to provide amino acids for fetal development, blood volume expansion, maternal tissues 2. 71 g → increase of about 25 g 3. Quality and quantity a) Animal products → sources of high-quality proteins b) Dairy c) See Table 14–3: Amount of Protein in Common Foods, p. 292 d) Soy-based products as alternative for women with allergies to milk, who are lactose intolerant, or who are vegetarian

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Fat 1. Valuable sources of energy a) More completely absorbed in pregnancy b) Essential fatty acids important for development of central nervous system of fetus (1) Omega-3 (2) Eicosapentaenoic (EPA): heart and immune function (3) Docosahexaenoic acid (DHA): brain, eye, and CNS development

E. Minerals 1. Calcium and phosphorus a) Involved in mineralization of fetal bones and teeth, energy and cell production, acid– base buffering (1) Calcium absorbed and used more efficiently during pregnancy b) Adequate intake → pregnant, lactating over age 19 = 1000 mg/day (1) 1300 mg/day if under age 19 c) Food is preferred source d) 4 cups of milk or equivalent dairy (Table 14–4, p. 293) (1) Recommended dietary allowance (RDA) for phosphorus → 700 mg/day >19 years old (a) 1250 mg/day <19 years 2. Iodine a) Essential part of thyroxine b) Iodized salt → will be able to meet requirement of 220 mcg/day c) Seafood good source d) If sodium restricted, supplement may need prescribed 3. Sodium a) Metabolism, fluid balance b) Moderate sodium intake → fresh food lightly seasoned c) Avoid extra salt at table, salty foods, and sodium-based seasonings d) Zinc (1) Part of numerous enzymes, protein metabolism, DNA & RNA synthesis (2) RDA >19 years → 11 mg/day pregnant (3) 12 mg/day lactation (4) Best sources meat, shellfish, poultry; good sources whole grains, legumes 4. Magnesium a) Cellular metabolism, structural growth b) RDA pregnancy → 350 mg for women 19 to 30; 360 for women 31 to 50 c) Milk, whole grains, dark green vegetables, nuts, legumes 5. Iron a) Increase → growth of fetus, placenta, expansion of maternal blood volume (1) Iron deficiency anemia → decrease in oxygen-carrying capacity of the blood 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Increase incidence of preterm birth, low-birth-rate infants, maternal and infant mortality b) Fetal liver stores iron → first 4 months of life c) Increase intake → lean meats, dark green leafy vegetables, eggs, whole-grain enriched cereals, dried fruits, legumes, shellfish, molasses (1) Absorption generally higher for animal products (2) Combine with foods rich in vitamin C d) Recommended intake in pregnancy → 27 mg per day (1) Impossible diet alone, supplements recommended (2) Supplements may cause gastrointestinal upset

F. Vitamins 1. Grouped by solubility a) Fat soluble → A, D, E, K b) Water soluble → C, B complex c) Balanced diet generally provides necessary vitamins 2. Fat-soluble vitamins a) Stored in liver b) Excessive intake can lead to toxicity (1) Symptoms nausea, GI upset, dryness & cracking of skin, loss of hair c) Vitamin A (1) Growth of epithelial cells, metabolism of carbohydrates and fats (2) Maternal stores of vitamin A adequate → effects of pregnancy not remarkable (3) RDA 770 mcg/day for pregnant women >19 years old (4) Deficiencies uncommon in US (5) Green and yellow or deep orange vegetables and some fruits, liver, egg yolk, cream, butter, fortified margarine, milk d) Vitamin D (1) Role in absorption and utilization of calcium and phosphorus in skeletal development (2) Pregnant woman → 600 IU (15 mcg) per day (3) Fortified milk, margarine, butter, liver, egg yolks (4) Synthesis of sunlight on skin (5) Overdoses due to vitamin supplementation (a) Symptoms excessive thirst, loss of appetite, vomiting, weight loss, irritability, high blood calcium levels e) Vitamin E (1) Antioxidant (a) Vitamin E takes on oxygen—preventing other nutrients from undergoing chemical changes (2) Enzymatic and metabolic reactions (3) Newborn’s need for vitamin E → human milk (4) Recommended intake unchanged → 15 mg/day 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Vitamin E → vegetable fats and oils, whole grains, greens, eggs (6) Excessive intake associated with abnormal coagulation in newborns f) Vitamin K (1) Essential factor for the synthesis of prothrombin (2) Synthesis occurs in intestinal tract by E. coli (3) Needs do not increase during pregnancy → 90 mcg/day 3. Water-soluble vitamins a) Vitamin C (1) Increased needs in pregnancy from 75 to 85 mg/day (2) Aid in formation of connective tissue and vascular system (3) Symptoms of scurvy (4) Plasma levels of vitamin C progressively decline throughout pregnancy (5) Nutritious diet should meet needs (6) Citrus fruits, tomatoes, cantaloupe, strawberries, potatoes, broccoli, leafy green vegetables b) B vitamins (1) Include (a) Thiamine (B1) (b) Riboflavin (B2) (c) Niacin (d) Folic acid (folate) (e) Pantothenic acid (f) Vitamin B6 (pyridoxine) (g) Vitamin B12 (cobalamin) (2) Coenzyme factors in many reactions (3) Thiamine requirement increases → 1.1 to 1.4 mg/day (a) Pork, liver, milk, potatoes, enriched breads, cereals (4) Riboflavin requirement increases → 0.3 to 1.4 mg/day (a) Cheilosis (b) Milk, liver, eggs, enriched breads, cereals (5) Niacin requirement increases → 4 mg/day to 18 mg/day (a) Meat, fish, poultry, liver, whole grains, enriched breads, cereals, peanuts (6) Folic acid (a) Normal growth, reproduction, lactation (b) Inadequate intake associated with neural tube defects (c) 400 mcg/day (d) Green leafy vegetables, liver, peanuts, whole-grain breads, cereals (7) Pantothenic acid → no requirement set → 5 mg/day considered adequate (a) Meat, egg yolk, legumes, whole grain bread, cereals (8) Vitamin B6 → associated with amino acid metabolism (a) RDA during pregnancy → 1.9 mg/day (b) Wheat germ, yeast, fish, liver, pork, potatoes, lentils (9) Vitamin B12 → animal sources only 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Pernicious anemia (b) Supplement vegans (c) RDA 2.6 mcg/day

G. Fluid 1. Water essential for life 2. Pregnant woman → 8 to 12 8 oz glasses of fluid a) 4 to 6 glasses of water b) Juice and milk c) Caffeine (1) In beverages, foods, medications (2) Diuretic effect

IV.

Vegetarianism A. Well-planned vegetarian diets usually adequate, appropriate for all stages of life B. Several types 1. Lacto-ovo-vegetarians 2. Lacto-vegetarians 3. Vegans

C. In pregnancy 1. Appropriate meal planning ensures adequate growth of fetus a) Supplementation: zinc, iron, vitamin B12, calcium b) Protein needs to increase c) See Table 14–6: Vegetarian Food Groups, p. 296

Factors Influencing Nutrition A. Common Discomforts of Pregnancy 1. GI discomfort

B. Complementary and Alternative Therapies 1. Caution with pregnant consumer 2. Consult with healthcare provider

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Saccharin d) Sucralose e) Stevia f) Advantame

D. Energy Drinks 1. Boost performance and delay fatigue a) Monster Energy b) Red Bull c) 5-Hour Energy 2. Soft drinks with caffeine, ginseng, guarana, taurine, sugar a) Pregnant women advised to use cautiously b) Limit total caffeine intake < 200 mg/day

E. Mercury in Fish 1. Can pose threat to unborn baby or young child 2. Recommendations a) Do not eat swordfish, shark, tilefish, king mackerel b) Eat up to 12 oz/week of variety of shellfish, fish lower in mercury (1) Salmon (2) Herring (3) Trout (4) Sardines c) Pollack (1) Mussels d) Only 6 oz/week of albacore tuna

F. Foodborne Illnesses 1. Salmonella and listeria monocytogenes infection 2. Salmonella in raw eggs → pregnant women advised to avoid foods that may contain raw, undercooked eggs 3. Listeria monocytogenes → found in refrigerated, ready-to-eat foods a) Recommendations b) Maintain refrigerator temperature at 40°F (4°C ) or below and freezer at 0°F (–18°C) (1) Refrigerate or freeze prepared foods, leftovers, perishables within 2 hours of eating or preparation (2) Do not eat hot dogs, luncheon meats unless reheated until steaming hot (3) Avoid soft cheeses such as feta, brie, Camembert, blue-veined cheeses, queso fresco or queso blanco unless label clearly states made with pasteurized milk (4) Do not eat refrigerated pâtés, meat spreads, or foods containing raw milk

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Avoid eating refrigerated smoked seafood (salmon, trout, cod, tuna, mackerel) unless in cooked dish (a) Canned or shelf-stable pâtés, meat spreads, smoked seafood considered safe to eat

G. Lactase Deficiency (Lactose Intolerance) 1. Lactose intolerance → inadequate amount of enzyme lactase 2. Common a) African Americans, Hispanic Americans, American Indians, Asian Americans 3. Abdominal distension, discomfort, nausea, vomiting, loose stools, cramps

H. Cultural, Ethnic, and Religious Influences 1. Different nationalities accustomed to eating foods available in country of origin 2. Certain foods have symbolic significance related to major life experience, developmental milestone 3. Nurse needs to understand cultural influences on woman’s eating habits

I. Psychosocial Factors 1. Sharing of food → friendliness, warmth, social acceptance 2. Socioeconomic level may be determinant of nutritional status 3. Knowledge about basic components of balanced diet essential 4. Attitudes and feelings about pregnancy → influence nutritional status

J. Eating Disorders 1. Anorexia nervosa 2. Bulimia nervosa 3. Woman with eating disorders who becomes pregnant at risk for complications a) Miscarriage b) Low birth weight c) Premature birth d) Perinatal mortality e) Birth defects f) Treatment a team approach (1) Medical, nutritional, psychiatric practitioners g) Woman closely monitored

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

K. Pica 1. Persistent craving and eating of nonnutritive substances a) Soil, clay (geophagia) b) Powdered laundry starch, corn starch (amylophagia) c) Soap d) Baking powder e) Ice (pagophagia) f) Freezer frost g) Burned matches h) Paint i) Ashes j) Iron deficiency anemia most common concern (1) Assessment important part of nutritional history

VI.

Nutritional Care of the Pregnant Adolescent

A. Risk factors 1. Interrelated a) Emotional b) Social c) Economic 2. Follow adult recommendations for weight gain determined by BMI a) Take nutritional needs of adolescents and add nutrient amounts recommended for all pregnant women to determine the pregnant teen needs

B. Specific Nutrient Concerns 1. Caloric needs vary widely 2. Inadequate iron intake a major concern 3. Calcium intake frequently a problem 4. Folic acid 5. Common deficiencies in this age group a) Zinc b) Vitamins A, D, E, B6

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Dietary Patterns 1. Often have irregular eating patterns 2. Frequent snackers (Figure 14–5, p. 300) 3. Consider eating pattern over time, not just single day

D. Counseling Issues 1. Positive approach to nutritional counseling 2. Include individual who does most of meal prep 3. Stress health of the baby 4. Focus on foods rather than nutrients 5. Group with teens

VII.

Postpartum Nutrition

A. Postpartum Nutritional Status 1. Assess new mother’s weight, hematocrit, hemoglobin, clinical signs, dietary history 2. Weight loss at birth approximately 4.5 to 5.4 kg (10 to 12 lb) a) First few weeks → additional weight loss b) Breastfeeding weight loss tends to be greater 3. Rate of weight loss influenced by many factors a) Weight gain during pregnancy 4. Evaluate weight, ideal weight for height, weight before pregnancy, weight before birth 5. Assess clinical symptoms a) Cravings, aversions b) Constipation 6. Obtain information on diet and eating habits 7. Communication with dietitian a) Risk for obesity increases during childbearing years

B. Nutritional Care of Formula-Feeding Mothers 1. Daily requirements return to prepregnancy levels (Table 14–1) 2. Understanding of nutrition a) Opportunity to teach b) Referral to dietitian if excessive weight gain

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Nutritional Care of Breastfeeding Mothers 1. Nutrient needs increase during breastfeeding (Table 14–1) 2. Calories a) Inadequate intake can reduce milk volume b) Increase caloric intake by 200 kcal over pregnancy → 500 kcal over pre-pregnancy requirement, total 2500–2700 kcal/day c) MyPlate food guide d) Weight loss not more than 1 lb/week 3. Protein a) 65 g/day during first 6 months b) 62 g/day thereafter 4. Calcium a) 1000 mg/day 5. Iron a) Continue supplementation of mother for 2 to 3 months after parturition (1) Replenish maternal stores 6. Fluids a) 8 to 10 8-oz glasses daily

D. Counseling Issues 1. Increased nutrient needs, issues related to infant feeding 2. Some foods may cause distress → avoid onions, turnips, cabbage, chocolate, spices, seasonings

E. Nursing Management for the Pregnant Woman Desiring Optimum Nutrition 1. Nursing Assessment and Diagnosis a) Data collection including (1) Height, weight, weight gain during pregnancy (2) Pertinent laboratory values (3) Clinical signs that have possible nutritional implications (4) Diet history to determine woman’s views on nutrition b) Diet history (1) 24-hour recall (2) Food frequency questionnaire include foods, fluids, supplements (3) Discuss important aspects of nutrition in context of family’s needs, lifestyle c) Formulate nursing diagnoses from data analysis (1) Nutrition, Imbalanced: Less than Body Requirements, related to nausea and vomiting (2) Overweight, Risk for, related to excessive calorie intake 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Knowledge, Readiness for Enhanced, related to nutrition 2. Nursing Plan and Implementation a) Health promotion education (1) Present information in clear, logical way → avoid jargon and “talking down” to client (2) Dietary change usually necessary (3) Develop plan with pregnant woman b) Implementation: Nutrition, Imbalanced: Less than Body Requirements related to low intake of calcium (1) Patient goal: woman will increase intake of calcium to DRI level (2) Implementation (a) Plan with woman additional milk or dairy products (b) Encourage the use of other calcium sources (c) Plan for addition of powdered milk in cooking, baking (d) Consider use of calcium supplements (3) Guidance about food purchasing and preparation c) Community-based nursing care (1) Meeting nutritional needs → challenge for families on limited incomes (2) Services offered through clinics, local agencies, schools, volunteer organization (a) Supplemental Nutrition Assistance Program (SNAP)—formally the Food Stamp Program (b) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (i) Income guidelines, residency requirements, nutritionally at risk 3. Evaluation a) Food journal b) Writing weekly menus c) Returning for weekly weighing d) Periodic hematocrit assessment e) Referral to dietitian → work with nurse, patient

VIII.

Focus Your Study

IX.

Activities 1. Individual Ask students to prepare a teaching plan for a prenatal class of adolescents. The students should include food safety and sanitation information in a developmentally appropriate presentation. 2. Small Group Divide the class into small groups of three to five students. Have each group conduct a nutritional assessment using a food questionnaire and collect physical data to prepare an analysis of protein, carbohydrate, and fat (in grams) dietary adequacy.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Large Group Watch the movie SuperSize Me. Facilitate a class discussion about fast food and adolescent pregnancy.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 15 Pregnancy in Selected Populations Adolescent Pregnancy.........................................................................................

Care of the Expectant Parents Over Age 35..………………………………………………….

Care of the Pregnant Woman with Special Needs………….………………………………

Focus Your Study.................................................................................................

Activities………………………………………………………………………………………………………..

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Adolescent Pregnancy

A. Health, social, and economic long-term consequences for teen parents and their children 1. In 2011, birth rate (number of births per 1,000 women) for adolescents 15–19 years of age fell to 20.3, a historic low a) Improvements in rate contributed to improvements in contraceptive technology and increased education & labor market opportunities for women b) U.S. teenage birth rate remains highest of any industrialized nation

B. Overview of the Adolescent Period 1. Physical changes a) When individuals are capable of reproduction b) Puberty lasts 1.5 to 6 years c) Menarche usually occurs in last half of puberty d) Contraception important for all sexually active adolescents 2. Psychosocial development a) Following major developmental tasks (1) Developing an identity (2) Gaining autonomy and independence (3) Developing intimacy in a relationship (4) Developing comfort with one’s own sexuality (5) Developing a sense of achievement b) Resolving tasks is a developmental process → occurs over time (1) Need to “try on” roles in process of experimentation, exploration (2) Teens work to separate themselves from their parents c) Early adolescence → < 14 years (1) Psychosocial development marked by rapid physical changes (2) Initiate struggle for independence (3) Conformity to peer group standards (4) Very egocentric; concrete thinker d) Middle adolescence → 15 to 17 years (1) Time for challenging authority (2) Experimentation with drugs, alcohol, sex (3) Move from concrete thinking to formal operational thought (4) Struggle for independence can lead to challenging family relationships e) Late adolescence → 18 to 19 years (1) More at ease with individuality, decision-making ability (2) Think abstractly, anticipate consequences (3) Formal operational thought f) See Evidence-Based Practice: Risk Factors for Adolescent Pregnancy, p. 307

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Factors Contributing to Adolescent Pregnancy 1. Socioeconomic and cultural factors a) Poverty → major risk factor for adolescent pregnancy (1) See pregnancy as option for adult status (2) Higher among African American and Hispanic teens than white teens b) Teens with warm, nurturing families who value future accomplishments, and are engaged academically are less likely to engage in risky sexual behavior c) Younger a teen is with first pregnancy → more likely to have another pregnancy in teens 2. High-risk behaviors a) Developmentally adolescents → not able to foresee consequences of actions b) Peer pressure to become sexually active during teen years c) Sexual innuendo permeates every aspect of popular media (1) Sexting → sending or posting sexually suggestive text, images d) High-risk sexual behaviors (1) Multiple partners (2) Lack of contraceptive use (3) Account for nearly half of new cases of sexually transmitted infections (STIs) e) Increased use of condoms but inconsistent contraceptive users overall f) Sex education programs (1) Do not increase rates of sexual initiation at an earlier age (2) Helps teens to withstand the pressure to have sex too soon 3. Psychosocial factors a) Pregnancy desire tends to be higher among teens who are older, who were younger when they became sexually active, who are in a short-term relationship, and who have greater perceived stress in their lives b) Family dysfunction, poor self-esteem (1) Use pregnancy → way out, punish parent(s) (2) Form of acting out (3) Milestone to enhanced maturity c) Incest, sexual abuse or rape as possible cause of pregnancy in very young adolescent

D. Risks to the Adolescent Mother 1. Physiologic risks a) Adolescents over age 15 → early, thorough prenatal care → no greater risk than pregnant women older than 20 (1) Many fail to seek early prenatal care (2) Risks include (a) Preterm births (b) Low-birth-weight (c) Cephalopelvic disproportion (d) Preeclampsia-eclampsia (e) Iron deficiency anemia 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(i) Problem in all pregnant women → adolescent already b) Prenatal care critical factor c) High incidence of STIs in pregnant moms 15–19 years d) Cigarette and drug use, often before pregnancy is confirmed 2. Psychologic risks a) Interruption of progress in developmental tasks b) Add tasks of pregnancy to normal developmental tasks c) See Table 15–1: Initial Reaction to Awareness to Pregnancy, p. 309 d) Early adolescent (< 14) → fears rejection by family and peers, enters healthcare system with adult, pregnancy probably not result of intimate relationship, self-consciousness, low self-esteem as physical changes of pregnancy progress (1) Nursing implications (a) Nonjudgmental (b) Focus on needs and concerns of adolescent (c) Encourage daughter, parent to express concerns, feelings about pregnancy and options (d) Realistic and concrete e) Middle adolescent (15 to 17) → fears rejection by peers and parents, unsure in whom to confide, may seek confirmation of pregnancy on own, economic dependence on parents (1) Nursing implications (a) Nonjudgmental approach (b) Reassure of confidentiality (c) Help adolescent identify individuals in whom she can confide (d) Be aware of state laws regarding notification requirements for abortion (e) Be aware of state laws regarding requirements for marriage (f) Encourage realistic expectations about parental response f) Late adolescent (18 to 19) → most likely to confirm pregnancy on own and earlier; relationship with father of baby, future educational plans, personal value system significant determinants of decision about pregnancy (1) Nursing implications (a) Nonjudgmental (b) Reassure of confidentiality (c) Help identify individuals in whom she can confide (d) Refer to counseling as appropriate (e) Encourage realistic expectations about parental response g) See Table 15–2: The Early Adolescent’s Response to the Developmental Tasks of Pregnancy, p. 310 (1) First trimester (a) Pregnancy confirmation, early prenatal care, diet and health habits evaluated, ambivalence (b) Early adolescent may delay confirmation of pregnancy, physical changes may be perceived as signs of puberty

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Nursing implications → explain physiologic changes of pregnancy, normal ambivalence, need for good nutrition (i) Simple explanations, audiovisuals (ii) Have adolescent listen to fetal heart with Doppler (2) Second trimester (a) Changes in physical appearance begin, fetal movement (b) May delay validation of pregnancy until now, family turmoil, emotional turmoil with physical changes and “loss of control” of body (c) Nursing implications → continue to discuss nutrition and adequate weight gain, ways of using common teen clothing, plans for baby, education, role of teen’s parents (3) Third trimester (a) Begins to view fetus as separate from self, buying clothes and supplies, prepares to give birth, increasing anxiety about labor, delivery, well-being of fetus (b) May focus on wanting it to be over, may have fears, fantasies, of labor and birth (c) Nursing implications → assess whether adolescent preparing for baby, childbirth education, discomforts of pregnancy 3. Sociologic risks a) Schooling interrupted or drop out, less likely to graduate high school and enroll/finish college. b) More likely to have big families and be single c) Higher risk for social and economic disadvantages than nonpregnant counterpart (1) Forced into adult role (2) May marry father of baby → may be teen (3) Frequently end in divorce → lack of maturity d) Dating violence often issue for teens (1) Especially younger girls dating older boys e) Costs $9.4 billion each year (1) Increased incidence of maternal complications, premature birth, low-birth-weight (LBW) babies

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Risks for the Child 1. Teen parent not developmentally or economically prepared to be parents 2. Adverse socioeconomic factors 3. High rates family instability and behavior problems 4. High rates of abuse and neglect 5. Likely to become adolescent parents themselves

F. Partners of Adolescent Mothers 1. Average age difference between teen mothers and their partners is 2–3 years 2. Adolescent males → sexually active earlier age than females, more partners 3. More likely to have problems with school, self-esteem, drugs, alcohol, work, aggression 4. May be involved in meaningful relationship 5. Unintended pregnancy seen as negative 6. Family and financial issues are barriers a) Included on birth certificates → legal paternity b) Special situations → rape, incest, exploitative sexual relations, casual sexual relations (1) Referral to other resources c) Support in decision to assume responsibility (1) Pregnant adolescent has opportunity to decide if father to participate in health care d) Caring relationship → may still not understand all changes partner experiencing (1) Mentoring e) Assess stressors, support systems, plans for involvement, future plans (1) Referrals as indicated

G. Reactions of Family and Social Network to Adolescent Pregnancy 1. Family reactions as varied as motivation and cause of pregnancy a) Anger, shame, sorrow → common reactions b) More likely to use contraception, or choose abortion unless culture or religious beliefs prevent it c) Adolescent pregnancy more prevalent, socially accepted → family and friends more supportive d) Mother of pregnancy adolescent usually among first to be told (1) Involved in decision making (2) Helps teen access health care, accompanies to first visit (3) Younger adolescent is → more she needs mother’s support

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

H. Nursing Management for the Adolescent Mother-to-Be 1. Nurse may be first contact with healthcare system 2. May be first time to give health history—should include a) Family, personal health history b) Medical history c) Menstrual history d) Obstetric and gynecologic history e) Substance abuse history 3. Nursing Assessment and Diagnosis a) Establish database to plan interventions (1) Diagnosis can vary based on age, support systems, socioeconomic status, health, and maturity (2) Include those for normal pregnancies plus additional as needed (3) Potential diagnosis (a) Nutrition, Imbalanced: Less than Body Requirements (b) Self-esteem, Situational low, Risk for

I. Planning and Implementation 1. Early, thorough prenatal care critical for reducing risk for mother, newborn 2. Community-based nursing care a) Agencies evolved to provide care for high-risk patients (1) Help access healthcare system as well as social services (a) Food banks (b) Special Supplemental Food Program for Women, Infants, and Children (WIC) b) Education in groups according to ages (1) Visual teaching aids (2) Realistic models (3) At reading level (4) Extensive counseling → challenges c) Issue of confidentiality (1) Emancipated minors (2) State legislation differs d) Development of a trusting relationship with the pregnancy adolescent (Figure 15–2, p. 312) (1) May be anxious and vulnerable (2) May be first pelvic examination (3) Honesty, respect for individual (4) Caring attitude e) Promotion of self-esteem and problem-solving skills (1) Overview of prenatal course, thorough explanations and rationale for procedures (2) Consider decision making capacity and influences from age perspective 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Give her some measure of control f) Promotion of physical well-being (1) Baseline weight, blood pressure → may have adolescent take own weight (2) Use time to teach nutrition (3) Lab work → hemoglobin and hematocrit values (a) Preeclampsia-eclampsia → most prevalent medical complication of pregnant adolescents (b) High BP (usual for ages 14–20 is a diastolic 50–66 mmHg) (i) Proteinuria (ii) Edema (iii) Increased incidence of STIs → tests, education (iv) Substance abuse → discussion of effects of woman, fetus (4) Ongoing care → same as older pregnant woman (Figure 15–3, p. 313) g) Promotion of family adaptation (1) Assess family situation at first prenatal visit (a) Ascertain level of involvement desired by adolescent from each member (b) Daughter–mother relationship → may change during teen’s pregnancy (c) Help mother to assess daughter’s needs, assist her in meeting them (d) Daughter–father relationship → may change during teen’s pregnancy (2) Include father of infant if desired (a) Goals for prenatal classes (Figure 15–4, p. 314) (i) Provide anticipatory guidance (ii) Prepare participants for labor and birth (iii) Help participants identify problems, conflicts of teenage pregnancy and parenting (iv) Increasing self-esteem (v) Providing information about available community resources (vi) Helping participants develop more adaptive coping skills (b) Use variety of teaching strategies (c) Teens may not retain information due to being present oriented (d) See info box: Health Promotion: Education: What Schools Can Do, p. 315 3. Hospital-based nursing care a) Adolescent in labor has same care needs as any pregnant woman (1) Sustained presence very important (2) Education to guide choices (3) Assist support people, often the adolescent’s mother (4) Postpartum (a) Make aware of community resources available b) Discharge Teaching: Contraception (1) Most teens adamant about not becoming pregnant again → statistics differ (2) Contraception critical part of effort to decrease adolescent pregnancy (a) Condoms, most common (i) Dual approach → pregnancy and STI prevention 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(ii) AAP & SAHM recommends LARC methods that limit reliance on individual adherence (b) Combined oral contraceptives (COC) (c) Intrauterine contraceptives (IUC) 4. Evaluation a) Expected outcomes include (1) Trusting relationship established (2) Adolescent is able to use her problem-solving abilities to make appropriate choices (3) Adolescent follows recommendations of healthcare team → receives effective health care throughout her pregnancy, birth, postpartum period (4) Adolescent, partner, families able to cope successfully with the effects of the pregnancy (5) Adolescent able to discuss pregnancy, prenatal care, childbirth (6) Adolescent develops skill in child care and parenting

J. Prevention of Adolescent Pregnancy 1. Individual level a) Balanced, realistic sexuality education → can delay onset of sexual activity, increase use of contraception, reduce number of sexual partners (1) Include information on abstinence and contraception 2. Strategies for prevention a) Provision of services that ensure accessible and high-quality reproductive health care b) Sex education programs that provide developmentally appropriate, evidence-based curricula c) Youth development strategies to enhance life skills d) Connection to supportive adults e) Educational and economic opportunities 3. National level → campaign to prevent teen and unplanned pregnancy a) Goals by 2026 (1) Working to reduce teenage pregnancy by 50% (2) Reduce unplanned pregnancy by 25% for 18–29-year-olds (3) Reduce socioeconomic and racial/ethnic disparities in teens and unplanned pregnancies by 50% b) Multifaceted problem → no easy answers 4. Major problem a) Intense conflict among different groups about how to approach adolescent pregnancy prevention (1) Abstinence-only versus abstinence-plus approaches b) Comprehensive programs (1) Information about unplanned pregnancies and STIs (2) Support both abstinence and use of contraceptives 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Characteristics of effective programs a) Evidence-based, long term and intensive b) Involve adolescents in program planning (1) Include good role models from same cultural and racial backgrounds c) Focus on adolescent male 6. Recommendations for parents see Key Facts to Remember: Recommendations for Parents to Help Their Teens Avoid Pregnancy, p. 316 a) Parents should be clear about own sexual attitudes and values → communicate clearly with children b) Parents need to talk with their children about sex early and often, and be specific c) Parents should supervise and monitor their children and teens with well-established rules, expectations, curfews, standards of behavior d) Parents should know their children’s friends and their families e) Parents need to clearly discourage early dating as well as frequent and steady dating f) Parents should take a strong stand against allowing a daughter to date a much older boy; similarly they should not allow a son to develop an intense relationship with a much younger girl g) Parents need to help children set goals for their future and have options that are more attractive than early pregnancy and childrearing h) Parents should show their children that they value education and take school performance seriously i) Parents need to monitor what their children are reading, listening to, and watching j) It is especially important that parents build a strong, loving relationship with their children from an early age by showing affection clearly and regularly, spending time with them doing age-appropriate activities, building children’s self-esteem, and have meals together as a family often

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

II.

Care of the Expectant Parents Over Age 35

A. Increasing rates, 2015 → birth rates increased ages 30–44 and decline for women < 30 years B. Factors contributing to this trend 1. Availability of effective birth control methods 2. Expanded roles, career options available for women 3. Increased number of women obtaining advanced education, pursuing careers, delaying parenthood until they established professionally 4. Increased incidence of later marriage, second marriage 5. High cost of living → delay childbearing until more secure financially 6. Increased availability of specialized fertilization procedures 7. Advantages to having first baby after age 35 a) Well educated b) Financially secure c) More aware of realities of having children

C. Medical Risks 1. Risk of maternal death higher for women over 35 → even higher for age 40 and older a) Chronic medical conditions 2. Incidence of multiple gestation, miscarriage, stillbirth, low-birth-weight infants, preterm births and perinatal morbidity and mortality higher 3. Down syndrome risk increases with age a) See Genetic Facts: Incidence of Down Syndrome Increases with Maternal Age, p. 317 b) Quadruple screening for Down and trisomy 18, typically between 15–22 6/7 weeks c) Follow-up testing for abnormal results 4. Amniocentesis routinely offered to all women over age 35

D. Special Concerns of the Expectant Parents Over Age 35 1. Having enough energy to care for new baby 2. Ability to deal with needs of older child as they themselves age 3. Financial concerns regarding college and retirement 4. May feel isolated socially a) Only couple in peer group expecting first baby b) Couples who already have children → response varies 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Attitudes of friends (2) Financial implications (3) Previous marriages-Blended families 5. Healthcare professionals may treat couple differently 6. May be concerned about limited time to bear children 7. Amniocentesis options

E. Nursing Management for the Pregnant Woman Over Age 35 1. Nursing Assessment and Diagnosis a) Decisional conflict b) Anxiety (moderate) 2. Planning and Implementation a) Respect and support older couple’s decision to have a child b) Identify and discuss concerns during pregnancy c) Childbirth education classes important d) Woman >35 and having first baby tend to be more educated e) Be sensitive to special needs (1) amniocentsis 3. Evaluation a) Outcomes: b) The woman and her partner are knowledgeable about the pregnancy and express confidence c) Able to cope with the pregnancy and its implications d) The woman receives effective healthcare (1) The woman and her partner develop skills in child care and parenting.

III.

Care of the Pregnant Woman with Special Needs

A. Approximately 163,700 women with chronic physical disability that cause need for assistance with ADLs become pregnant yearly 1. Can include: mobility difficulties that involve upper or lower extremities, arthritis, vision or hearing problems, disorders such as multiple sclerosis or cerebral palsy, heart or lung problems, and a variety of diseases. 2. Changes in societal attitudes → decreased stigmatization of disability 3. ADA increased support and acceptance 4. Decision to become pregnant influenced by biologic, personal, social factors a) The personal importance of pregnancy and motherhood b) The feasibility of pregnancy and raising a child in light of the woman’s health condition, finances, support, and available resources 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) The costs of pregnancy including the physical risks (including death), genetic issues, dangers for the fetus of maternal medications, and potential impact of the woman’s disability on the child’s future quality of life. 5. IDD a) High incidence of unplanned pregnancy b) Seek prenatal care late c) Lower reading and comprehension levels d) higher rates of preterm birth, preeclampsia, longer hospital stays, higher rate of cesarean births e) Babies more likely to be low birth weight f) Family-centered approach recommended, professional support and team effort essential

B. Nursing Management for the Woman with a Disability 1. Nursing Assessment and Diagnosis a) Condition specific b) Will vary based on extent of woman’s disability c) Careful assessment for mobility disorders (1) Hypotension (2) Bradycardia (3) Pulmonary complication (4) Pressure ulcers (5) Bladder infection (6) GERD (7) DVT (8) Stool impaction (9) Anemia (10) Autonomic dysreflexia (11) Increased fall risk → change in center of gravity (12) Assess for level of understanding of instructions & materials 2. Nursing diagnosis a) Dysreflexia, Autonomic, related to a spinal cord injury b) Skin Integrity, Risk for Impaired, related to decreased or absent mobility c) Knowledge, Deficient, related to a documented learning disability 3. Nursing Plan and Implementation a) Lower extremity disability may need assistance in transferring b) Use adaptive equipment c) Weight gain can limit wheel chair function d) During labor, monitor for respiratory distress, DVT, autonomic dysreflexia (1) Pushing may be difficult (2) may need additional support caring for newborn

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Evaluation a) Outcomes (1) The expectant woman is able to cope with the pregnancy and its implications for the future. (2) The woman receives effective healthcare throughout her pregnancy and during birth and the postpartum period.

IV.

Focus Your Study

Activities 1. Individual Have students interview a woman who has had a child, ideally one who represents one of the special populations. Have them investigate at what age the women became pregnant, what their experiences were, and if they had any special considerations related to their age, health or a disability. 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a spreadsheet that lists the details. Have the groups analyze the results based on the age of their findings. 3. Large Group Show the movie Juno in class, discussing the developmental tasks that Juno met and did not meet.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 16 Assessment of Fetal Well-Being Psychologic Reactions to Antenatal Testing..........................................................

Ultrasound..............................................................................................................

Assessment of Fetal Well-Being in the First Trimester.........................................

Assessment of Fetal Well-Being in the Second Trimester....................................

Assessment of Fetal Well-Being in the Third Trimester........................................

Other Diagnostic Tests...........................................................................................

Focus Your Study....................................................................................................

Activities.................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Psychologic Reactions to Antenatal Testing

A. Severe maternal morbidity (SMM): physical and psychologic conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health B. Approximately 3% newborns are born with a birth defect, 10% prematurely C. Studies indicate testing leads to maternal anxiety 1. Ultrasound has become routine a) Counseling to minimize shock, confusion b) Invasive testing → fear, anxiety 2. All testing → present as optional

D. Nursing Management for the Woman Undergoing Antenatal Testing 1. Nursing Assessment and Diagnosis a) Assessment (1) History of present prenatal course, possible indications (2) Assess knowledge of woman and family’s understanding b) Diagnoses c) Knowledge, Readiness for Enhanced (1) Fear (2) Attachment, Risk for Impaired (3) Anxiety 2. Nursing Plan and Implementation a) Education b) Advocate c) Support (1) Remain nonjudgmental d) Community care integral through antepartum period 3. Evaluation 4. Woman and family understand antepartum testing procedures a) Determine if family understands indication for follow-up testing b) Woman and family have adequate resources for support c) Women from different cultures have necessary support

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

II.

Ultrasound

A. Diagnostic procedure → high-frequency sound waves exceeding 20,000 cycles per second 1. Produce image that varies based on density of structure under transducer a) Very dense → bone → white b) Soft tissues → gray c) Fluid → black 2. Higher frequency of sound → shallower depth → better resolution of image 3. Transducer → turns sound waves into electrical signals 4. Motion (M) mode → moving display 5. Brightness mode (B) → produces two-dimensional image 6. Three dimensional → uses algorithms to project image

B. Extent of Ultrasound Exams 1. Limited → address specific question a) Determine fetal presentation b) Locate placenta c) Confirm fetal heart activity d) Estimate amniotic fluid volume e) Diagnose multiple gestation f) Evaluate interval growth g) Evaluate cervix h) Guide amniocentesis 2. Standard ultrasound examination a) Performed during second or third trimesters b) Evaluates presentation, number, amniotic fluid volume, placental position, cardiac activity, fetal biometry, anatomic survey c) Specialized ultrasound examination (1) Suspect anomaly (2) May include fetal Doppler, biophysical profile, fetal echocardiogram, amniotic fluid assessment, biometric studies

C. Methods of ultrasound Scanning 1. Transabdominally a) See Figure 16–1: Ultrasound scanning permits visualization of the fetus in utero, p. 325 2. Transvaginally a) See Figure 16–2: Transvaginal ultrasound, p. 326 b) See Table 16–1: Comparison of Transvaginal and Transabdominal Ultrasound, p. 327 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Indications for Ultrasound 1. US should be performed by licensed medical practitioners to obtain the following data a) Estimation of gestational age b) Evaluation of cervical insufficiency c) Evaluation of fetal growth or fetal well-being d) Evaluation of vaginal bleeding e) Determination of fetal presentation f) Evaluation of abdominal or pelvic pain g) Suspected multiple gestation h) Significant discrepancy between uterine size and clinical date i) Evaluation of pelvic mass or uterine abnormality j) Examination of suspected hydatidiform mole k) Adjunct to special procedures including amniocentesis, cervical cerclage placement, or external cephalic version l) Evaluation for premature rupture of the membranes or premature labor m) Evaluation of suspected fetal death n) Evaluation of suspected ectopic pregnancy o) Evaluation of suspected amniotic fluid abnormalities p) Evaluation of suspected placental abruption q) Evaluation of abnormal biochemical markers r) Follow-up evaluation of fetal anomaly s) Follow-up evaluation of placental location for suspected placenta previa t) Evaluation of those with history of previous congenital anomaly u) Evaluation of fetal condition in late presentation for prenatal care v) To assess findings that may increase the risk of chromosomal abnormalities w) To screen for fetal anomalies

III.

Assessment of Fetal Well-Being in the First Trimester

A. Viability 1. Potential for pregnancy to result in live infant a) Urine human chorionic gonadotropin (hCG) → presence of hormone, does not confirm viability b) Bleeding common symptom associated with first-trimester ultrasound → miscarriage, ectopic or extrauterine pregnancy c) Previous fetal loss, unknown LMP, and dating & size discrepancy → need first-trimester ultrasound 2. Quantitative Beta hCG testing a) Beta human chorionic gonadotropin b) Product of trophoblast or placenta c) Accurate marker of presence of pregnancy and placental health d) Double every 2 days in first 10 days 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Peaking at 60 to 90 days after conception f) See Table 16–2: Approximate Beta hCG Values in Pregnancy, p. 328 g) If beta hCG plateaus or drops → ectopic pregnancy suspected h) Serologic evaluation with history of spontaneous abortion, ectopic pregnancy, risk of ectopic pregnancy, vaginal bleeding, conception through assisted reproductive methods i) 48 hours between tests can be anxious for couple 3. Progesterone-level testing a) Secreted in early pregnancy by corpus luteum until about 8 weeks (1) Placenta manufactures own progesterone b) Low levels associated with spontaneous abortions, ectopic pregnancies c) Levels above 25 ng/mL → associated with normally developing intrauterine pregnancy d) Levels < 5 ng/mL indicate nonviable fetus e) Levels 5–25 are inconclusive, levels can be treated with supplementation for first trimester 4. Ultrasound a) Sonographic landmarks predictable (1) Gestational sac → yolk sac approximately 5½ weeks (2) Embryo visible → 6 to 6½ weeks → cardiac motion (3) Gestational sac and crown-rump length measured for gestational age estimate 5. Gestational age a) Accurate estimated date of birth (EDB) essential for evaluating well-being b) Traditional means (1) Last menstrual period (LMP) (2) Measure uterine size (3) Date of first recognized fetal heart tones (4) Date of quickening (5) Early transvaginal or abdominal sonogram if LMP uncertain (a) Accurate within ±3 to 5 days (b) Based on crown–rump length, most accurate at 6–12 weeks (c) After 12 weeks, femur length, abdominal circumference, biparietal diameter most accurate (d) See Figure 16–5: Measurement of crown–rump length, p. 329 (6) After 26 weeks (a) Femur length, abdominal circumference, biparietal diameter (b) See Figure 16–6: Measurement of the biparietal diameter, p. 329 (c) Accurate to ±7 to 14 days (7) See Table 16–3: Parameters for Estimating Gestational Age, p. 330 (8) After 26 weeks, fetal growth rates less uniform, making ultrasound inappropriate means of determining EDB 6. Genetic Screening Options a) First-trimester single screening tests → nuchal translucency testing, serum free beta hCG, total hCG, PAPP-A 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Combination of ultrasound and maternal serum test (2) Screens for risk of chromosomal disorder (3) If nuchal folds > 3 mm → incidence of Down syndrome increased (4) Performed in conjunction with PAPP-A and free beta hCG (5) 82 to 87% accurate for Down syndrome b) Cell-free fetal DNA (cff-DNA) (1) 98% detection rate for fetal trisomy 13, 18, 21 (2) Done any time after 10 weeks’ gestation

IV.

Assessment of Fetal Well-Being in the Second Trimester A. Integrated test: first-trimester combined test, nuchal translucency testing, PAPP-A, and second trimester maternal serum testing (quadruple screen) 1. Contingent testing → follow up to first-trimester results 2. Stepwise screening

B. Ultrasonographic Screening 1. Most advantageous time for basic obstetric ultrasound a) Uniformity of fetal growth b) Large volume of amniotic fluid relative to fetal size c) Fetal anatomy can be visualized in extreme detail 2. Standard second trimester sonogram provides the following information: a) Fetal life b) Fetal number c) Fetal presentation d) Fetal anatomy survey (1) Head (2) Spine (3) Thorax and heart (4) Abdomen (5) Extremities e) Gestational age and growth f) Amniotic fluid volume g) Placental localization h) Umbilical cord, number of vessels i) Survey of uterine anatomy j) Further evaluation of multiple gestations

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Fetal life → cardiac motion 4. Fetal number → identify number of fetuses in uterus 5. Fetal presentation → will change repeatedly before birth 6. Fetal anatomy survey a) Head (1) Symmetrical, cranium ossified and intact (2) Ventricular system (3) Nuchal thickness (4) Anencephaly b) Spine (1) Sagittally and coronally (a) Sac or outward splaying may suggest spinal cord defect c) Thorax and heart (1) Transverse plane of fetal thorax → information about size, shape, symmetry of the chest (2) Size, location, and axis, 4 chambers of heart d) Abdomen (1) Bladder, stomach, kidneys should be visualized (2) Abdominal wall, transverse image of umbilical cord with 3 vessels e) Extremities (1) Femur the only bone routinely measured on basic ultrasound (a) If length is abnormal, comprehensive follow-up needed (2) Upper extremities, presence of hands, feet documented 7. Gestation age and growth a) Hadlock method (1) Average of measures of biparietal diameter, head circumference, abdominal circumference, and femur length to estimate gestational age (2) See Figure 16–7: Measurement of the head circumference, p. 332; Figure 16–10: Measurement of the abdominal circumference, p. 333 8. Amniotic fluid volume a) Changes with gestational age (1) Subjective assessment b) Amniotic fluid index (AFI) (1) Divide maternal abdomen into quadrants (2) Deepest vertical pocket of fluid in each quadrant measured (3) Four measurements summed 9. Placenta location a) Appearance, location, relationship to cervical os b) Placenta previa (1) Location of placenta may change

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Low-lying placenta on second trimester ultrasound → confirm with follow-up ultrasound in third trimester 10. Survey of uterine anatomy a) Examine maternal anatomy, identify defects, abnormalities b) Measure cervical length, dilatation of internal cervical os (1) Shortened cervix and a dilated internal os → be predictive of preterm birth

Assessment of Fetal Well-Being in the Third Trimester A. Conditions Warranting Fetal Surveillance 1. Maternal conditions a) Hypertensive disorders b) Diabetes mellitus c) Chronic renal disease d) Cyanotic heart disease e) Systemic lupus erythematosus f) Hyperthyroidism (poorly controlled) g) Antiphospholipid syndrome h) Hemoglobinopathies 2. Prenatal conditions a) Preeclampsia b) Gestational diabetes c) Decreased fetal movement d) Oligohydramnios e) Hydramnios f) Intrauterine growth restriction g) Postterm pregnancy h) Isoimmunization (moderate to severe) i) Previous fetal demise j) Multiple gestation k) Known fetal anomaly l) Abnormal biochemical test results

B. Fetal Movement Assessment 1. Acceptable, noninvasive, cost-effective fetal surveillance a) Vigorous fetal movement reassuring → fetal well-being, oxygenation b) Monitored by mother daily, beginning at 28 weeks c) Cardiff Count-to-Ten method (Figure 16–11, p. 334) d) Education of woman at 28 weeks (1) The woman should feel fetal movement at least 10 times in 12 hours (2) Many women will feel 10 fetal movements in much less time, perhaps as little as 2 hours 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Daily Fetal Movement Record (DFMR) (1) Woman lies on her side in a comfortable position (2) Counts the number of movements until she reaches a minimum of three movements within a 1-hour period f) Reduced fetal activity (1) Possible fetal or placental issue (2) Warrants further assessment (3) Indirect measure of fetal CNS integrity and function (4) Variation in fetal movement dependent on individual, gestational age (5) Fetal rest-sleep cycle (6) See Teaching Highlights: What to Tell the Pregnant Woman About Assessing Fetal Activity, p. 335

C. Nonstress Test 1. External electronic fetal monitor → tracing of fetal heart rate (FHR) a) Observe acceleration of FHR with fetal movement (1) Acceleration → intact central nervous system and autonomic nervous system (2) Nonreactive NST not diagnostic of fetal compromise b) Advantages (1) Quick and easy to perform (2) Inexpensive (3) Easy to interpret (4) Can be performed in an outpatient setting (5) No known side effects c) Disadvantages (1) Can be difficult to obtain a suitable tracing (2) Results are influenced by fetal sleep cycle (3) Extended monitoring may be required (4) Maternal obesity, excessive fetal movement, hydramnios, and other factors can make the test difficult to perform d) Fetal age → 30 to 32 weeks → accelerations with movement e) Accelerations (1) 15 beats/min above baseline for 15 to 120 seconds (2) Two accelerations within 20-minute period f) Assessment tool → especially in (1) Diabetes (2) Preeclampsia (3) Intrauterine growth restriction (4) Spontaneous rupture of membranes (5) Multiple gestation (6) Postdates 2. Procedure for performing an NST a) Inpatient or outpatient 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Eat prior to, no smoking for 2 hours before exam c) Semi-Fowler’s position → small pillow under right hip d) FHR monitored by placement of electronic metal monitor (1) One or two belts (2) Second belt for tocodynamometer → detects uterine, fetal movement (3) Monitor for 20 to 40 minutes 3. Interpretation of the NST a) Negative (normal) (1) Two or more fetal heart accelerations within 20 min period, with or without discernible fetal movement (Figure 16–12, p. 336) b) Positive (1) Lacks sufficient FHR accelerations over 40 min period (Figure 16–13, p. 338) (2) Spontaneous decelerations → variable decelerations (a) If nonrepetitive and brief → does not indicate fetal compromise (b) Repetitive variable decelerations (3+ in 20 minutes) → associated with increased risk of cesarean for fetal intolerance (3) Deceleration lasting 1 minute or longer → ominous (4) Responsibility of nurse performing test to contact physician, midwife regarding reactivity 4. Clinical application a) Reactive after 20 minutes → concluded (1) Next test scheduled as indicated (2) One to two times weekly 5. Nursing Management for the Woman Undergoing a Nonstress Test a) Assess woman’s understanding of NST b) Review indications for NST c) Maternal blood pressure monitored during test d) Report findings to healthcare provider

D. Contraction Stress Test 1. Means of evaluating respiratory function of placenta 2. Identify fetus at risk of intrauterine asphyxia 3. In many areas, CST given way to biophysical profile 4. CST procedure a) Necessary component of CST → uterine contractions b) Spontaneous contractions or induced (1) Breast stimulation → produces oxytocin (2) Intravenous (IV) oxytocin c) Electronic fetal monitor → uterine activity and FHR recorded d) 15 minutes → baseline 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) If three spontaneous contractions of good quality and lasting 40 to 60 seconds occur in a 10-minute window, the results are evaluated, and the test is concluded f) If not, after baseline → intravenous oxytocin CST or breast self-stimulation test g) Conducted only in setting where tocolytic medications are available 5. Interpretation of CST results a) Negative → three contractions of good quality lasting 40 or more seconds in 10 minutes without evidence of late decelerations (Figure 16–14, p. 339) b) Positive → repetitive persistent late decelerations with more than 50% of the contractions (Figure 16–15, p. 339) (1) Not a desired result (2) Hypoxic stress of the uterine contraction causes a slowing of the FHR (3) Pattern will not improve and will most likely get worse with additional contractions c) Equivocal or suspicious (1) Has nonpersistent late decelerations (2) Decelerations associated with tachysystole (contraction frequency of every 2 minutes or duration lasting longer than 90 seconds) (3) More information is needed 6. Clinical application a) Negative CST with reactive NST desired result b) Placenta is functioning normally c) Fetal oxygenation is adequate (1) Fetus will probably be able to withstand stress of labor d) Positive CST with nonreactive NST → fetus would probably not withstand stress of labor

E. Amniotic Fluid Index 1. Based on rationale that decreased uteroplacental perfusion → diminished fetal renal blood flow, decreased urination, ultimately oligohydramnios 2. AFI of 5 or less requires further assessment (oligohydramnios)

F. Biophysical Profile 1. BPP assesses five criteria a) FHR acceleration b) Fetal breathing c) Fetal movements d) Fetal tone e) Amniotic fluid volume

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. FHR assessed with NST 3. Other assessment → ultrasound 4. Combination identifies compromised or healthy fetus 5. Indications a) Situations in which NST or CST would be done b) Decreased fetal movement c) Management of other conditions 6. Most important components: NST, AFI a) See Table 16–4: Criteria for Normal and Abnormal Assessments of the BPP, p. 341 (1) Fetal breathing → 30 seconds within 30 minutes (2) Gross body movements → greater than or equal to discrete body, limb movements in 30 minutes (3) Fetal tone → extension/flexion of extremity, opening or closing of hand (4) Reactive FHA and NST → ≥2 accelerations ≥15 sec in 20 to 40 minutes (5) Amniotic fluid volume > 5 cm (6) Each normal variable assigned score of 2, abnormal 0 (7) FHR most sensitive to hypoxia (8) Total possible score 10 (9) See Table 16–5: Biophysical Profile Test Interpretation and Recommended Management, p. 341 (a) 10/10 → normal → no intervention, repeat weekly (diabetics, postterm → twice weekly) (b) 8/10 (normal fluid), 8/8 with no NST → no intervention, repeat weekly (diabetics, postterm → twice weekly) (c) 8/10 (abnormal fluid) → induce birth (d) 6/10 → induce birth (i) If repeat test 6 or less → induce (ii) If repeat test above 6, observe, repeat per protocol (e) 4/10 → repeat same day, if less than 6 induce birth (f) 2/10 → induce birth (g) 0/10 → induce birth

G. Modified Biophysical Profile 1. Labor intensive, expensive 2. NST plus AFI 3. Considered normal if amniotic fluid volume >5 cm, NST reactive

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Determine placental function and velocity of blood flow in vessels c) Analyze wave form of signal (1) Highest peak is systolic (2) Lowest point is diastolic (3) Most common evaluation of blood flow velocity → systolic/diastolic ration (S/D) (a) Normally decreases as pregnancy nears term (b) Decrease in fetal cardiac output, increase in resistance of placental vessels → reduced umbilical artery blood flow (i) Use when intrauterine growth restriction diagnosed (cerebroplacental ratio) (ii) Hypertension (iii) Preeclampsia

I. Evaluation of Placental Maturity 1. Grading process 2. 0 through III, III → mature, extensive calcifications 3. Factors that cause placenta to mature a) Smoking, postterm pregnancy, and certain maternal conditions, such as preeclampsia and gestational diabetes 4. See Figure 16–18: Placental grading, p. 343

J. Estimation of Fetal Weight 1. Intrauterine growth restriction (IUGR) a) Fetus that falls below 10th percentile in ultrasonic estimation of weight at given gestational age b) Etiology (1) Fetoplacental (2) Maternal c) Management includes careful surveillance of fetus 2. Macrosomia a) Excessive fetal growth b) Weight greater than 4000 to 4500 g (8 1b 13 oz to 9 1b 4 oz) c) Carefully manage labor and birth → prevent complications (1) Shoulder dystocia d) Diagnosis imprecise (1) Leopold maneuver (2) Measuring fundal height (3) Combined estimation e) Greatest risk → shoulder dystocia (1) Mother in McRoberts position, stool available for suprapubic pressure (2) Trial of labor (TOL) after previous cesarean birth → increased risk

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Other Diagnostic Tests

A. Birth defects 1. Structural abnormalities present at birth 2. 1 in 33 infants in United States, 1 in 5 infant deaths annually 3. Biochemical markers, ultrasound → prenatal diagnosis

B. Maternal Serum Alpha-Fetoprotein 1. Alpha-fetoprotein (AFP) Fetal protein excreted from fetal yolk sac during first 6 weeks 2. Quadruple Check a) MSAFP component of quadruple check b) Alpha-fetoprotein (AFP), hCG, diametric inhibin-A, estriol c) Screens for neural tube defect (NTD), trisomy 21 and 18 d) 15 to 22 weeks e) Universal screening for all women (1) 90% of NTD cases in women with no risk factors (2) Risk factors include previous fetus with an NTD, maternal age less than 20 or greater than 35 years, primiparity or grandmultiparity, low socioeconomic status with nutritional deficiencies, English or Irish ancestry, and inadequate folic acid intake f) MSAFP first marker in quadruple check (1) 2 to 2.5 multiples of the mean (MoM) of AFP → high (2) 90% detection rate (3) Majority of elevated MSAFP → fetus not affected (a) In 90 to 95% of the group with an elevated MSAFP, the elevation is caused by other variables, such as incorrect gestational age, more than one fetus, other fetal anomalies such as gastroschisis (a hole in the abdominal wall that allows the abdominal contents to protrude outside the body), or fetal death g) Quadruple screen (1) Trisomy 21 (Down syndrome) → most common live-birth chromosomal abnormality (2) Trisomy 18 → death of infant within first year of life h) Abnormal test → reported as a calculated Down syndrome risk (1) Patient education, counseling (2) MSAFP, quadruple check not diagnostic tests → screening (3) Ethical issues

C. Amniocentesis 1. Used for genetic diagnosis a) Sterile needle under ultrasound guidance inserted into uterine cavity through maternal abdomen b) Small amount of amniotic fluid removed c) Ideally done at 15–16 weeks’ gestation 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Chromosomal and biochemical determinations early in pregnancy, at 30–39 weeks lung maturity studies 2. Indications a) Pregnant woman will be 35 or older on due date b) Couples who have had child with birth defect c) Pregnant women with other abnormal screening or genetic test results 3. Procedure a) Outpatient (1) Near birthing area b) Abdomen scanned by ultrasound → locate placenta, fetus, adequate pocket of fluid (1) Need to avoid fetus, placenta, umbilical cord, bladder, uterine arteries c) Skin cleansed with povidone-iodine d) 22-gauge spinal needle inserted into uterine cavity (1) First few drops discarded → syringe to aspirate e) 15 to 20 mL amniotic fluid f) Fluid put into appropriate test tubes g) Needle withdrawn using ultrasound h) Fluid contaminated with blood → centrifuge immediately i) Monitor FHR for 20–30 minutes afterward j) See Figure 16–20: During amniocentesis, amniotic fluid is aspirated into a syringe, p. 346 4. Risks/side effects a) Minor b) Transient vaginal spotting, cramping, amniotic fluid leakage, chorioamnionitis c) Needle injuries rare with ultrasound use d) Early amniocentesis (< 14 weeks) → higher rate of loss, complications 5. Nursing Management for the Woman Undergoing Amniocentesis a) Assists physician b) Supports woman

D. Chorionic Villus Sampling 1. CVS is procedure to detect genetic, metabolic, and DNA abnormalities a) Small sampling of chorionic villi from edge of developing placenta b) First-trimester diagnosis after 9 completed weeks c) Cannot detect neural tube defects 2. Risks and Benefits of CVS a) Risks (1) Spontaneous abortion (0.22%—double amniocentesis risk) (2) Fetal limb reduction defects especially when performed before 9 completed weeks (3) Failure to obtain tissue (4) Rupture of membranes (5) Leakage of amniotic fluid 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(6) Vaginal spotting or bleeding (7) Chorioamnionitis (8) Intrauterine infection (9) Maternal tissue contamination (10) Oromandibular defects (11) Rh isoimmunization b) Benefits (1) Earlier diagnosis (a) Detect fetal karyotype, hemoglobinopathies (e.g., sickle cell disease and alpha and some beta thalassemias), phenylketonuria, alpha antitrypsin deficiency, Down syndrome, Duchenne muscular dystrophy, factor IX deficiency (2) Decreased waiting time for results 3. Procedure for CVS a) Ultrasound to determine placental location, uterine position b) After counseling regarding diagnosis, procedure c) Full bladder d) Transcervical CVS → lithotomy position (1) Vulva cleansed with povidone-iodine solution (2) Sterile speculum inserted into vagina (3) Vaginal vault and cervix cleanse to decrease contamination (4) Catheter/cannula slowly inserted under ultrasound guidance (5) Obturator withdrawn (6) 30-mL syringe aspirated e) Transabdominal sampling → supine position (1) Skin cleansed (2) Local anesthesia (3) 18- to 20-gauge needle inserted through abdominal wall, uterine myometrium (4) Tip of needle advanced into long axis of chorion frondosum under ultrasound guidance (5) Repeated rapid aspirations of syringe containing culture medium, heparin f) Normal CVS result indicating normal chromosomal configuration in first trimester (1) Does not ensure healthy infant

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Nursing Management for the Woman Undergoing CVS 1. Assess understanding of CVS, procedure, results 2. Support 3. Education

F. Fetal Fibronectin 1. fFN → glycoprotein produced by trophoblast, other fetal tissues 2. Absence of cervicovaginal fFN between 20 and 34 weeks → strong predictor of not experiencing premature labor or premature rupture of membranes 3. Negative predictive value is 99.5% but positive findings only 12.7% 4. No longer recommended by ACOG

G. Evaluation of Fetal Lung Maturity 1. Possibility of inducing birth of woman and fetus at risk if preterm a) Repeat cesarean birth, premature rupture of membranes, diabetes, hypertensive conditions, placental insufficiency b) Prematurity most common cause perinatal mortality, especially neonates weighing < 1000 g c) Need to determine lung maturation of fetus by amniotic fluid analysis (1) Typically at < 32 weeks’ gestation 2. Lecithin/sphingomyelin (L/S) ratio a) Alveoli of lungs lined with surfactant b) Fetal lung maturity can be assessed → determining ratio of two components of surfactant → L/S ratio (1) 30 to 32 weeks amounts of two substances becomes equal (2) Concentration of lecithin begins to exceed sphingomyelin → 35 weeks L/S ratio 2:1 (3) Ratio two times → respiratory distress syndrome (RDS) unlikely (4) Infants of diabetic mothers → lung maturation can be delayed (5) Infants of mothers with nonhypertensive renal disease, isoimmunization → delay lung maturation c) Chronic intrauterine fetal stress → acceleration of lung maturation in fetus (1) Premature rupture of membranes (> 24 hr) d) Cumbersome, labor intensive method of testing 3. Phosphatidylglycerol a) Phosphatidylglycerol (PG) second most abundant phospholipid in surfactant (1) Appears after 35 weeks’ gestation b) Presence of PG associated with low-risk RDS c) Absence of PG associated with development of RDS d) Combination of L/S ratio and PG 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Useful in blood contaminated specimens 4. Lamellar body counts a) Lamellar body counts (LBCs)-Concentrated phospholipids produced by type II alveoli cells b) Representative of stored surfactant c) Amniotic fluid LBC < 15,000/mcl → indicate fetal lung maturity and increased risk of RDS d) Values > 30,000 mcL and < 50,000 mcL, L/S ratio testing may be performed to ensure accuracy in determining fetal lung maturity status e) Foam stability index (FSI) is a measure that assesses total surfactant activity (1) 47 are positive → fetal lung maturity

H. Nursing Management for the Woman Undergoing Testing for Fetal Lung Maturity 1. Premature rupture of membranes → specimen obtained for analysis 2. Assists in gathering supplies 3. Positioning for speculum exam in lithotomy

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students prepare a teaching plan for the procedure of their choice. The teaching plans should include strategies for different types of learning needs. 2. Small Group Divide the class into small groups of three to five students. Have each groups observe nonstress testing at an antenatal testing center and write a short evaluation of the nursing process observed. 3. Large Group Role-play teaching scenarios for the patient undergoing the following procedures: • Ultrasound • Fetal activity • Nonstress test (NST)—nonreactive, reactive • Contraction stress test • Biophysical profile (BPP) • Amniocentesis • Chorionic villus sampling (CVS) • Percutaneous umbilical blood sampling (PUBS) • Nuchal testing

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 17 Pregnancy at Risk: Pregestational Problems Care of the Woman with Diabetes Mellitus..........................................................

Care of the Woman with Anemia..........................................................................

Care of the Pregnant Woman with Substance Abuse……………………………………….

Care of the Woman with a Psychologic Disorder………………………………………………

Care of the Woman with HIV.................................................................................

Care of the Woman with Heart Disease................................................................

Other Medical Conditions and Pregnancy…………..................................................

Focus Your Study....................................................................................................

Activities.................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman with Diabetes Mellitus

A. Normal Glucose Homeostasis 1. After meal → body metabolizes carbohydrates into glucose a) Insulin lowers blood glucose levels → enables glucose to move from blood into muscle, liver cells

B. Carbohydrate Metabolism in Normal Pregnancy 1. Early pregnancy → hormones stimulate maternal insulin production 2. Second half of pregnancy → prolonged hyperglycemia, hyperinsulinemia following meal a) Increased maternal peripheral resistance to insulin → sustained supply of glucose for fetus (1) Catabolic state during fasting → maternal fat metabolized → ketones may be present in urine 3. Balance between glucose production/use stressed by growing fetus (diabetogenic effect of pregnancy) → any diabetic potential may precipitate gestational diabetes mellitus

C. Pathophysiology of Diabetes Mellitus 1. Pancreas does not produce sufficient amounts of insulin for necessary carbohydrate metabolism and/or there is a diminished tissue response to insulin 2. Body cells energy depleted → fats and proteins used as source of energy 3. High level of glucose in blood eventually spills into urine 4. Four cardinal signs and symptoms a) Polyuria (frequent urination) b) Polydipsia (excessive thirst) c) Weight loss d) Polyphagia (excessive hunger)

D. Classification of Diabetes Mellitus 1. Type 1 diabetes 2. Type 2 diabetes 3. Gestational diabetes mellitus 4. Other specific types → genetic defects, drug-induced diabetes, endocrine disorders, and other causes 5. Gestational diabetes mellitus (GDM) → glucose intolerance of variable severity a) Onset or first recognition during pregnancy b) Even if only mild diabetes increases risk of perinatal morbidity and mortality 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Influence of Pregnancy on Diabetes 1. Physiologic changes of pregnancy drastically alter insulin requirements 2. Accelerate progress of vascular disease 3. More difficult to control during pregnancy a) Insulin requirements changeable (1) Decrease early in first trimester (2) May double or quadruple by end of pregnancy (3) Increased energy needs during labor (4) After delivery of placenta → insulin requirements decrease abruptly b) Nausea and vomiting may cause dietary fluctuations (1) Increase risk of hypoglycemia c) Other factors (1) Renal threshold for glucose decreases (2) Increased risk of ketoacidosis (3) Vascular disease (4) Hypertension (5) Nephropathy (6) Retinopathy (7) Increased energy needs during labor→ may need more insulin to balance IV glucose (8) Delivery of placenta→ abrupt decrease in insulin requirements

F. Influence of Diabetes on Pregnancy Outcome 1. Higher risk of complications → perinatal mortality, congenital anomalies 2. Maternal risks a) Hydramnios b) Preeclampsia-eclampsia c) Hyperglycemia → leads to ketoacidosis d) Dystopia → fetopelvic disproportion with fetal macrosomia e) Monilial vaginitis, urinary tract infections f) Worsening retinopathy 3. Fetal-neonatal risks a) Congenital anomalies (1) Heart (2) Central nervous system (CNS) (3) Skeletal system (4) Large for gestational age (LGA) → result of high levels of fetal insulin production (a) Macrosomia, deposition of fat (5) After umbilical cord severed → risk for hypoglycemia (6) Interuterine growth restriction (IUGR) → infants of mothers with diabetes with vascular involvement (7) Respiratory distress syndrome (RDS) 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

G. Clinical Therapy 1. Detection and diagnosis of gestational diabetes a) More common than pregestational diabetes b) All pregnant women should have risk assessed at first prenatal visit (1) High risk (a) Non-Caucasian (b) Prior history of GDM or birth of LGA infant (c) Marked obesity (d) Diagnosis of polycystic ovarian syndrome (e) Hypertension (f) Presence of glycosuria (g) Strong family history of type 2 diabetes mellitus c) Two-step approach (1) Recommended by National Institutes of Health (NIH) Consensus Conference and ACOG (2) Step 1: Non-fasting, 50-g, 1-hour OGTT (3) Step 2: 100-g, 3-hour OGTT (4) Gestational diabetes diagnosed if two or more of the following values are met or exceeded: (a) Fasting: 95 mg/dL (b) 1 hour: 180 mg/dL (c) 2 hours: 155 mg/dL (d) 3 hours: 140 mg/dL d) One-step approach (1) Recommended by International Association of Diabetes and Pregnancy Study Groups (2) In the morning, following an overnight fast, 75-g oral glucose solution (3) Gestational diabetes diagnosed if any one of these values are equaled or exceeded in plasma glucose levels (a) Fasting: 92 mg/dL (b) 1 hour: 180 mg/dL (c) 2 hours: 153 mg/dL 2. Laboratory assessment of long-term glucose control a) Glycosylated hemoglobin (HbA1c ) → loosely reflects glucose control over previous 4 to 8 weeks b) Measures percentage of glycohemoglobin in the blood c) Women with known pregestational diabetes → abnormal HbA1c correlates directly with frequency of spontaneous abortion, fetal congenital anomalies d) Target level → less than 6%

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

H. Antepartum Management of Diabetes Mellitus 1. Major goals a) Maintain physiologic equilibrium of insulin availability, glucose utilization b) Ensure optimally healthy mother, newborn 2. Team approach a) Education of woman and her partner → active involvement of managing her care b) Diagnosis may be shocking and upsetting c) Interventions (1) Counseling, preconception counseling if pregestational diabetic (2) Careful dating of pregnancy (3) Diet therapy and regular exercise 3. Dietary regulation a) Pregnant woman → additional 300 kcal/day (1) 30 kcal/kg of ideal body weight (IBW) → first trimester (2) 35 to 36 kcal/kg IBW→ second and third trimesters (3) 33 to 40% from complex carbohydrates (4) 20% from protein (5) 40% from fats (6) Divide calories/food among three meals, 2–3 snacks b) Dietitian works out meal plans (1) Lifestyle, culture, food preferences (2) Teaches food exchanges 4. Glucose monitoring a) Essential part of diabetes management → determining need for insulin, assessing glucose control b) Office visits for weekly assessment of fasting glucose levels & one or two postprandial levels. 5. Insulin administration a) Need for additional insulin depends on control of blood glucose levels with diet alone b) Pregestational diabetic, type 1 diabetic → requires insulin c) Semi-synthetic human insulin or insulin analog should be used d) Multiple injections or continuous subcutaneous infusion (1) Three-dose approach e) Certain oral hypoglycemic agents may be safe to use but do cross placenta 6. Evaluation of fetal status a) See Key Facts to Remember: Fetal Surveillance by Weeks of Gestation, p. 357 (1) 8–10: Ultrasound crown–rump measurement for estimated date of birth (EDB) (2) 16–18: Maternal serum alpha fetoprotein (3) 18–20: Targeted ultrasound examination (4) 20–22: Fetal echocardiogram 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) 24: Begin ultrasounds for assessment of fetus and fetal growth (6) 28: Ultrasound for growth; begin daily fetal movement counting (7) 32: Ultrasound for growth (8) 32: Twice-weekly nonstress tests; fetal surveillance should be initiated earlier in pregnancies complicated by IUGR, hypertension, nephropathy, ketoacidosis, pyelonephritis, preeclampsia, and poor compliance (9) 36: Ultrasound for growth (10) 37–39: Consider birth if there is poor compliance or clinical concern for fetal wellbeing (11) 39: Childbirth

I. Intrapartum Management of Diabetes Mellitus 1. Medical therapy includes a) Timing of birth (1) Most allowed to go to term (2) Induction before 39 weeks if nonreassuring fetal status or worsening HTN (3) If fetal weight estimate >4500 g, counsel on risks and benefits of schedule cesarean birth b) Labor management (1) Maternal prenatal and laboring euglycemia → important in preventing neonatal hypoglycemia (2) Every 1–2 hours measure serum glucose (3) No long-acting insulin, only regular (4) Two IV lines → saline for IV insulin in one, 5% dextrose in other

J. Postpartum Management of Diabetes Mellitus 1. Maternal insulin requirements fall significantly postpartum a) Levels of hPL, progesterone, estrogen → fall after placental separation b) Mother with preexisting diabetes may require little or no insulin; managed on sliding scale c) Women with GDM seldom need insulin during postpartum period d) Antihyperglycemic agents contraindicated during breastfeeding e) Reassess at 12 weeks postpartum f) Breastfeeding encouraged → insulin requirements decrease should consider prenursing snack 2. Diabetic control and establishment of parent–child relationships priorities a) Newborn in special care nursery → effort to provide parental/newborn contact b) Family planning information (1) Barrier and LARCs versus combined oral contraceptives (COCs)

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

K. Nursing Management for the Woman with Diabetes Mellitus or Gestational Diabetes Mellitus 1. Nursing Assessment and Diagnosis a) Assessment of disease process, woman’s understanding (1) Physical exam, lab work at first prenatal visit (2) Twice monthly during first two trimesters (3) Weekly during last trimester (4) Assessment of woman’s ability to cope and follow regimen of care b) Diagnoses that may apply (1) Overweight, Risk for (2) Injury, Risk for (3) Family Processes, Interrupted 2. Nursing Plan and Implementation a) Prepregnancy counseling (1) Culturally sensitive approach (2) Team approach b) Community-based nursing care (1) May be hospital initially → stabilize (2) Majority of ongoing teaching and supervision → outpatient c) Effective insulin use (Figure 17–2, p. 361) (1) Nurse ensures couple understands (a) Purpose of insulin (b) Types of insulin (c) Number of doses (d) Correct procedure for administration (e) Insulin pump as appropriate (2) Monitoring blood sugar → appropriate levels, importance (a) Glucose meter (b) Tips about finger puncture (i) Spring-loaded devices available → easier (ii) Hanging arm down for 30 seconds increases blood flow to fingers (iii) Warming hands increases blood flow (iv) Sides of fingers (c) Record each blood sugar d) Planned exercise program (1) After meals (2) Monitor blood glucose levels (3) Wear diabetic identification (4) Carry a simple sugar (5) Avoid injecting insulin into extremity to be used soon during exercise (6) Begin gradually (7) If not exercising regularly, encourage to start 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Health promotion education (1) Glucose monitoring (a) Home glucose monitoring accurate and convenient (b) Four times/day (2) Symptoms of abnormal blood glucose levels (a) Hypoglycemia may develop fairly rapidly. Symptoms: sweating, periodic tingling, disorientation, shakiness, pallor, clammy skin, irritability, hunger, headache, blurred vision (b) Carry snack at all times (c) Fast sources of glucose at hand (d) Hyperglycemia, ketoacidosis → develop more slowly (i) More common during second half of pregnancy (ii) Symptoms: polyuria, polydipsia, dry mouth, fatigue, nausea, hot flushed skin, rapid deep breathing, abdominal cramps, acetone breath, headache, drowsiness, depressed reflexes, oliguria or anuria, stupor, coma (3) Smoking contraindicated (4) Travel: keep insulin at room temperature when traveling and kept with the traveler (5) Support groups (6) Cesarean birth risk increased f) Hospital-based nursing care (1) Evaluate blood glucose, adjust insulin dosages 3. Evaluation a) Woman able to discuss condition, possible impact b) Woman participates in developing healthcare regimen to meet needs → follows it throughout pregnancy c) Woman avoids developing hypoglycemia, hyperglycemia d) Woman gives birth to a health newborn e) Woman able to care for newborn

II.

Care of the Woman with Anemia

A. Hemoglobin less than 11 g/dL; indicates inadequate levels of hemoglobin 1. Race, altitude, smoking, nutrition, medications 2. Common anemias of pregnancy due to a) Insufficient hemoglobin production related to nutritional deficiency iron or folic acid (1) Hemoglobin destruction (sickle cell disease or thalassemia)

B. Iron Deficiency Anemia 1. Dietary iron needed to synthesize hemoglobin a) Most common medical complication of pregnancy b) Pregnant needs 1000 mg more iron intake during pregnancy c) Greatest need in second half of pregnancy 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Many women begin pregnancy slightly anemic → can rapidly become more severe 2. Maternal risks a) Asymptomatic → still more susceptible to infection, tire easily, increased chance of preeclampsia, bleeding (1) Blood loss not well tolerated (2) Healing may be delayed (3) Severe → cardiac failure 3. Fetal-neonatal risks a) Increased risk → low birth weight, prematurity, stillbirth, neonatal death b) Increased risk for developing iron deficiency during infancy 4. Clinical therapy a) Prevention first goal (1) Pregnant women → at least 30 mg supplements of iron daily starting at first prenatal visit (2) Iron-rich diet b) Anemia diagnosed → dosage increased to 60 to 120 mg/day of iron (1) If the woman remains anemic after 1 month of therapy, further evaluation is indicated (2) Twin pregnancy → larger dose (3) Large dose may cause vomiting, diarrhea, constipation → parenteral iron 5. Nursing Management for the Pregnant Woman with Anemia a) Nursing Assessment and Diagnosis (1) Main presenting symptom → fatigue (a) Nutritional history → poor dietary intake (b) Lab studies → hemoglobin (Hb) <11 g/dL, low serum ferritin levels (c) Possibly microcytic and hypochromic red blood cells (late finding) (2) Diagnoses include (a) Nutrition, Imbalanced: Less than Body Requirements, Risk for (b) Constipation b) Nursing Plan and Implementation (1) Education (a) Importance of iron-rich diet, iron supplements (b) Take iron tablets with vitamin C (c) Iron absorption is reduced by 40 to 50% if the tablets are taken with meals (d) Stool will turn black (e) Out of reach of children → may be fatal if ingested by young children c) Evaluation (1) Woman able to identify risks associated with iron deficiency anemia during pregnancy (2) Woman takes her iron supplements as recommended (3) Woman’s Hb levels remain normal, return to normal

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Folic Acid Deficiency Anemia 1. Most common cause of megaloblastic anemia during pregnancy a) Folic acid needed for DNA and RNA synthesis, cell duplication b) Inadequate intake associated with neural tube defects (NTDs) 2. Clinical therapy a) Diagnosis may be difficult b) Serum folate levels normally fall during pregnancy c) Prevent with daily supplement of 0.4 mg folate d) Iron deficiency anemia almost always coexists → iron supplements 3. Nursing Management for the Pregnant Woman with Folic Acid Deficiency Anemia a) Education → food sources of folic acid, cooking for preserving folic acid (1) Fresh leafy green vegetables, orange juice, other citrus fruits and juices, red meats, fish, poultry, legumes (2) All women of childbearing age should consume 0.4 mg folic acid daily

D. Sickle Cell Disease 1. SCD → recessive autosomal disorder in which normal adult hemoglobin (hemoglobin A [HbA]) abnormally formed a) African descent b) Occasionally Southeast Asian, Mediterranean origin c) Abnormal cells breakdown → causing anemia d) Homozygous for sickle cell gene → disease e) Heterozygous → carriers sickle cell trait (SCT) f) Hemoglobin S (HbS) causes RBCs to be sickle shaped (1) Low oxygenation → HbS semisolid, distorts RBC shape (2) Sickling (3) Diagnosed → hemoglobin electrophoresis 2. Maternal risks a) Sickle cell trait (SCT) mothers (1) Good prognosis for pregnancy → adequate nutrition, prenatal care (2) Increased risk → nephritis, bacteriuria, hematuria, tend to become anemic b) SCD (1) More risk (2) Low oxygen pressure → precipitate vaso-occlusive crisis (a) caused by high temperature, dehydration, infection, or acidosis (3) More often in second half of pregnancy (4) Maternal mortality rare (5) Complications include anemia requiring blood transfusion, infections, and emergency cesarean births. Acute chest syndrome, congestive heart failure, or acute renal failure may also occur

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Fetal-neonatal risks a) Incidence of fetal death decreased greatly in recent years (1) Fetal death is believed to be due to sickling attacks in the placenta b) Prematurity, IUGR associated with SCD 4. Clinical therapy a) Additional folic acid (4 mg/day) b) Treat maternal infection promptly → can trigger sickling and crisis c) Vaso-occlusive crisis → perinatal team in medical center d) Rehydration, oxygen, antibiotics, analgesics e) Monitoring fetal heart rate (FHR) f) Crisis during labor → same therapies, left lateral position maintained (1) May promote labor → oxytocic agents 5. Nursing Management for the Pregnant Woman with Sickle Cell Disease a) Nursing Assessment and Diagnosis (1) History → frequent illnesses, recurrent abdominal, joint pains, anemic (a) Diagnosis SCD confirmed by hemoglobin electrophoresis (b) Assess for infection (c) Fetal status assess during crisis → electronic fetal monitoring (d) Frequent vital signs, continuous FHR monitoring during labor (e) Blood available for transfusion (f) Oxygen (2) Diagnoses include (a) Pain, Acute (b) Knowledge, Readiness for Enhanced b) Nursing Plan and Implementation (1) Education → prevent sickle cell crisis, improve anemia, prevent infection (2) Genetic counseling if both partners SCT or SCD c) Evaluation (1) Woman able to describe condition, identify impact (2) Woman take appropriate healthcare measures to avoid sickle cell crisis (3) Woman gives birth to healthy infant (4) Woman and caregivers quickly identify and successfully manage any complications that arise

E. Thalassemia 1. Group of autosomal recessive disorders 2. Characterized by defect in synthesis of alpha or beta chains in hemoglobin molecule 3. Most often in persons from Greece, Italy, southern China (Mediterranean anemia and Cooley anemia) a) β-thalassemia frequently encountered in United States (1) Heterozygous → half beta chains formed normally → β-thalassemia minor or trait 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Minor anemia only symptom (3) Homozygous → β-thalassemia major → no symptoms in newborns for several months (a) Severe anemia → dependent on transfusions (b) Iron chelation therapy must be instituted after chronic transfusions to prevent liver & heart damage 4. Maternal–fetal-neonatal risks a) β-thalassemia minor → mild anemia, small red cells b) No iron therapy unless also deficient in iron c) β-thalassemia major → pregnancy rare d) If it occurs → severe anemia, needs transfusion therapy, risk for congestive heart failure e) Perinatologist 5. Clinical therapy a) Folic acid supplements, no iron supplements b) Transfusion, chelation therapy discontinued during pregnancy → lack of data on effect on fetus

III.

Care of the Pregnant Woman with a Substance Abuse Disorder

A. Perinatal substance abuse → highly variable 1. Women 15 to 44 years of age: 5.4% illicit drug users 2. See Table 17–1: Possible Effects of Selected Drugs of Abuse/Addiction on Fetus and Newborn, p. 367 a) Depressants → alcohol b) Narcotics → heroin, methadone c) Barbiturates → phenobarbital d) Tranquilizers → diazepam e) Antianxiety drugs → lithium f) Stimulants → amphetamines, cocaine, nicotine g) Psychotropics → PCP, marijuana 3. Frequently missed diagnosis a) Present late for prenatal care b) Challenges for clinicians c) May not voluntarily disclose addiction d) See Table 17–2: Possible Signs of Substance Abuse, p. 367 (1) History (a) Vague, unusual medical complaints (b) Family history of alcoholism, other addiction (c) History of childhood physical, sexual, emotional abuse (d) History of cirrhosis, pancreatitis, hepatitis, gastritis, sexually transmitted infections, unusual infections such as cellulitis, endocarditis

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(e) History of high-risk sexual behavior (f) Psychiatric history of treatment and/or hospitalization (2) Physical signs (a) Dilated or constricted pupils (b) Inflamed nasal mucosa (c) Evidence of needle “track marks” or abscesses (d) Poor nutritional status (e) Slurred speech or staggering gait (f) Odor of alcohol on breath (3) Behavioral signs (a) Memory lapses, mood swings, hallucinations (b) Pattern of frequently missed appointments (c) Frequent accidents, falls (d) Signs of depression, agitation, euphoria (e) Suicidal gestures

B. Alcohol 1. Central nervous system depressant and potent teratogen 2. 9.4% of pregnant women ages 15–44 reported using alcohol in past month, 2.3% reported binge drinking 3. Chronic abuse → undermines maternal health 4. Effects on fetus → fetal alcohol spectrum disorders (FASDs) a) Characteristic physical and mental abnormalities b) Expectant woman should avoid alcohol completely c) Nursing staff should be aware of manifestations of alcohol abuse → prepare for patient’s needs (1) Sedation with benzodiazepines (2) Seizure precautions (3) Intravenous (IV) fluid therapy for hydration (4) Thiamine replacement (5) Preparation for addicted newborn d) Breastfeeding not contraindicated (1) Alcohol secreted in breast milk

C. Cocaine/Crack 1. Acts on the nerve terminals to prevent reuptake of dopamine and norepinephrine 2. Results in vasoconstriction, tachycardia, and hypertension 3. Ingested three ways: snorting, smoking, IV injection a) Crack → freebase cocaine made of baking soda, water, cocaine paste → microwaved to form rock → smoked

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Quicker, more intense high c) More often seen in low-income areas, cheaper and more readily available form d) Euphoria lasts only about 30 minutes e) Irritability, depression, pessimism, fatigue, and a strong desire for more cocaine usually follow this profound euphoria and excitement 4. Difficult to identify cocaine user prenatally a) Subtle signs (including mood swings and appetite changes, and withdrawal symptoms such as depression, irritability, nausea, lack of motivation, and psychomotor changes) b) Adverse maternal effects (1) Seizures, hallucinations (2) Pulmonary edema (3) Respiratory failure (4) Cardiac problems 5. Increased incidence a) First trimester abortion b) Abruptio placentae c) Intrauterine growth restriction (IUGR) d) Preterm birth e) Stillbirth 6. Exposure of fetus to cocaine a) Intrauterine growth restriction (IUGR) b) Microcephaly c) Altered brain development d) Shorter body length e) Congenital anomalies f) Neurobehavioral abnormalities g) Exposed infants found to have more feeding difficulties 7. Newborns exposed a) Neurobehavioral disturbances b) Marked irritability c) Exaggerated startle reflex d) Labile emotions e) Increased risk of sudden infant death syndrome 8. Feeding a) Cocaine crosses into breast milk b) Cocaine-using mothers were found to be less flexible, less engaged, and less responsive to their babies’ feeding cues

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) smoking of any type—be it tobacco or marijuana— poses a risk during pregnancy and is best avoided

E. MDMA (Ecstasy) 1. “Club drugs” a) MDMA, Molly b) Flunitrazepam (Rohypnol) c) Gamma hydroxybutyrate (GHB) d) Ketamine hydrochloride e) Sometimes include phencyclidine (PCP) and lysergic acid diethylamide (LSD) 2. Adverse responses unpredictable a) Taken by mouth, effects last for about 3–6 hours b) Euphoria, feelings of empathy (“hug drug”) c) Clouded thinking, agitation, disturbed behavior, sweating, dry mouth, increased heart rate, muscle spasms, jaw clenching, hyperthermia d) Multiple doses (“stacking”) → hyperthermia, hyponatremia, hypertension, arrhythmias, kidney failure 3. Effects on fetus → preliminary research a) Delay on motor development at 4 months to 2 years of age

F. Prescription Opioids and Heroin 1. Opioid use disorder (OUD) increased dramatically in recent years, 0.9% of pregnant women between the ages of 15 and 44 misused opioids in the past month a) Includes prescribed medications and illicit substances like heroin 2. Central nervous system (CNS) depressant narcotic; addictive drug 3. Oral, IV, sniffed, smoked 4. Risks in pregnancy a) Preeclampsia-eclampsia b) Abnormal placenta implantation c) Premature rupture of membranes (PROM) d) Abruptio placentae e) Preterm labor f) Meconium staining 5. Fetal effects a) Preterm birth b) IUGR c) Withdrawal d) Meconium aspiration e) Fetal distress

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Heroin a) Illicit opioid b) Addictive c) Pregnancy if user high risk because of associated poor nutrition, iron deficiency anemia, and preeclampsia-eclampsia d) Users higher risk of STIs, HIV e) Fetus of woman addicted to heroin (1) Risk for preterm birth, IUGR, and withdrawal symptoms (NAS) after birth (2) NAS (a) Restlessness; lack of habituation; shrill, high-pitched cry; irritability; fist sucking; vomiting; seizures (b) Signs of withdrawal usually appear within 72 hours and may last for several days (3) Can interfere with successful maternal-newborn attachment (4) Increase risk for parenting problems or abuse 7. Methadone as treatment for prescription and illicit drug use a) Blocks withdrawal symptoms and the craving b) Dosage should be individualized to achieve the most therapeutic level for the mother during pregnancy c) Crosses placenta, can lead to NAS d) Buprenorphine (1) May decrease severity of NAS (2) Newborns require less morphine and have a shorter hospital stay than babies born to mothers on methadone therapy

G. Clinical Therapy 1. Hospitalization for withdrawal, detoxification a) “Cold turkey” not recommended in pregnant women 2. Urine screening done regularly if woman suspected of abusing drugs 3. Informed consent before screening a) Review state laws

H. Nursing Management for the Pregnant Woman with Substance Abuse Disorders 1. Nursing Assessment and Diagnosis a) Screen all pregnant women for substance abuse (1) Screening tools (2) Clues in history, appearance (3) Direct questions (4) Focus on general health (5) Nutrition (6) Susceptibility to infections (7) Evaluation of body systems b) Diagnoses 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Nutrition, Imbalanced: Less Than Body Requirements (2) Infection, Risk for (3) Health Maintenance, Ineffective c) Nursing Plan and Implementation (1) Prevention ideal goal → education (2) Ongoing assessment, teaching (a) Provide care that is truly effective (b) Maintain a nonjudgmental, nonpunitive, positive attitude when caring (3) Review with woman what screen revealed → express concern for woman, unborn child (a) If possible, discuss strategies to help the woman quit (b) Suggest a referral for more in-depth assessment by a specialist (c) If feasible, make an appointment while the woman is in the office or clinic (d) Treatment options available for women who lack financial resources (e) Make a follow-up appointment to see the woman again after her drug or alcohol assessment (f) Establish a relationship of trust and support → woman’s cooperation may be gained (4) Preparation for labor and birth (5) Postpartum follow-up and referral (a) May include home visits (b) Coordinate community resources d) Evaluation (1) Woman able to describe impact of substance abuse on self and unborn child (2) Woman successfully gives birth to healthy infant (3) Woman agrees to cooperate with referral to social services for follow-up

IV.

Care of the Woman with a Psychologic Disorder A. Roughly 17.9% adults in United States 1. Characterized by alterations in thinking, mood, behavior

B. Maternal implications 1. Depression a) 1:7 women have perinatal depressive episode during pregnancy or 12 months postpartum (1) May be more likely to deliver preterm birth, small-for-gestational-age (SGA) infant, low-birth-weight (LBW) infant (2) Reduce woman’s ability to concentration or process information (3) Labor process may feel overwhelming b) Bipolar disorder → depressive, manic episodes (1) Depressive and manic episodes (2) Behaviors dangerous to herself or her fetus 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Hyperexcitable (4) May exhibit poor judgment c) Anxiety disorder (1) Panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD) (2) Wide range of symptoms d) Schizophrenia (1) Most disabling of psychologic disorders (2) Uncontrolled → difficulty managing emotions, interacting with healthcare team, thinking clearly (3) May be dramatically inappropriate, withdrawn (4) Difficult to treat schizophrenia in pregnant women because many of the medications are teratogenic, contraindicated (a) Risk for medication-related congenital malformations (5) Antipsychotics can cause cardiovascular defects

C. Clinical therapy 1. Support to a) Decrease anxiety b) Keep woman oriented to reality c) Promote optimal functioning while in labor d) Pharmacologic measures (1) Sedatives (2) Analgesics (3) Antianxiety medications (4) Determined on an individual basis following careful assessment 2. Nursing Management for the Pregnant Woman with a Psychologic Disorder a) Nursing Assessment and Diagnosis (1) Assess background (2) Knowledge of labor process (3) History of psychologic disorders (4) Alert for verbal, nonverbal responses to pain, anxiety (5) Recognize impact of fatigue, pain, or anxiety (6) Nursing diagnoses include (a) Anxiety (b) Fear (c) Coping, Ineffective b) Planning and implementation (1) Ensure environment free from excessive stimuli (2) Maintain consistency in care providers as possible (3) Encourage woman to identify, use coping mechanisms that work well for her (4) Identify, reduce source of distress if possible (5) Acknowledge fears, pain, other symptoms 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(6) Repeatedly orient woman to person, place, time (7) Offer methods to promote relaxation, comfort (8) Provide clear, succinct information about labor, medical procedures, environment, simple breathing exercises, relaxation techniques (9) Employ calm, caring, confident, nonjudgmental approach (10) Provide frequent attention and therapeutic interaction (11) May continue to have symptoms → medication, support c) Evaluation (1) Woman experiences decrease in physiologic, psychologic stress and increase in physiologic and psychologic comfort (2) Woman remains oriented to person, place, time (3) Woman uses effective coping mechanisms to manage her stress, anxiety in labor (4) Woman verbalizes feelings about her labor (5) Woman’s and family’s fear is decreased

Care of the Woman with HIV A. AIDS caused by human immunodeficiency virus (HIV) 1. Estimated 973,846 persons in United States living with HIV/AIDS in 2016 2. Estimated 2322 children < 13 years of age→ majority exposed perinatally 3. Pediatric cases declining → Centers for Disease Control (CDC) guidelines a) Universal counseling about risks of HIV transmission from mother to fetus b) Recommended opt-out HIV screening of all pregnant women during each pregnancy c) Repeat HIV testing in third trimester in areas with high HIV prevalence rates (1) HIV-negative individuals with high-risk behaviors (2) Individuals with unknown HIV status at the time of labor d) Immediate antiretroviral prophylaxis for HIV-positive pregnant women in labor and infants following birth

B. Pathophysiology of HIV/AIDS 1. Found in blood, semen, and vaginal fluid; breast milk implicated in disease transmission 2. Once infected with virus → develops detectable antibodies

C. Maternal Risks 1. Antiretroviral therapy (ART) increases life expectancy 2. Priorities a) Maintaining the health of the mother before, during, and after the pregnancy b) Preventing transmission to a potentially seronegative father c) Preventing mother-to-child transmission

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Women who have not had access to ART, noncompliant → AIDS-defining symptoms more common

D. Fetal-Neonatal Risks 1. HIV transmission can occur during pregnancy, breast milk 2. Majority of infections occur during labor and birth 3. HIV infected pregnant women → prophylactic ART, elective cesarean at 38 weeks before rupture of membranes, no breastfeeding → rate of transmission drops to 1% or less

E. Clinical Therapy 1. Treatment of the HIV-infected mother a) CDC screening guidelines → routine part of all prenatal care b) Initial testing c) Enzyme-linked immunosorbent assay (ELISA) (1) Confirmed with the Western blot test or immunofluorescence assay (IFA) d) Informed reproductive choice e) cART recommended to all infected pregnant women → reduce rate of perinatal transmission (1) Combination ART (a) Contains at least three drugs (b) Consistent with the principles of treatment for nonpregnant adults (2) ARV regimens include dual nucleoside reverse transcriptase inhibitor (NRTI) backbone that includes one or more NRTIs with high levels of transplacental passage (zidovudine, lamivudine, emtricitabine, tenofovir, or abacavir) f) Evaluate and treat for other STIs, common conditions occurring with HIV g) Assess regularly for serologic changes h) Monitor for early signs of complications (1) Weight loss (2) Fever i) Considered high-risk pregnancy (1) Increased risk for preterm birth, IUGR (2) Weekly NST after 32 weeks (3) Serial ultrasounds (4) Biophysical profiles (5) Invasive procedures avoided j) Scheduled cesarean birth indicated for women with HIV RNA levels >1000 copies/mL, and unknown levels k) Intrapartum care similar to that for all pregnant women (1) Strict universal precautions l) At risk for complications (1) Postpartum infection (2) Poor wound healing 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Infections of genitourinary tract m) Referred to physician knowledgeable about treating individuals with HIV infection

F. Nursing Management for the Pregnant Woman Who Is HIV Positive 1. Nursing Assessment and Diagnosis a) Woman who tests positive for HIV may be asymptomatic or present with symptoms (1) Fatigue, anemia, malaise, progressive weight loss, lymphadenopathy, night sweats, diarrhea, fever, neurologic dysfunction, cell-mediated immunodeficiency, and evidence of Kaposi sarcoma b) Tests positive or in relationship/activity that places her at high risk → assess knowledge level c) Nursing diagnoses include (1) Knowledge, Readiness for Enhanced (2) Infection, Risk for (3) Family Processes, Interrupted d) Nursing Plan and Implementation (1) Community-based nursing care (a) Help women understand that AIDS can be treatable disease (b) Education for women at risk (c) Discuss HIV testing during normal prenatal assessment (i) No testing without her knowledge, no written consent required (d) Nurse should assure woman of confidentiality (e) Nurse should provide environment that is private, comfortable, nonjudgmental (f) Nurse should provide woman with information about HIV/AIDS (g) Posttest counseling should be provided (h) If test results positive, offer supportive follow-up (i) Woman should not donate blood or share implements that could be contaminated with blood (j) Information can be overwhelming for woman who is HIV positive (i) Orally and in writing (k) Monitoring of asymptomatic HIV-positive pregnant woman (i) Explain HIV positive does not mean has AIDS (l) Education about nutrition, maintenance of wellness (2) Hospital-based nursing care (a) See Nursing Care Plan: The Woman with HIV Infection, p. 376 (b) Precautions with all patients → standard precautions e) Health promotion education (1) Psychologic implications of HIV/AIDS for childbearing family is staggering (a) May have decreased life expectancy (b) Provide complete, accurate information (2) Couple must deal with the impact of the illness on the partner (3) Comprehensive program: social services, psychologic support, appropriate health care

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Evaluation (1) Woman discusses implications of her positive HIV-antibody screen (2) Woman uses information about referral to social services for follow-up assistance, counseling (3) Woman begins to verbalize her feelings about her condition, implications

VI.

Care of the Woman with Heart Disease

A. Healthy woman with normal heart has adequate cardiac reserve for easy adjustment to pregnancy demands B. Cardiovascular diseases were the leading cause of pregnancy-related deaths in the United States from 2011 to 2013 (15.5%), followed by noncardiovascular diseases (14.5%), infection or sepsis (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%) C. Congenital Heart Defects 1. More common finding in pregnant women a) Seen are tetralogy of Fallot, atrial septal defect, ventricular septal defect, patent ductus arteriosus, and coarctation of the aorta 2. Exact pathology depends on specific defect

D. Rheumatic Heart Disease 1. Declined rapidly in last four decades 2. Develops in untreated streptococcal infections a) When heart affected → mitral valve stenosis, aortic insufficiency 3. Increased blood volume of pregnancy → stresses heart of woman with mitral valve stenosis

E. Mitral Valve Prolapse 1. MVP → usually asymptomatic condition commonly found in women of childbearing age 2. Midsystolic click and a late systolic murmur are heard 3. Women with MVP usually tolerate pregnancy well 4. Some women experience symptoms a) Palpitations, chest pain, dyspnea, which are usually due to arrhythmias

F. Marfan Syndrome 1. Autosomal dominant disorder of connective tissue a) Serious cardiovascular involvement → dissection or rupture of aorta

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Women with aortic roots greater than 40 mm → delay pregnancy until after repair or root replacement c) Aortic root less than 40 mm → better outcomes in pregnancy 2. Careful cardiovascular assessment, counseling → prognosis for pregnancy 3. 50% chance disease will be passed to offspring

G. Peripartum Cardiomyopathy 1. Dysfunction of left ventricle occurs in last month of pregnancy, first 5 months postpartum a) Rare but serious b) Mortality rate is as high as 25 to 50% c) Symptoms related to CHF (1) Dyspnea, orthopnea, chest pain, palpitations, weakness, edema d) Cause unknown e) Presentation → with anemia, infection f) Treatment → digitalis, diuretics, vasodilators, anticoagulants, sodium restriction, strict bedrest often part of treatment

H. Clinical Therapy 1. Primary goal is early diagnosis, ongoing treatment 2. Heart disease severity determined by functional capacity a) WHO-I → Low risk of maternal mortality and morbidity; limited cardiology follow-up required; includes conditions such as uncomplicated or mild pulmonary stenosis and successfully repaired simple lesions such as patent ductus arteriosus (PDA) b) WHO- II → Small increase in risk; includes conditions such as unoperated atrial septal defect (ASD), ventricular septal defect (VSD), repaired tetralogy of Fallot (TOF), and most arrhythmias c) WHO-III → Significantly increased risk requiring expert cardiac and obstetric care; includes conditions such as cyanotic heart disease, mechanical valves, systemic right ventricle, and other complex congenital heart disease d) WHO-IV → Very high risk of maternal mortality; pregnancy contraindicated; if pregnancy occurs, termination may be discussed; includes conditions such as pulmonary hypertension, severe mitral stenosis, severe symptomatic aortic stenosis, severe coarctation of the aorta e) Class I and II → normal pregnancy, few complications f) Class III and IV → at risk for more severe complications (1) Preconception counseling g) See Table 17–4: Severity of Heart Disease by Functional Category, p. 379 h) Anemia can increase work of heart → diagnose early i) Minimize cardiac workload, promote tissue perfusion 3. Drug therapy a) Additional drug therapy 23 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Antibiotic prophylaxis not indicated unless infection suspected c) Heparin for anticoagulant therapy (1) Does not cross placenta d) Thiazide diuretics, furosemide for CHF e) Digitalis glycosides, common antiarrhythmic drugs (1) Cross placenta → no reported teratogenic effect 4. Labor and childbirth a) Classes I and II → spontaneous natural labor with adequate pain relief b) Classes III and IV → hospitalized before onset of labor → cardiovascular stabilization c) Vaginal birth with low-dose regional analgesia → forceps, vacuum assistance → limit maternal pushing

I. Nursing Management for the Pregnant Woman with Heart Disease 1. Nursing Assessment and Diagnosis a) Note category of functional capacity assigned to woman at each visit b) Vital signs c) Identify, evaluate other factors that increase strain on heart d) Symptoms indicative of CHF (1) Cough (2) Dyspnea (3) Edema (4) Heart murmurs (5) Palpitations (6) Rales e) Diagnoses include (1) Cardiac Output, Decreased (2) Gas Exchange, Impaired (3) Fear 2. Nursing Plan and Implementation a) Antepartum period (1) Varies according to severity of the disease (2) Woman should thoroughly understand condition, management (3) Explains purposes of dietary, activity changes (4) 8 to 10 hours of sleep and frequent daily rest periods are essential (5) Woman seen every 2 weeks during first half of pregnancy (a) Assessments are especially important between weeks 28 and 30 (6) Weekly during second half of pregnancy b) Intrapartum period (1) Labor, birth exert tremendous stress on woman, fetus (a) Fatal to fetus if inadequate oxygen, blood supply (2) Nurse evaluates maternal vital signs frequently

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) A pulse rate >100 beats per minute or respirations > 24 per minute may indicate beginning cardiac decompensation, especially if accompanied by dyspnea, and require further evaluation (3) Encourage laboring woman to assume semi-Fowler position with lateral tilt, or sidelying position with head, shoulders elevated → ensure cardiac emptying, adequate oxygenation (a) Oxygen by mask, diuretics to reduce fluid retention, sedatives and analgesics, prophylactic antibiotics, and digitalis may also be used as indicated by the woman’s status (4) Remain with woman for support (5) Continuous electronic fetal monitoring c) Postpartum period (1) Significant changes → strain on heart, decompensation possible (2) Woman may remain in hospital longer than low-risk woman (a) Keep her in the semi-Fowler or side-lying position, with her head and shoulders elevated, and have her begin a gradual, progressive activity program (3) Nurse gives opportunity to discuss birth, deal with feelings, concerns (a) Provide opportunities to encourage maternal-newborn bonding (4) Only concern with lactation → related to medication (a) Nurse positions baby (5) Stress follow-up (6) Plan activity schedule that is gradual progressive, appropriate (7) Teaching 3. Evaluation a) Woman able to discuss condition and impact b) Woman participates in developing appropriate healthcare regimen c) Woman gives birth to healthy baby d) Woman does not develop congestive heart failure, thromboembolism, or infection e) Woman able to identify signs, symptoms of possible postpartum complications f) Woman able to care effectively for newborn infant

VII.

Other Medical Conditions and Pregnancy

A. Woman with preexisting medical condition should be aware of impact of pregnancy on condition B. See Table 17–5: Less Common Medical Conditions and Pregnancy, p. 381 1. Asthma a) Poor control associated with increased complications b) Prematurity, LBW more common 2. Epilepsy a) Majority of pregnancies uneventful; continue with medication b) Certain medications associated with increased incidence of congenital anomalies 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Hepatitis B a) Does not usually affect course of pregnancy b) Perinatal transmission most often occurs at, near childbirth (1) Infants infected perinatally highest risk of chronic infection if not treated 4. Hyperthyroidism (thyrotoxicosis) a) Mild hyperthyroidism not dangerous (1) Increased incidence of preeclampsia, postpartum hemorrhage if not controlled b) Neonatal thyrotoxicosis rare (1) Low doses of antithyroid drug may produce fetal/neonatal hypothyroidism 5. Hypothyroidism a) Long-term replacement therapy usually continues at same dosage during pregnancy b) Mother untreated → fetal loss high 6. Maternal phenylketonuria (PKU) (hyperphenylalaninemia) a) Low phenylalanine diet mandatory before conception, during pregnancy b) Risk if maternal treatment not begun preconception 7. Multiple sclerosis (MS) a) Relapse rate reduced during second, third trimester → increased during 3 months following birth b) Some evidence for slightly lower birth weight infants, genetic predisposition 8. Rheumatoid arthritis (RA) a) Usually remission during pregnancy with relapse postpartum (1) Extra rest b) Woman taking prednisone during pregnancy → give birth slightly earlier 9. Systemic lupus erythematosus (SLE) a) Active management with surveillance of blood pressure, proteinuria, placental blood flow b) Increased incidence of caesarean birth, postpartum hemorrhage, blood transfusion, prematurity, smaller babies, congenital heart block 10. Tuberculosis (TB) a) Complications may be higher (1) Treat with isoniazid, rifampin, ethambutol b) Maternal TB inactive → mother may breastfeed, care for infant (1) TB active → newborn should not have direct contact with mother until noninfectious

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VIII.

Focus Your Study

IX.

Activities 1. Individual Have students prepare a teaching plan for injecting insulin for the pregnant woman who is newly diagnosed with gestational diabetes mellitus. 2. Small Group Divide the class into small groups of three to five students. Assign each group a medical condition covered in this chapter. Have each group prepare a teaching plan for the assigned medical condition, including diet, medication, and family teaching, and instruct the groups to cite resources for their research. 3. Large Group Facilitate a class discussion on pregnancy and sexually transmitted infections, including HIV/AIDS and tuberculosis. Be sure to include the social stigma of these medical conditions and the emotional issues facing the pregnant family. Invite the class to role-play for possible scenarios during assessment, teaching sessions, and diagnosis discussions.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 18 Pregnancy at Risk: Gestational Onset Care of the Woman at Risk Because of Bleeding During Pregnancy.....................

Care of the Woman with Hyperemesis Gravidarum..............................................

Care of the Woman with a Hypertensive Disorder................................................

Care of the Woman with a Perinatal Infection Affecting the Fetus……………………

Care of the Woman Requiring Surgery During Pregnancy....................................

Care of the Woman Suffering Major Trauma ……………………………………………………

Care of the Pregnant Woman Experiencing Intimate Partner Violence………………

Care of the Woman at Risk for Rh Alloimmunization…………………………………………

Care of the Woman at Risk Due to ABO Incompatibility…………………………………….

Focus Your Study.....................................................................................................

Activities..................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman at Risk Because of Bleeding During Pregnancy

A. First and second trimesters 1. Abortion → pregnancy termination or loss prior to 20 weeks’ gestation or fetus weighing <500 g 2. Complications a) Bleeding in the first half of pregnancy (up to 20 weeks’ gestation) b) Ectopic pregnancy, gestational trophoblastic disease, and trauma c) Second half of pregnancy, particularly in the third trimester d) Placenta previa, abruptio placentae, trauma 3. See Table 18–1: Pregnancy-Related Bleeding by Trimester, p. 387

B. General Principles of Nursing Intervention 1. Vaginal bleeding relatively common during pregnancy a) Causes 2. Often nurse’s responsibility to make initial assessment a) Monitor blood pressure and pulse frequently b) Observe for indications of shock c) Count and weigh pads d) If pregnancy at 12 weeks or more → assess fetal heart tones with Doppler e) Prepare for intravenous (IV) therapy f) Obtain order to type and cross-match for blood g) Obtain an order for an obstetric ultrasound h) Prepare equipment for examination i) Have oxygen therapy available j) Collect and organize all data k) Assess coping mechanisms and support system of woman in crisis l) Assess family’s response to situation

C. Spontaneous Abortion (Miscarriage) 1. Describe both spontaneous and elective interruptions of a pregnancy 2. Many pregnancies end in first trimester (11 to 22%) a) Vaginal bleeding most common sign b) More than half related to chromosomal abnormalities c) Other causes d) Pathophysiology differs according to cause e) Spontaneous abortion can be extremely distressing (1) Chances for carrying next pregnancy to term still good (2) Following two to three consecutive losses → evaluate, candidates for genetic counseling 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Classification (see Table 18–2: Classification of Abortions and Defining Characteristics, p. 388) a) Clinically silent abortion, “silent miscarriage,” chemical pregnancy b) Early abortion c) Late abortion d) Elective abortion e) Therapeutic abortion (TAB) f) Spontaneous abortion g) Threatened abortion h) Inevitable or imminent abortion i) Complete abortion j) Incomplete abortion k) Missed abortion l) Empty sac (preferred term), anembryonic pregnancy, blighted ovum m) Recurrent pregnancy loss (RPL), formerly called habitual abortion n) Septic abortion 4. Clinical therapy a) Indicators (1) Pelvic cramping and backache (2) Vaginal bleeding occurs in one-quarter of first trimester pregnancies (a) Approximately half → miscarriage b) Evaluations (1) Speculum examination (2) Ultrasound scanning (3) Laboratory determination of hCG level c) Therapy prescribed (1) Bedrest (2) Abstinence from coitus (3) Persistent bleeding → hospitalization (a) IV therapy or blood transfusions (b) Dilation and curettage (D&C) or suction evacuation of products of conception (c) Rh negative → Rh immune globulin within 72 hours

D. Nursing Management for the Woman Experiencing Spontaneous Abortion 1. Nursing Assessment and Diagnosis a) Assessment (1) Amount, appearance of vaginal bleeding, vital signs, pain (2) Blood type, antibody status (3) Fetal heart rate (FHR) if 10 to 12 weeks’ gestation or more b) Diagnoses include (1) Childbearing Process, Ineffective (2) Fear (3) Fluid Volume: Risk for Deficient 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nursing plan and implementation a) Community-based nursing care (1) Evaluate as outpatient (2) Emotional support (3) Woman may feel ambivalence → guilt (4) Psychologic support → encourage verbalizing feelings (5) Referrals to help deal with loss (6) Physical pain may be more severe than couple anticipates b) Hospital-based nursing care (1) Suction D&C for incomplete or missed abortion (2) Rh immune globulin before discharge (3) Monitor physical status (4) Emotional support (5) Answer questions c) Health promotion education (1) Post D&C instructions (a) Someone should remain with her for first 12-24 hours (2) Referrals d) Evaluation (1) Woman able to explain spontaneous abortion, treatment measures, long-term implications (2) Woman suffers no complications (3) Woman and partner begin verbalizing grief

E. Pregnancy of Unknown Location 1. Pregnancy of unknown location (PUL) a) when a pregnant woman undergoes an ultrasound without a definitive finding of either an intrauterine pregnancy or an ectopic pregnancy b) Not a diagnosis, but is an interim finding (1) Every effort needs made to determine correct diagnosis

F. Ectopic Pregnancy 1. Implantation of fertilized ovum in site other than endometrial lining of uterus a) Ectopic pregnancy (EP), also called extrauterine pregnancy or tubal pregnancy b) Risk factors (1) Tubal damage caused by pelvic inflammatory disease (PID) from a sexually transmitted infection or mixed bacterial infection; previous pelvic or tubal surgery; endometriosis; previous ectopic pregnancy; presence of an intrauterine device (IUD); high levels of progesterone, which can alter the motility of the egg in the fallopian tube; congenital anomalies of the tube; use of ovulation-inducing drugs; primary infertility; smoking; advanced maternal age c) Symptoms (1) Begin between 6 and 8 weeks’ gestational age (after the last menstrual period) 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) 0.5 to 1.5% of pregnancies in US (3) Accounts for 3% of all pregnancy-related deaths d) Pathogenesis (1) See Figure 18–2: Various implantation sites in ectopic pregnancy, p. 391 (2) Normal symptoms of pregnancy may be present (3) Trophoblastic cells grow into adjacent tissues (4) Symptoms may not be obvious e) Internal hemorrhage (1) When embryo outgrows space → tube ruptures; bleeding into abdominal cavity (a) One-sided lower abdominal pain or diffuse lower abdominal pain and vasomotor disturbances such as fainting or dizziness (2) Slow → abdomen gradually rigid, tender (a) Adnexal tenderness or mass (3) Laboratory tests (a) β-hCG levels that do not rise as expected 2. Clinical therapy a) Differentiate from other disorders (1) Careful assessment of menstrual history, last menstrual period (LMP) (2) Careful pelvic exam → masses, tenderness (3) Laboratory testing (4) Transvaginal ultrasound (5) Serial measurements of serum hCG (6) Laparoscopy b) Confirmed (1) Therapy options (a) Medical management with methotrexate (i) Administered intramuscularly (IM), single dose, two dose, or multiple dose (ii) Monitor as outpatient for pain, hCG titers (b) Surgery (i) Preservation of tube if future pregnancy desired, tube not ruptured (ii) Assess risk for bleeding 3. Nursing Management for the Woman with an Ectopic Pregnancy a) Nursing Assessment and Diagnosis (1) Assess (a) Vaginal bleeding, vital signs (b) Emotional status, coping abilities (2) Diagnoses include (a) Childbearing Process, Ineffective (b) Fear (c) Pain, Acute (d) Fluid Volume: Risk for Deficient b) Nursing Plan and Implementation (1) Community-based nursing care 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Clinic office → alert to possibility if presents with abdominal pain, lack of menses for 1 to 2 months (b) Confirmed ectopic → methotrexate → education (i) Follow-up β-hCG testing (ii) Follow-up phone call between visits (iii) Nausea expected (iv) Severe pain → follow up warranted, treatment may have failed (2) Hospital-based nursing care (a) Surgery (i) IV, preoperative teaching (ii) Analgesics (3) Health promotion (a) Teaching (b) Emotional support c) Evaluation (1) Woman able to explain ectopic pregnancy, treatment alternatives, implications (2) Woman and caregivers detect possible complications early, manage appropriately (3) Woman and partner able to begin verbalizing loss

G. Gestational Trophoblastic Disease 1. Pathologic proliferation of trophoblastic cells a) Hydatidiform mole (molar pregnancy) (1) Proliferation of trophoblastic cells results in formation of an abnormal placenta characterized by hydropic grapelike clusters (a) Loss of pregnancy (b) Possibility of developing choriocarcinoma (c) Complete mole→ anuclear ovum that contains no maternal genetic material (i) Avascular hydropic vesicles (d) Partial mole → usually triploid karyotype (69 chromosomes) (i) Villi often vascularized (ii) Identifiable fetal parts may be present (2) 1 per 1000 to 1500 live births (3) Invasive mole → chorioadenoma destruens → involves uterine myometrium (4) Choriocarcinoma → invasive, malignant, trophoblastic disease, usually metastatic, can be fatal 2. Clinical therapy a) Signs (1) Vaginal bleeding (around fourth week)→ brownish to bright red (2) Anemia (3) Hydropic vesicles may be passed → diagnostic (4) Uterine enlargement greater than expected for gestational age (5) Absence of fetal heart sounds in presence of other signs of pregnancy (6) Markedly elevated serum hCG 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(7) Very low levels of maternal serum α-fetoprotein (MSAFP) (8) Hyperemesis gravidarum may occur (9) Preeclampsia may be seen, especially in second trimester b) Diagnosis (1) Transvaginal ultrasound c) Therapy (1) Suction evacuation and curettage of uterus (2) Early evacuation decreases complications (3) Rh immune globulin if mother Rh negative d) Complications (1) Anemia (2) Hyperthyroidism (3) Infection (4) Disseminated intravascular coagulation (DIC) (5) Trophoblastic embolization of lung (6) Ovarian cysts e) Risk of choriocarcinoma (1) Extensive follow-up care (2) Baseline chest X-ray and repeat (3) Weekly β-hCG until negative three times, monthly for 6 to 12 months (4) If hCG plateaus or rises or metastases detected; treat appropriately 3. Nursing Management for the Woman with Gestational Trophoblastic Disease a) Nursing Assessment and Diagnosis (1) Observe for symptoms at each antepartum visit (a) Monitor vital signs, vaginal bleeding (b) Assess pain (c) Assess emotional state (2) Diagnoses include (a) Childbearing Process, Ineffective (b) Fear (c) Knowledge, Readiness for Enhanced b) Nursing Plan and Implementation (1) Community-based nursing care (a) Emotional support (b) Education (2) Hospital-based nursing care (a) Education (b) Type and cross-match blood (c) Oxytocin (d) Monitor urine output; signs of bleeding, infection (e) Rh immune globulin if Rh negative (3) Health promotion education (a) Woman needs to know importance of follow-up visits for 1 year 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Delay becoming pregnant for 1 year c) Evaluation (1) Woman has smooth recovery following successful evacuation of molar pregnancy (2) Woman able to explain GTD (3) Woman and partner able to begin verbalizing grief (4) Woman able to discuss importance of follow-up

II.

Care of the Woman with Hyperemesis Gravidarum

A. Nausea and vomiting so severe → affects hydration, nutritional status 1. Temporarily disabling a) Psychologic impact b) Nulliparous, adolescents, multiple gestation, increased body weight, certain ethnic groups, pregnancies complicated by GTD or fetal abnormalities, mother or sister experienced hyperemesis, woman’s history of hyperemesis 2. Cause unclear a) hCG may play a role b) Other potential factors: displacement of the gastrointestinal tract, hypofunction of the anterior pituitary gland and adrenal cortex, abnormalities of the corpus luteum, psychologic factors 3. Pathology begins with dehydration a) Hypovolemia b) Fluid-electrolyte imbalance

B. Diagnostic criteria 1. Intractable vomiting, dehydration, ketonuria, weight loss of 5% of pregnancy weight

C. Clinical Therapy 1. Control vomiting, correct dehydration, restore electrolyte balance, maintain nutrition a) Avoid triggers b) Frequent small meals c) Carbonated or sour beverages d) Ginger e) Acupuncture or acupressure f) Hypnosis g) Pyridoxine first-line pharmacologic treatment (1) 10 to 25 mg orally three times daily, 25 mg at bedtime (2) Diclegis, Promethazine (Phenergan), metoclopramide (Reglan), ondansetron (Zofran) h) IV fluids as outpatient i) See Complementary Health Approaches: Hyperemesis, p. 395

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Diagnosis a) Ultrasound to rule out molar pregnancy 3. Nothing by mouth, IV fluids 4. Total parenteral nutrition if no response to above management a) Start oral feeding when condition improved

D. Nursing Management for the Woman with Hyperemesis Gravidarum 1. Nursing Assessment and Diagnosis a) Assess (1) Emesis (2) Intake and output (3) Fetal heart rate (4) Maternal vital signs (5) Initial weight (6) Evidence of jaundice or bleeding (7) Emotional state b) Diagnoses include (1) Nutrition, Imbalanced: Less Than Body Requirements (2) Fluid Volume: Deficient 2. Nursing Plan and Implementation a) Community-based nursing care (1) Evaluate family and lifestyle stressors (2) Discuss strategies b) Hospital-based nursing care (1) Supportive, directed at maintaining relaxed, quiet environment (2) Oral hygiene (3) Monitor weight (4) Psychotherapy c) Health promotion education (1) Review actions to prevent, decrease nausea 3. Evaluation a) Woman able to explain hyperemesis gravidarum b) Woman’s condition corrected, complications avoided

III.

Care of the Woman with a Hypertensive Disorder

A. Most common medical disorder in pregnancy (10%) B. Classifications (see Table 18–3: Hypertensive Disorders in Pregnancy, p. 397) 1. Preeclampsia and Eclampsia Syndrome a) Preeclampsia → 5% of all pregnancies in United States

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Syndrome that affects both mother and fetus (2) Increase in blood pressure after 20 weeks’ gestation accompanied by proteinuria in a previously normotensive woman b) Eclampsia → occurrence of a seizure in a woman with preeclampsia with no other cause for seizure 2. Pathophysiology of preeclampsia a) Eclampsia syndrome b) Impaired trophoblastic invasion and/or poor implantation (1) Abnormal immunologic response to paternal antigens (2) Imbalance in angiogenesis; an exaggerated systemic inflammatory response (3) Increased oxidative stress (4) Vascular endothelial dysfunction and coagulation abnormalities (5) Genetic propensity for the development of preeclampsia c) Key features (1) Failure of uterine spiral arteries to transform from thick-walled muscular vessels to saclike flaccid vessels (2) Loss of normal vasodilatation of uterine arterioles resulting in decreased placental perfusion (3) Systemic maternal vasospasm resulting in decreased perfusion to virtually all organs, including the placenta (Figure 18–5) (4) Decrease in plasma volume, activation of the coagulation cascade, and alterations in glomerular capillary endothelium (5) Increased sensitivity to pressor agents,imbalance between prostacyclin and thromboxane (6) Decreased NO production (7) Inappropriate endothelial-cell activation (8) Increased platelet activation can predate clinically evident disease (9) See Figure 18–5: Clinical manifestations and possible pathophysiology of preeclampsia-eclampsia, p. 399 (10) Women who develop preeclampsia more sensitive to pressor agents (a) Linked to ratio between prostaglandins (b) Prostacyclin-thromboxane (c) No effective intervention → low-dose aspirin results in modest risk reduction d) Risk factors e) First pregnancies (1) Adolescent pregnancies (2) Out-of-wedlock pregnancies (3) Conception with new partner (4) Paternal contribution (5) Other theories (a) Decreased renal perfusion associated with preeclampsia (i) Edema more profound than in normal pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Pathology→Higher salt retention draws out intravascular fluid→Plasma colloid osmotic pressure decreases → serum albumin loss 3. HELLP syndrome a) Hemolysis, elevated liver enzymes, low platelet count b) Associated with severe preeclampsia c) Usually manifests at 27–37 weeks’ gestation d) Hemolysis (1) Microangiopathic hemolytic anemia e) Blood flow obstructed in liver → hepatocellular injury→ hyperbilirubinemia and jaundice f) Symptoms (1) Nausea, vomiting, malaise, flulike symptoms, epigastric pain, swelling of liver (2) Misdiagnosis g) Require tertiary care center h) Maternal risks (1) Hypertensive disorders (2) Central nervous system (CNS) changes (3) Intracerebral hemorrhage rare → most common cause of death in women with severe preeclampsia and eclampsia (4) Acute tubular necrosis (5) Pulmonary edema (6) Thrombocytopenia (7) Subcapsular hematoma of liver rare (a) Rupture life-threatening event i) Fetal-neonatal risks (1) Small for gestational age (SGA) (2) Placental abruption (3) Prematurity (4) Oversedation due to medications used to treat j) Clinical manifestations and diagnosis k) Preeclampsia (1) After 20 weeks → blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic (a) Two occasions 6 hours apart (2) Proteinuria generally between 300 mg/L (1+) and 1 g/L (2+) (a) 24-hour urine protein >300 mg abnormal (3) Edema (a) Puffy face, hands, dependent areas such as the ankles and lower legs (b) Weight gain of more than 4 lb in a week l) Preeclampsia with severe features (1) Can develop rapidly (2) Blood pressure of 160/110 mm Hg or higher on two occasions 4-6 hours apart while woman on bedrest (a) Oliguria <500 mL in 24 hours (3) Cerebral or visual disturbances 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Pulmonary edema or cyanosis (5) Epigastric or right upper quadrant pain (6) Impaired liver function to at least twice normal (7) Thrombocytopenia (8) Intrauterine growth restrictions (9) Signs or symptoms (a) Severe headache (b) Blurred vision or scotomata (c) Narrow segments on retinal arterioles (d) Retinal edema (10) Dyspnea due to pulmonary edema (11) Pitting edema (12) Epigastric pain (13) Hyperreflexia (14) Nausea (15) Vomiting (16) Irritability (17) Emotional Tension (18) See Table 18–4: Signs and Symptoms of Worsening Preeclampsia, p. 401 m) Eclampsia (1) Convulsion or coma (2) Before onset of labor, during labor, early in postpartum period n) Clinical therapy (1) Goals are to prevent severe complications, birth of an uncompromised newborn as close to term as possible (2) Antepartum management (a) Cure = delivery of placenta (3) Home care of gestational hypertension and preeclampsia (a) Proteinuric preeclampsia → admitted to hospital (b) Management at home if: (i) BP ≤150/100 mm Hg, proteinuria less than 1 g/24 hours, platelet count greater than 120,000 mm3, normal fetal growth, no other complicating factors (ii) Must have understanding of condition (iii) Recognize signs, symptoms of worsening preeclampsia (iv) Be able to count fetal movements (c) Monitor blood pressure, weight, urine protein daily (d) Remote non-stress test on daily to biweekly basis (e) Nursing contact varies (f) Lab work o) Hospital care of gestation hypertension and preeclampsia (1) Bedrest, left lateral recumbent position (2) Diet well balanced and nutritious (3) Monitoring fetal well-being 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Fetal movement record (b) NST (c) Amniotic fluid index: normal is greater than 5 centimeters (d) Ultrasound at least every 2 to 4 weeks (e) Biophysical profile weekly (f) Amniocentesis to determine fetal lung maturity as necessary (g) Doppler velocimetry beginning 30 to 32 weeks (4) Monitoring maternal well-being (a) Blood pressure four times daily (b) Daily weight, evaluation for worsening edema, persistent headache, visual changes, epigastric pain (c) Daily urine dipstick for protein (d) Periodic assessment of laboratory values p) Hospital care of preeclampsia (1) Immediate hospitalization (2) Childbirth considered in all pregnant women who develop preeclampsia after 34 weeks’ gestation (3) Other therapies (a) Bedrest (b) Diet (c) Anticonvulsants (d) Corticosteroids (e) Fluid and electrolyte replacement (f) Antihypertensives (4) Therapeutic goal to maintain diastolic blood pressure between 90 and 100 mm Hg (a) Methyldopa → long-term control (b) Labetalol, hydralazine → IV bolus (i) Parenteral labetalol should be avoided in women with moderate to severe asthma, bradycardia, or congestive heart failure (c) Oral labetalol and nifedipine (d) Magnesium sulfate (e) Sodium nitroprusside in acute emergency q) Hospital care of eclampsia (1) Occurrence of either seizure of coma associated with pregnancy and not caused by other neurologic disease (2) Multifocal, focal, or generalized seizures (3) Nursing assessment includes (a) Time of onset (b) Progress of the seizure (c) Body involvement (d) Duration (e) Presence of incontinence (f) Status of the fetus (g) Signs of the placental abruption 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(h) Airway should be maintained (i) Oxygen administered during seizure (4) Treatment (a) Magnesium sulfate (i) Bolus of 4 to 6 g over 15 to 20 minutes in 100 ml of IV fluid (ii) 2 g/hour IV infusion (iii) Second seizure → additional bolus of 2 g (iv) Side effects (a) Loading dose: flushing, feeling of warmth, headache, nystagmus, nausea, dry mouth, dysphoria, dizziness (b) Lethargy, sluggishness, risk of pulmonary edema (v) Fetal side effects → hypotonia, lethargy, hypoglycemia, hypocalcemia (b) Antihypertensive agents (i) Used to keep diastolic blood pressure between 90 and 100 mm Hg (5) Fetal reaction to seizure → bradycardia, transient late decelerations, decreased variability, compensatory tachycardia (a) Stabilize mother → recover (b) If nonreassuring FHR for 10 to 15 minutes despite resuscitative efforts → consider birth (c) Nurse–patient ratio 1:1 (6) Nursing care (a) Frequent auscultation of maternal lungs (b) Watch for circulatory, renal failure and signs of cerebral hemorrhage (c) Administer meds as ordered (d) Indwelling catheter (e) May awaken confused, combative → family member (f) Environment (i) Avoid bright light, loud noises, and frequent disturbances (7) Uncontrolled hypertension → cerebral hemorrhage (a) Hydralazine, labetalol, nitroprusside r) Intrapartum management (1) Preeclampsia (a) Induction of labor by IV oxytocin (i) Cesarean birth if severe (b) Oxytocin and magnesium sulfate simultaneously (c) Narcotic for pain relief or regional anesthesia (d) Sims’ position for childbirth (i) Lithotomy with wedge under right buttock (e) Oxygen (2) Eclampsia (a) Intensive care unit until labor unless in tertiary care center (b) Invasive hemodynamic monitoring indications (i) Oliguria (ii) Severe cardiac disease 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(iii) Severe renal disease (iv) Pulmonary edema resulting in impaired maternal oxygenation (v) Refractory hypertension with administration of vasoactive drug (c) Stabilize mother → consider birth of fetus (3) Pediatrician, neonatologist, neonatal nurse practitioner → available to care for newborn at birth s) Postpartum management (1) Usually improves rapidly after childbirth (2) Magnesium sulfate → continue for 24 hours (3) Possibility of worsening condition (4) Monitor for 4–6 weeks (5) Blood pressure remains above 160/100 mm Hg for 2 to 3 days → antihypertensive therapy (6) Hypertension remaining past the 84th day postpartum is classified as chronic hypertension (7) Risk of recurrence dependent on several factors 4. Nursing Management for the Woman with Preeclampsia a) Nursing Assessment and Diagnosis (1) Essential part of assessment → baseline blood pressure early in pregnancy (a) Taken, recorded each antepartum visit (b) Elevation based on two determinations (i) Seated, standing (c) Use Korotkoff phase V to measure diastolic (d) Calibrate mercury sphygmomanometer (e) If using electronic device, use one validated for pregnancy (2) Hospitalization → assessment (a) Blood pressure every 1 to 4 hours (b) Temperature every 4 hour (c) Pulse and respirations with BP (d) Fetal heart rate monitoring continuously (e) Urinary output should be 700 mL or greater in 24 hours, or at least 30 mL per hour (f) Urine protein hourly if catheter or with each void (g) Urine specific gravity: readings over 1.040 correlate with oliguria and proteinuria (h) Edema (i) Weight (j) Pulmonary edema (k) Deep tendon reflexes in the brachial, wrist, patellar, or Achilles tendons (Table 18–5, p. 405) (l) Clonus (m) Placental separation (n) Headache (o) Visual disturbance 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(p) Epigastric pain (q) Laboratory blood tests (i) Hematocrit, BUN, creatinine, uric acid, clotting studies, liver enzymes, electrolytes (r) Level of consciousness (s) Emotional response and level of understanding (t) Assess effects of medications (3) Diagnoses include (a) Fluid Volume: Risk for Imbalanced (b) Injury, Risk for (c) Maternal/Fetal Dyad, Risk for Disturbed b) Nursing Plan and Implementation (1) Community-based nursing care (a) Woman has several major concerns (i) Identify and discuss concerns (ii) Refer couple to resources (b) Health promotion education (i) Woman knows which symptoms are significant and should be reported (ii) Seen once or twice a week; come in earlier if with symptoms (iii) Understands diet plan (2) Hospital-based nursing care (a) Increased concern → worsening prognosis (i) Honest, hopeful information (b) Quiet low-stimulus environment (c) Nursing management of eclampsia (i) Frightening to family (ii) Tonic phase → turn to side, head turned face down (iii) Padded side rails (iv) Oxygen, oral airway (v) Physician, anesthesiologist notified (vi) Apply pulse ox and obtain IV access if not already done (vii) Monitor fetal heart tones continuously (viii) Monitor maternal vitals every 5 minutes until stable, then every 15 minutes (d) Nursing management during labor and birth (i) Plan of care depends on maternal and fetal condition (ii) Position on side as much as possible (iii) Monitor woman and fetus throughout labor (iv) Second stage → push on side or with wedge under hip (v) Family member with woman as is possible (e) Nursing management during the postpartum period (i) Monitor bleeding, pulse, urine output (ii) Blood pressure and pulse checked every 4 hours (iii) Lab work daily (a) Intake and output for 48 hours 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(iv) Monitor for postpartum depression (v) Combined oral contraceptives → progesterone-only pills c) Evaluation (1) Woman able to explain preeclampsia, implications, treatment, possible complications (2) Woman suffers no eclamptic seizures (3) Woman and caregivers detect signs of increasing severity of preeclampsia, complications (4) Woman gives birth to healthy newborn

C. Chronic Hypertension 1. Blood pressure 140/90 mm Hg or higher before pregnancy, before 20th week, persists 12 or more weeks following childbirth a) Challenge to differentiate hypertension from preeclampsia b) Early prenatal care important → risks to fetus 2. Counseling at first visit a) Nutrition b) Bedrest c) Medication (1) Methyldopa or labetalol first choice in pregnancy if medication required (2) Angiotensin-converting enzyme (ACE) inhibitors contraindicated during second and third trimesters d) Prenatal visits e) Blood pressure monitoring f) Fetal surveillance 3. First visit a) Thorough examination 4. More frequent prenatal visits a) 24-hour urine tests, serum creatinine, uric acid, hematocrit, ultrasound examinations at least once in second and third trimesters

D. Chronic Hypertension with Superimposed Preeclampsia 1. Preeclampsia develops in approximately 25% of women with chronic hypertension a) Difficult to diagnose b) After 20 weeks’ gestation, onset of proteinuria and worsening hypertension suggestive of superimposed preeclampsia

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Gestational Hypertension 1. Transient elevation of blood pressure without proteinuria, preeclampsia 2. Diagnosis- final determination that the woman has gestational hypertension is made retrospectively in the postpartum period

IV.

Care of the Woman with a Perinatal Infection Affecting the Fetus A. Perinatal infections are most likely to cause harm when embryo exposed during first trimester B. TORCH infections C. Toxoplasmosis 1. Protozoan Toxoplasma gondii (T. gondii) a) Feces of infected cat b) Eating raw or undercooked meat c) Drinking unpasteurized goat’s milk 2. Fetal-neonatal risks a) First-trimester infection → severe fetal damage → spontaneous abortion b) Highest rate of fetal infection (60%) → third trimester (1) Half of these infants will develop signs, symptoms if left untreated (2) Mild cases (3) Severe infection (4) Can cause chorioretinitis (inflammation of the retina and choroid layer of the eye), disseminated purpuric rash, hepatosplenomegaly, ascites, fever, seizures, periventricular calcifications, microcephaly, ventriculomegaly (5) Survivors are often blind, deaf, severely neurodevelopmentally impaired 3. Clinical therapy a) Goal of medical treatment → identify at-risk woman, treat promptly (1) Serologic testing IgM and IgG (2) Maternal infection established → spiramycin to decrease frequency of fetal transmission (3) Not treat fetal infection (a) Pyrimethamine/sulfadiazine/folinic acid after first trimester 4. Nursing Management for the Pregnant Woman with Toxoplasmosis a) Nursing Assessment and Diagnosis (1) Incubation 10 days (2) Asymptomatic or Symptoms myalgia, malaise, rash, splenomegaly, fever, headache, and enlarged posterior cervical lymph nodes (3) Diagnoses include (a) Knowledge, Readiness for Enhanced 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Grieving b) Nursing Plan and Implementation (1) Education for prevention c) Evaluation (1) Woman able to discuss toxoplasmosis, transmission, implications, prevention (2) Woman implements health measure to avoid contracting toxoplasmosis (3) Woman gives birth to healthy newborn

D. Rubella 1. Mild illness in children, adults a) Infection in fetus → CRS → overwhelming consequences b) Immunize with live, attenuated virus c) Postpartum immunization 2. Fetal-neonatal risks a) Greatest risk during first trimester b) Maternal–fetal transmission 80% of cases c) Congenital cataracts, sensorineural deafness, congenital heart defects d) Intellectual disability, cerebral palsy e) Born with congenital rubella syndrome → infectious, isolated (1) Shed virus for up to 12 months 3. Clinical therapy a) Best therapy is prevention b) Live attenuated virus not given to pregnant women, vaccinate all children c) Recently vaccinated children safe to have contact with pregnant woman d) Pregnant woman becomes infected in first trimester → therapeutic abortion may be alternative 4. Nursing Management for the Pregnant Woman with Rubella a) Nursing Assessment and Diagnosis (1) Asymptomatic or mild infection (a) Titers (2) Diagnoses include (a) Coping, Ineffective (b) Health Maintenance, Ineffective b) Nursing Plan and Implementation (1) Support and understanding for couple contemplating abortion (2) Education c) Evaluation (1) Woman able to describe implications of rubella exposure during first trimester (2) If exposure occurs in woman not immune, able to identify options, make decision (3) Nonimmune woman receives rubella vaccine during early postpartum period (4) Woman gives birth to healthy infant

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Cytomegalovirus 1. CMV → belongs to herpes simples virus group → congenital and acquired disorders a) Found in urine, saliva, cervical mucus, semen, breast milk (1) Spread by close contact (2) Asymptomatic CMV common in children, gravid women (3) Cervix can harbor virus b) Accurate diagnosis → seroconversion c) Fetal diagnosis (1) Culture of amniotic fluid (2) Ultrasound findings may include fetal hydrops, growth restriction, hydramnios, cardiomegaly, fetal ascites d) No treatment for maternal CMV, congenital disease 2. Fetal-neonatal risks a) CMV most common viral infection in human fetus b) Congenital CMV leading cause of hearing loss in children c) Can result in extensive intrauterine tissue damage (1) Microcephaly, hydrocephaly, cerebral palsy, intellectual disability (2) Often small for gestational age (SGA) (3) No effective therapy exists

F. Herpes Simplex Virus 1. HSV-I or HSV-II 2. 1 in 6 ages 14–49 infected with genital herpes in United States 3. Fetal-neonatal risks a) Primary infection can increase risk of spontaneous abortion in first trimester b) Preterm labor (PTL), intrauterine growth restriction, neonatal infection c) Risk varies with route of birth, presence of lesion d) If HSV-I or HSV-II acquired close to time of labor → risk of transmission 30% to 50% for vaginal birth e) Exposure of newborn to recurrent lesion → risk of transmission 2% to 5% f) Outbreak during labor → preferred method of childbirth is cesarean g) Infected infant (1) Often asymptomatic at birth (2) Up to 4 weeks → symptoms (a) Vesicular skin lesions, respiratory distress, fever (or hypothermia), seizures, and poor feeding 4. Clinical therapy a) No history but partner with it → type-specific serology testing to determine risk of contracting b) Antiviral therapy after 36 weeks’ gestation (1) Acyclovir, famciclovir, valacyclovir 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Nursing Management for the Pregnant Woman with Herpes Simplex Virus a) Nursing Assessment and Diagnosis (1) Initial prenatal visit → learn whether woman, partner have had previous herpes infections (2) Diagnoses include (a) Pain, Acute (b) Coping, Ineffective b) Nursing Plan and Implementation (1) Education c) Evaluation (1) Woman able to describe infection with regard to method of spread, expected medical therapy, comfort measures, implications (2) Woman has appropriate lab testing done as recommended throughout pregnancy (3) Woman gives birth to healthy infant

G. Group B Streptococcus Infection 1. Group B streptococcus (GBS) → bacterial infection found in lower gastrointestinal (GI), urogenital tract a) May transmit to fetus in utero or during childbirth b) Leading cause of infectious neonatal sepsis and mortality c) Estimated 10 to 40% pregnant women carriers d) Maternal morbidity → pyelonephritis, chorioamnionitis, postpartum endometritis, sepsis, wound infections, meningitis 2. Fetal-neonatal risks a) GBS may result in unexpected intrapartum stillbirths b) Vertical transmission → risk for GBS neonatal sepsis (1) Prematurity (2) Maternal intrapartum fever (3) Membranes ruptured for longer than 18 hours (4) Previously infected infant with GBS disease (5) GBS bacteriuria in the current pregnancy (6) Young maternal age (7) African American or Hispanic c) Severe, invasive disease in affected infants 3. Clinical therapy a) Guidelines (1) All women screened for vaginal, rectal GBS at 35 to 37 weeks (2) GBS carriers →intrapartum antibiotic prophylaxis (IAP) at onset of labor or rupture of membranes (ROM) b) GBS in urine → intrapartum antibiotic prophylaxis (1) Women who have given birth to newborn with invasive GBS → intrapartum antibiotic prophylaxis 21 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Prophylaxis indicated if results of GBS not known when labor begins (a) Gestation less than 37 weeks (b) Membranes ruptured ≥18 hours (c) Temperature >100.4°F (38°C) (3) Intrapartum prophylaxis not indicated (a) Cesarean birth, no labor, intact membranes (b) Positive GBS in previous pregnancy, negative result in current pregnancy (c) Negative vagina and rectal GBS screening (4) Figure 18–7, p. 414, provides an algorithm for assessing the need for intrapartum antibiotic prophylaxis (a) Intrapartum antibiotic therapy (i) Initial dose penicillin G 5 million units IV → 2.5 to 3.0 million units IV every 4 hours until childbirth (ii) Or ampicillin may be used (iii) Clindamycin if an allergy (5) If the GBS strain is resistant to clindamycin, vancomycin

H. Human B19 Parvovirus 1. Causes erythema infectiosum, fifth disease a) “Slapped cheek” rash b) Transmitted via hand-to-hand contact or respiratory droplets c) Symptoms in adults: myalgia, arthralgia, and coryza d) Low risk of fetal morbidity, transplacental transmission as high as 33% (1) Associated with spontaneous abortion, fetal hydrops, stillbirth (2) Before 20 weeks’ gestation → nonimmune hydrops, fetal anemia e) Weekly measurements of peak systolic velocity of the MCA (1) Fetal death → 4 to 12 weeks postinfection (2) Risk of fetal death remains several months post maternal infection, even when fetal hydrops is not evident

I. Zika Virus 1. Relatively new, no vaccine or cure a) Viral infection caused by a bite from the Aedes species of mosquito, or via blood, sex, handling specimens, or perinatal transmission 2. Congenital Zika syndrome (CZS) a) Microcephaly in 1:10 fetuses b) Decreased brain tissue with a specific pattern of brain damage c) Damage to the back of the eye d) Joints with limited range of motion, such as clubfoot e) Too much muscle tone, restricting body movement soon after birth f) Education (1) Follow CDC guidelines for women planning pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Delay conception at least 2 months from onset of symptoms in women, men for 6 months (b) Women of reproductive age who are planning a pregnancy in the upcoming year, or who are already pregnant, should absolutely avoid Zika-infested areas (c) Pregnant women with symptoms → If confirmed, refer to maternal-fetal medicine (i) Up to 2 weeks after symptom onset or last possible exposure, urine or serum RNA nucleic acid testing; a positive test confirms the diagnosis of recent maternal Zika virus infection (ii) From 2 to 12 weeks after symptom onset or last date of possible exposure, serologic assays can be offered to detect Zika virus–specific IgM antibodies

J. Other Infections in Pregnancy 1. See Table 18–6: Infections That Put Pregnancy at Risk, pp. 415–416 a) Urinary tract infections (1) Asymptomatic bacteruria (ASB) → oral sulfonamides early in pregnancy, ampicillin and nitrofurantoin in late pregnancy (2) Cystitis → oral sulfonamides early in pregnancy, ampicillin and nitrofurantoin in late pregnancy (3) Acute pyelonephritis → hospitalization, IV antibiotic therapy with carbenicillin, methenamine, cephalosporins (a) Follow-up urine cultures (b) Catheterization if no urine output b) Vaginal infections (1) Vulvovaginal candidiasis → intravaginal insertion of miconazole butoconazole, clotrimazole vaginal tablets (2) Bacterial vaginosis → metronidazole 250 mg orally (PO) TID × 7, metronidazole 500 mg PO twice daily (BID) × 7; clindamycin 300 mg PO BID × 7 (3) Trichomoniasis → single 2-g dose of metronidazole orally c) Sexually transmitted infections (1) Chlamydial infection → azithromycin or amoxicillin; repeat culture (2) Syphilis → follows regimen recommended for general population (a) Early latent → 2.4 million units benzathine penicillin G IM (b) Late latent, latent of unknown duration → 2.4 million units benzathine penicillin G IM once a week × 3 weeks (c) Desensitize allergic women then treat with penicillin (d) Sexual partners screened, treated (3) Gonorrhea → cephalosporin or spectinomycin (4) Condylomata acuminata → surgical or laser removal

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman Requiring Surgery During Pregnancy A. Essential surgery can be undertaken 1. Risk for spontaneous abortion → less during early second trimester 2. Special considerations a) Shield fetus from radiation b) Nasogastric tube may be recommended before major surgery c) Indwelling urinary catheter d) Fetal heart tones monitored e) Increased respiratory secretion → may need endotracheal tube for respiratory support f) Position to allow optimal uteroplacental–fetal circulation g) Spinal or epidural anesthesia preferred h) Blood loss monitored carefully 3. Nursing Management for the Pregnant Woman Requiring Surgery a) Nursing Assessment and Diagnosis (1) Assess (a) Health status same as any preoperative patient (b) Consider impact of surgery on woman’s pregnancy (2) Pre/intra/postoperatively, fetal heart should be assessed (3) Diagnoses include (a) Anxiety (b) Fear b) Nursing Plan and Implementation (1) Educational needs (2) Support (3) Pre/intra/postoperatively, you are caring for two patients (4) Consider stage of pregnancy (5) Discharge teaching c) Evaluation (1) Woman able to explain procedure, risks and benefits, implications for pregnancy (2) Caregivers maintain adequate maternal oxygenation throughout surgery and postoperatively (3) Potential complications are avoided or detected early, treated successfully (4) Woman able to describe necessary postdischarge activities, limitations, follow-up (5) Woman maintains her pregnancy successfully

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Care of the Woman Suffering Major Trauma

A. Trauma from motor vehicle accidents leading cause of fetal and maternal death B. Violence next most common causes 1. Complicates 6 to 7% of all pregnancies 2. Early pregnancy → body changes increase potential for injury 3. Normal physiologic changes of pregnancy have clinical implications for victims of trauma 4. Trauma that causes concern includes blunt trauma, penetrating abdominal injuries 5. Complications a) maternal shock, premature labor, and spontaneous abortion b) Maternal mortality most often from head trauma or hemorrhage c) Fractures of pelvis can result in significant retroperitoneal hemorrhage (1) Cesarean birth may be necessary (2) Penetrating trauma → mother generally fares better than fetus 6. Clinical Therapy a) Stabilize injury, promote well-being for both mother and fetus b) Care to avoid development of supine hypotensive syndrome c) Noncatastrophic trauma → fetal monitoring for 4-24 hours if no vaginal bleeding, uterine tenderness, contractions, leaking amniotic fluid d) Abruption placenta → abdominal blunt force trauma (1) Fetomaternal hemorrhage (2) Kleihauer-Betke test → identify Rh negative unsensitized women who have experienced fetal–maternal trauma e) Cardiopulmonary resuscitation (CPR) on pregnant women in late gestation (1) Perimortem cesarean birth if CPR unsuccessful in first 5 minutes 7. Nursing Management for the Woman Suffering Major Trauma a) Nursing Assessment and Diagnosis (1) Assessed according to type and extent of injuries (a) Initial assessment → airway, breathing, existence of cardiovascular stability, extent of injury, brief neurologic assessment (b) Ongoing assessments → uterine tone, contractions, tenderness, fundal height, fetal heart rate, intake and output, indicators of shock, normal postoperative evaluation (2) Diagnoses include (a) Pain, Acute (b) Constipation (c) Fear b) Nursing Plan and Implementation (1) Ongoing assessment 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Woman and fetus (b) Assess woman’s emotional state (2) Education (3) Support c) Evaluation (1) Woman and family able to understand effects of trauma on her, unborn child (2) Adequate maternal oxygenation maintained (3) Woman’s pain adequately relieved, trauma treated (4) Potential complications quickly identified, interventions instituted (5) Woman gives birth to healthy newborn (6) If trauma results in fetal demise → woman able to verbalize her feelings, begin working through grief process

VII.

Care of the Pregnant Woman Experiencing Intimate Partner Violence

A. True extent of domestic violence difficult to determine, estimates 6 to 22% 1. Violence may escalate during pregnancy 2. Complications more frequent 3. Pattern of violence may increase or decrease

B. Risk factors 1. Victim of physical, sexual, or psychologic abuse 2. Low socioeconomic status 3. Unemployment/ family financial difficulties 4. Heavy alcohol or drug use 5. Antisocial personality traits 6. Belief in strict gender roles (e.g., male dominance and aggression in relationships) 7. Negative or volatile family dynamics 8. Low social support 9. Weak community sanctions against IPV 10. May cause a) Psychologic distress b) Loss of pregnancy, preterm labor c) Low-birth-weight babies, injury to the fetus, and fetal death d) Poor maternal weight gain e) Infection f) Anemia 26 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

g) Second- and third-trimester bleeding seen more frequently h) Women who are battered may also experience sexual abuse and are at increased risk of contracting STIs 11. Identify a) Chronic psychosomatic symptoms b) Old scars c) Bruising (especially to breasts, abdomen, genitals) d) Decreased eye contact, silence when partner in room e) History (1) Nervousness, insomnia, drug overdose, alcohol problems (2) Frequent visits to emergency department, accidents 12. Goals a) Identify women at risk b) Increase decision-making abilities c) Provide safe environment for her and unborn child 13. Screening in private setting, direct questions 14. Determine immediate safety of woman a) Information available → community resources

VIII.

Care of the Woman at Risk for Rh Alloimmunization

A. Rh blood group present on surface of erythrocytes 1. Present → Rh positive 2. Absent → Rh negative a) If Rh-negative person exposed to Rh-positive blood → antigen-antibody response → sensitized (1) Subsequent exposure → serious reaction (2) Rh alloimmunization → Rh-negative woman carries Rh-positive fetus to term, termination (a) Transfusion, Rh-positive tubal pregnancy, amniocentesis, trauma (3) Screening of Rh-negative woman for D antibodies accepted (4) Duffy and Kell antibodies → irregular antibodies 3. Pathophysiology of RhD Alloimmunization a) During normal pregnancy → small amounts of fetal blood cross placenta (1) Rh-negative mother → anti-D antibodies (2) Develop IgM antibodies b) Subsequent exposure to RhD cells results in rapid production of IgM antibodies (1) If maternal hemorrhage → pregnancy termination, ectopic pregnancy, chorionic sampling (2) No problem during first pregnancy → subsequent pregnancies 27 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Possibility → Rh-negative female fetus of Rh-positive mother sensitized in utero (a) Positive antibody screen

B. Fetal-Neonatal Risks 1. Hemolysis caused by maternal IgG antibodies → fetal anemia a) Increasing RBC production → nucleated RBCs erythroblastosis fetalis→ severe hemolytic disease of the fetus and newborn (HDFN) b) Anemia can cause fetal edema → hydrops fetalis, congestive heart failure c) RBC destruction → hyperbilirubinemia, jaundice d) Fetal death can be from severe anemia or hypoxia and cardiac arrest 2. Screening for Rh incompatibility and sensitization a) First prenatal visit (1) History of past pregnancies, sensitization, abortions, transfusions, children who developed jaundice or anemia during newborn period (2) Maternal blood type, Rh factor, Rh antibody screen (3) Medical complications b) Sensitization may occur antepartum → small transplacental bleeds (1) Repeat D antibody determination made at 28 weeks

C. Clinical Therapy 1. Goal prevention of Rh alloimmunization or, if alloimmunization has occurred, birth of a mature fetus that has not developed severe hemolysis in utero 2. Antepartum management of nonalloimmunized pregnant woman a) Four RhIg immune globulin products available: RhoGAM (the first approved for clinical use), HyperRHO, Rhophlac, WinRho-SDF b) Woman Rh negative, unsensitized and father Rh+ or unknown → Rh immune globulin given prophylactically at 28 weeks (1) After abortion, ectopic pregnancy, chorionic villus sampling, multifetal pregnancy reduction, partial molar pregnancy, amniocentesis, PUBS, antepartum hemorrhage, fetal death, blunt trauma, external cephalic version (2) Kleihauer-Betke test → determine amount of Rh(D) positive blood present in maternal circulation → calculate dosage (3) Standard dose of RhIg (300 mcg) can prevent alloimmunization after exposure of up to 30 mL of Rh-positive fetal whole blood or 15 mL of packed red cells 3. Antepartum management of the alloimmunization pregnant woman a) If father homozygous for Rh positive, all his offspring will be Rh positive b) If father heterozygous, 50% of offspring will be Rh positive; 50% Rh negative c) If woman alloimmunized for first time done at 14 to 16 weeks to determine gestational age d) If the father is heterozygous or if paternity is questionable or unknown, fetal DNA testing should be done to determine the fetal Rh status e) Maternal anti-D antibody titers monthly until 24 weeks 28 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) If titers higher than critical levels, Doppler ultrasound g) Intrauterine transfusion (1) Correct anemia → PUBS, intraperitoneally h) Intravascular transfusion → improved outcomes (1) Fetus temporarily paralyzed (2) Fetal hematocrit obtained (3) Leukocyte-poor Rh-negative packed red blood cells (PRBCs) transfused (4) Most transfused fetuses survive (5) Complications (a) Nonreassuring fetal status, umbilical vein hematoma, fetal-maternal hemorrhage, fetal death, chorioamnionitis (b) Birth delayed until 32 weeks if possible i) Postpartum management (1) Goals → prevent sensitization in unsensitized woman, treat isoimmune hemolytic disease in newborn (2) Rh-negative mother with no titer → gave birth to Rh+ fetus →IM injection of 300 mcg Rh immune globulin within 72 hours (a) Temporary passive immunity (3) Not given to newborn, father, previously sensitized woman 4. Nursing Management for the Woman with Alloimmunization a) Nursing Assessment and Diagnosis (1) Initial prenatal history (a) Asks blood type, Rh factor (i) If Rh negative → ask about Rh immune globulin, previous pregnancies, partner’s Rh factor (a) Uncertain paternity (ii) Lab work (b) Knowledge level and coping skills (c) Review data about Rh type of fetus (2) Diagnoses include (a) Knowledge, Readiness for Enhanced (b) Coping, Ineffective b) Nursing Plan and Implementation (1) Education (2) If sensitized → threat to any Rh+ fetus (3) Support (4) During labor → ensure woman’s blood assessed for antibodies (5) Rh immune globulin postpartum (6) See Key Points: Rh Alloimmunization, p. 407 c) Evaluation (1) Woman able to explain process of Rh sensitization, implications for unborn child, subsequent pregnancies

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) If woman not alloimmunized, able to explain importance of receiving Rh immune globulin when necessary, cooperates with recommended dosage schedule (3) Woman gives birth to healthy newborn (4) If complications develop for fetus (or newborn), they are quickly detected, therapy instituted

IX.

Care of the Woman at Risk Due to ABO Incompatibility A. Common with rare significant hemolysis 1. Most cases → type O mothers, type A, B fetus 2. Anti-A and anti-B antibodies naturally occurring 3. Once pregnant → maternal anti-A and anti-B antibodies cross placenta → hemolysis of fetal RBCs a) ABO incompatibility rarely has serious life-threatening scenarios because the antigen/antibody response is not as robust 4. Not treated antepartum a) Note if potential exists 5. Affected neonates → mild anemia

Focus Your Study

XI.

Activities 1. Individual Have students prepare drug cards, including pregnancy category or risk and special considerations for the following drugs: Acyclovir Oxytocin RhoGAM Rhophylac Sodium amobarbital Spiramycin Valacyclovir WinRho-SDF

Nitroprusside Famciclovir Hydralazine HyperRHO Labetalol Magnesium sulfate Nicardipine Nifedipine

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan, including community resources available for support or follow-up for one of the following conditions: • Hyperemesis gravidarum • Hypertension in pregnancy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

• • •

Rh incompatibility Motor vehicle accidents in pregnancy Physical violence in pregnancy

3. Large Group Invite a perinatal nurse from a tertiary care facility or perinatology practice to speak to the students in your class. Give the speaker a list of potential topics that may or may not have been covered in the text and encourage the speaker to bring case studies for presentation.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 19 Processes and Stages of Labor and Birth Methods of Childbirth Preparation………………………………………………………………… …

Preparation for Childbirth That Supports Individuality………………………………………

Critical Factors in Labor..........................................................................................

Psychosocial Considerations……………………………………………………………………………..

Physiology of Labor…………………………………………………………………………………………..

Stages of Labor and Birth.......................................................................................

Maternal Systemic Response to Labor..................................................................

Fetal Response to Labor........................................................................................

Focus Your Study...................................................................................................

Activities.................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Methods of Childbirth Preparation

A. Programs share similarities 1. Usually taught by certified childbirth educators 2. Educational component to help eliminate fear, teach coping techniques 3. Relaxation techniques 4. What to expect in maternity cycle, labor and birth 5. Advantages → reduced need for analgesics, anesthetics; awareness of available options a) Helps understand choices b) Satisfaction of parents c) Shorten labor d) International Childbirth Education Association (ICEA) → education and resources to childbirth educators

B. Programs for Preparation 1. See Box 19–1: Most Commonly Used Childbirth Education Methods in the United States, p. 428 a) Lamaze → Psychoprophylactic b) Techniques (1) Disassociation relaxation (2) Controlled muscular relaxation (3) Breathing patterns (a) Used to promote birth as a normal process (i) Bradley → Partner-coached childbirth (4) Techniques (a) 12-week session (b) Controlled breathing and deep abdominopelvic breathing (c) Focus on achieving natural childbirth c) Hypnobirthing (1) Techniques (a) Breathing and relaxation techniques (b) Prepare body to work in neuromuscular harmony to make the birthing process easier, safer, more comfortable

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Body-Conditioning Exercises 1. Pelvic tilt 2. Pelvic rock 3. Kegel exercises 4. Strengthen abdominal muscles for expulsion phase

D. Relaxation Exercises 1. Conserve energy, uterine muscles work more effectively 2. Touch relaxation → pain relief measure where partner’s touch enhances the woman’s ability to relax 3. Light touching, stroking, massaging a) Combines abdominal breathing with focused touch relaxation b) See Box 19–2: Touch Relaxation Technique, p. 429 c) Disassociation relaxation (1) Woman taught to become familiar with contracting/relaxing voluntary muscle groups → learns to contract specific muscle group and relax rest of body (2) See Box 19–3: Visualization, Imagery, and Meditation, p. 429

E. Breathing Techniques 1. Key element to most childbirth preparation programs a) Increase the woman’s pain threshold, encourage relaxation, provide distraction, enhance the ability to cope with uterine contractions, allow uterus to function more efficiently 2. Lamaze uses partner-paced 3. Bradley encourages abdominopelvic breathing 4. Kitzinger uses chest breathing with abdominal relaxation 5. Hypnobirthing uses deep, slow breathing a) Pant-blow “quick method” to keep from breathing too rapidly

II.

Preparation for Childbirth That Supports Individuality

A. Encourage woman to incorporation her own natural responses to coping with the pain of labor and birth 1. Nurse can help couple by doing the following a) Identify the methods of childbirth preparation commonly used in your area b) Learn the basic relaxation and breathing c) Encourage making the birth a personal experience.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Suggest the couple bring items from home that help create a more personal birthing space e) Encourage the couple to listen to soothing music on their cell phone or MP3 player or watch favorite DVDs to increase personalization of the childbearing experience

III.

Critical Factors in Labor

A. See Table 19–1: Critical Factors in Labor, p. 430 B. Birth Passageway 1. Pelvic types a) Size of maternal pelvis b) Diameters of pelvic inlet, midpelvis, outlet c) Type of maternal pelvis (1) Gynecoid (2) Android (3) Anthropoid (4) Platypelloid (5) Combination d) Ability of cervix to dilate, efface e) Ability of vaginal canal, introitus to distend

C. Birth Passenger (Fetus) 1. Fetal head a) Bony parts (1) Three major parts → face, base of skull, vault of cranium (2) See Figure 19–3: Lateral view of the fetal skull ..., p. 433 (3) Sutures → allow for molding of fetal head (a) Frontal (b) Sagittal (c) Coronal (d) Lambdoidal (e) See Figure 19–2: Superior view of the fetal skull, p. 432 (4) Intersection of several sutures forms fontanelle (a) Anterior (b) Posterior (5) Other landmarks a) Mentum → fetal chin b) Sinciput → brow c) Vertex → between anterior, posterior fontanelles d) Occiput → occipital bone (6) Diameters vary (a) See Figure 19–4A: Anteroposterior diameters of the fetal skull, p. 433

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Fetal Attitude 1. Relation of fetal body parts to one another (a) General flexion (b) See Figure 19–5: Fetal attitude, p. 433 2. Fetal lie a) Relationship of long (cephalocaudal) axis of fetus to that of mother (1) Longitudinal → cephalocaudal axis of fetus parallel to woman’s spine (2) Transverse → fetus is at right angle to woman’s spine b) See Table 19–3: Characteristics Associated with Longitudinal versus Transverse Fetal Lie, 434 3. Fetal presentation a) Body part that enters maternal pelvis first (1) Presenting part → felt through cervix on vaginal exam (2) Cephalic → head first (97% of term births) (a) Vertex (b) Sinciput (c) Brow (d) Face (e) See Figure 19–6: Cephalic presentation, p. 435 (3) Breech → lower extremities, buttocks first (a) Complete (b) Frank (c) Footling (4) Shoulder presentation (< 1%)

E. Relationship of maternal pelvis and presenting part 1. Engagement → largest diameter of presenting part reaches/passes through pelvic inlet a) See Figure 19–7: Process of engagement in cephalic presentation, p. 436 b) Can be determined by vaginal examination (1) Primigravida usually starts 2 weeks before term (2) Floating (ballottable) → freely movable above the inlet (3) Dipping → begins to descend into inlet before engagement (a) See Figure 19–7: C. Descending, p. 436 2. Station → relationship of presenting part to an imaginary line drawn between ischial spines of maternal pelvis a) Landmark designated as zero station b) Higher → negative number → centimeters above zero station c) Station –5 at inlet; station +4 at outlet d) See Figure 19–8: Measuring the station of the fetal head ..., p. 436

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Fetal position → refers to relationship of landmark on presenting fetal part to anterior, posterior, or sides of maternal pelvis a) Landmark for vertex presentation → occiput b) Landmark for face presentation → mentum c) Breech presentation → sacrum designated landmark d) Shoulder presentation → acromion process e) Three notations (1) Right (R) or left (L) side of maternal pelvis (2) Landmark of fetal presenting part (a) Occiput (O) (b) Mentum (M) (c) Sacrum (S) (d) Acromion (scapula [Sc]) process (A) (e) Anterior (A), posterior (P), or transverse (T) (3) Table 19–4 lists positions and abbreviations used for various fetal presentations, p. 437 f) Positions in vertex (1) ROA (2) ROT (3) ROP (4) LOA (5) LOT (6) LOP g) Positions in face presentation (1) RMA (2) RMT (3) RMP (4) LMA (5) LMT (6) LMP h) Positions in breech (1) RSA (2) RST (3) RSP (4) LSA (5) LST (6) LSP i) Dorsal added → fetal position in shoulder presentation (1) RADA (2) RADP (3) LADA (4) LADP j) Position influences labor and birth (1) Most common fetal position → occiput anterior 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

k) Determining fetal position → inspection, palpation

F. Physiologic Forces of Labor 1. Primary force → uterine contractions 2. Secondary force → use of abdominal muscles 3. Contractions a) Rhythmic tightening, shortenings of uterine muscles, three phases (1) Increment → building up (2) Acme → peak (3) Decrement → letting up b) Frequency → time in between beginning of one contraction to beginning of next contraction c) Duration → measured from beginning of the contraction to the end of the contraction d) Intensity → strength of uterine contraction during acme (1) Mild, moderate, strong (2) Beginning of labor usually mild, short, infrequent 4. Bearing down a) Cervix dilates completely → maternal abdominal musculature contracts → woman pushes (1) Cervix not completely dilated → causes cervical edema

IV.

Psychosocial Considerations A. Readiness includes: 1. Fears, anxieties 2. Birth fantasies 3. Level of social support 4. Preconceived ideas about birth a) See Table 19–5: Factors Associated with a Positive Birth Experience, p. 439 (1) Motivation for pregnancy (2) Attendance at childbirth education classes (3) A sense of competence or mastery (4) Self-confidence and self-esteem (5) Positive relationship with partner (6) Maintaining control during labor (7) Support from partner or other person during labor (8) Not being left alone in labor (9) Trust in the medical/nursing staff (10) Having personal control of breathing patterns, comfort measures (11) Choosing physician/certified nurse-midwife who has similar philosophy of care 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(12) Receiving clear information regarding procedures b) Encourage to share dreams, fantasies c) Explore options, identify interventions to help cope with discomfort d) Support system e) Hindsight may have implications for mothering behaviors

Physiology of Labor A. Possible Causes of Labor Onset 1. Between 38th and 42nd week 2. Hypotheses a) Progesterone withdrawal → decreased availability of progesterone to myometrial cells toward end of gestation b) Prostaglandin hypothesis → successful induction of labor after vaginal prostaglandin E c) Corticotropin-releasing hormone → corticotropin-releasing hormone (CRH) concentration increases throughout pregnancy → sharp increase at term

B. Myometrial Activity 1. Two portions → physiologic retraction ring a) Upper portion → contractile segment → thickens b) Lower portion → passive → expands, thins c) Effacement d) See Figure 19–11: Effacement of the cervix in the primigravida, p. 441 e) Fetal axis pressure → uterus elongates with contraction → straightens fetal body → thrusting presenting part down toward lower uterine segment and cervix f) Round ligament pulls fundus forward

C. Musculature Changes in the Pelvic Floor 1. Levator ani muscle, fascia of pelvic floor → draw rectum, vagina upward and forward with each contraction 2. Physiologic anesthesia from decreased blood supply to area

D. Premonitory Signs of Labor 1. Lightening → fetus begins to settle into pelvic inlet a) Leg cramps, pains due to pressure b) Increased pelvic pressure c) Increased venous stasis d) Increased urinary frequency e) Increased vaginal secretions 2. Braxton Hicks contractions → irregular, intermittent contractions a) Stronger, drawing sensation 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Cervical changes a) Ripening (softening) 4. Bloody show a) Mucus plug expelled → softening, effacement of cervix (1) Pink-tinged secretions b) Sign of impending labor → 24 to 48 hours c) Rupture of membranes (ROM) (1) ROM → 12% of women before onset of labor (a) 80% of those → spontaneous labor within 24 hours (b) If ROM and labor doesn’t start in 12 to 25 hours, labor may need induced (2) Spontaneous rupture of membranes (SROM) → generally occurs at height of an intense contraction (a) Fetus not engaged → risk of umbilical cord expelled with fluid → prolapsed cord (b) Woman advised to notify healthcare provider, proceed to hospital, birthing center (3) Spontaneous rupture of membranes, leakage of fluid before labor → premature rupture of membranes (PROM) (4) Spontaneous rupture of membranes before 37 weeks → preterm premature rupture of membranes (PPROM) 5. Sudden burst of energy a) 24 to 48 hours before labor b) Prenatal teaching → warning about overexertion 6. Other signs 7. Weight loss of 1 to 3 lb a) Increased backache, sacroiliac pressure b) Diarrhea, indigestion, nausea, vomiting

E. Differences Between True Labor and False Labor 1. See Key Facts to Remember: Comparison of True Labor and False Labor, p. 442 2. True labor → progressive dilatation and effacement of cervix a) Regular contractions b) Intervals between contractions gradually shorten c) Contractions increase in duration and intensity d) Discomfort begins in back, radiates around abdomen e) Intensity usually increases with walking f) Cervical dilatation, effacement progressive g) Contractions do not decrease with rest, warm tub bath 3. False labor → does produce progressive cervical effacement, dilatation a) Contractions irregular b) Intervals usually do not change 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Duration, intensity usually do not change d) Discomfort usually in abdomen e) Walking has no effect on or lessens contractions f) No cervical dilatation or effacement g) Rest and warm tub baths lessen contractions h) Nurse’s response to false labor (1) Education about characteristics of true labor (a) False labor common (2) Interventions to decrease anxiety, discomfort (a) False labor can last for several hours and can be exhausting

VI.

Stages of Labor and Birth

A. First Stage 1. Latent or early phase a) Onset of regular contractions b) Cervical dilation and effacement begins c) First labor → averages 7.3 to 8.6 hours d) Multiparas → average 4.1 to 5.3 hours e) Uterine contractions established (1) Increase in frequency, duration, intensity (2) Usually mild → woman able to cope (3) Lasting 20 to 40 seconds, frequency of 10 to 30 minutes (4) Excited, talkative, smiling 2. Active phase a) Anxiety tends to increase b) Contractions increase (1) 2 to 5 minutes, a duration of 40 to 60 seconds c) Support person important d) Cervix dilates from 4 to 7 cm 3. Transition phase a) Last part of first stage b) Woman entering transition → significant anxiety c) Increasing force, intensity of contractions d) Cervical dilatation slows → fetal descent increases e) Contractions more frequent, longer, stronger (1) From every 2 to 5 minutes to every 1½ to 2 minutes f) Dilatation approaches 10 cm → increased rectal pressure (1) Urge to bear down (2) Increase in bloody show (3) Rupture of membranes (ROM) g) Woman likely to withdraw into self h) Other characteristics include: 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Hyperventilation (2) Restlessness (3) Difficulty understanding directions (4) Sense of bewilderment and anger at contractions (5) Generalized discomfort (6) Increased sensitivity to touch (7) Increased need for partner’s and/or nurse’s presence or support (8) Increased apprehension and irritability (9) Statements that she “can’t take it anymore” (10) Requests for medication (11) Hiccupping, belching, nausea, vomiting (12) Beads of perspiration on upper lip (13) Increasing rectal pressure (14) Curling of her toes (15) Loss of control (16) Crying or yelling

B. Second Stage 1. Begins when cervix completely dilated a) Ends with birth of infant 2. As fetal head descends → woman has urge to push a) Intra-abdominal pressure exerted → fetal head descends → perineum begins to bulge, flatten, move anteriorly b) Labia begin to part c) Crowning → fetal head encircled by external opening of vagina d) Birth imminent e) May feel acute, increasingly severe pain, burning sensation f) Instruct to push through the pain and burning (1) Childbirth-prepared woman → relief that transition over (2) Woman may become frightened 3. Spontaneous birth (vertex presentation) a) Perineum thins, anus stretches, protrudes b) Extension under symphysis pubis → head is born c) Anterior shoulder meets underside of symphysis pubis → gentle push by mother d) Body follows e) See Figure 19–12: The birth sequence, p. 446 4. Positional changes of the fetus a) Descent → forces of pressure of amniotic fluid, fundus, contraction of abdominal muscles, straightening and extension of fetal body b) Flexion → fetal head descends, meets resistance → fetal chin flexes downward onto chest c) Internal rotation → fetal head rotates to fit diameter of pelvic cavity 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Extension → resistance of pelvic floor, movement of vulva assist with extension of fetal head e) Restitution → shoulders enter pelvis obliquely when head rotates → neck twists → head emerges → neck untwists, head aligns with position of back in birth canal f) External rotation → as shoulders rotate to anteroposterior position in pelvis → head turned farther to one side g) Expulsion → anterior shoulder meets undersurface of symphysis pubis, slips under h) See Figure 19–13: Cardinal movements (mechanisms of labor), p. 448

C. Third Stage 1. Birth of infant until completed delivery of placenta 2. Placental separation a) After infant born → uterus contracts firmly b) Diminishes capacity, surface area of placental attachment c) Separation accompanied by bleeding → hematoma formation → accelerates separation d) Signs → usually 5 to 30 minutes to manifest (1) Globular-shaped uterus (2) Rise of fundus in abdomen (3) Sudden gush or trickle of bleed (4) Further protrusion of umbilical cord out of vagina e) Placental delivery (1) Woman may bear down (2) If fundus firm → CNM or physician may apply gentle traction to cord while pressure exerted on fundus (3) Retained → more than 30 minutes have elapsed from completion of second stage (4) Shiny side presenting → separates from inside to outer margins (a) Schultze mechanism → Shiny Schultze (5) Maternal surface delivers first → separates from outer margins inward (a) Duncan mechanism → Dirty Duncan (b) See Figure 19–14: Placental separation and expulsion, p. 448

D. Fourth Stage 1. 1 to 4 hours after birth a) Physiologic readjustment of mother’s body begins (1) Moderate drop in BP occurs, increased pulse pressure, moderate tachycardia b) Uterus remains contracted, midline c) Nausea and vomiting experienced during transition usually cease d) Shaking chill e) Bladder often hypotonic → may lead to urinary retention

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VII.

Maternal Systemic Response to Labor

A. Cardiovascular System 1. Contractions, pain, anxiety, apprehension 2. Increase in cardiac output with contractions 3. Maternal position affects cardiac output 4. Valsalva maneuver as she pushes → increased venous pressure 5. Next breath → intrathoracic pressure decreased, venous return increases 6. Cardiac output peaks immediately after birth → then decreases a) Remains elevated for at least 24 hours after the birth

B. Blood Pressure 1. Increased cardiac output → systolic blood pressure rises during uterine contractions 2. Blood pressure may drop precipitously when woman in supine position a) Women with hydramnios, multiple gestation, obese → highest risk of aortocaval compression

C. Fluid and Electrolyte Balance 1. Profuse diaphoresis, hyperventilation → insensible water loss 2. Parenteral intravenous fluids

D. Respiratory System 1. Oxygen demand and consumption increase → presence of uterine contractions a) 50% of increased oxygen used by placenta, uterus, fetus 2. Increased metabolism as labor progresses → mild increase in respiratory rate 3. By end of first stage → mild metabolic acidosis compensated by respiratory alkalosis a) Pushing in second stage → PaCO2 may rise → mild respiratory acidosis

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Changes quickly reversed in fourth stage

E. Renal System 1. During labor → increase in maternal renin, plasma renin activity, angiotensinogen 2. Polyuria common → increased cardiac output 3. Base of bladder pushed forward, upward with engagement 4. Pressure from presenting part → impair blood, lymph drainage → edema of tissues

F. Gastrointestinal System 1. Gastric motility, absorption of solid food reduced 2. Gastric volume remains over 25 mL → risk for aspiration if general anesthesia necessary 3. Fluid requirements not clear a) Oral hydration b) Saline lock for intravenous access

G. Immune System and Other Blood Values 1. White blood cell (WBC) count increases to 25,000/mm3 to 30,000/mm3 → labor, early postpartum 2. Maternal blood glucose decreases → decrease in insulin requirements a) Glucose levels can drop significantly during a prolonged or difficult labor

H. Pain 1. Pain during labor a) Accompanies normal physiologic process b) Pain during first stage of labor from (1) Dilatation of cervix (2) Hypoxia of uterine muscle cells (3) Stretching of lower uterine segment (4) Pressure on adjacent structures (5) See Figure 19–15: Pain pathways from uterus to spinal cord, p. 450 (6) Pain from uterus → directly referred to dermatomes supplied by 10th through 12th thoracic nerves (7) See Figure 19–16: Area of reference of labor pain during the first stage, p. 451 c) Second stage of labor (1) Pain due to: (a) Hypoxia of contracting uterine muscle cells (b) Distention of the vagina and perineum (i) Pressure on adjacent structures: Lower back, Buttock, Thighs

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) See Figure 19–17: Distribution of labor pain during the later phase of the first stage and early phase of the second stage, p. 451 d) Third stage of labor (1) Uterine contractions, cervical dilatation → placenta expelled (2) Pain felt above symphysis pubis bone, perineal area, lower back (3) See Figure 19–18: Distribution of labor pain during the later phase of the second stage and actual birth, p. 452 2. Factors affecting response to pain a) Preparation for childbirth shown to reduce need for analgesia during labor b) Individuals respond to painful stimuli → culturally acceptable way c) Families react to healthcare system based on own culture d) Nurse needs to identify cultural norms of family e) Fatigue and sleep deprivation → less energy and ability to use strategies for coping f) Previous experience with pain g) Anxiety h) Attention and distraction influence perception of pain i) Culture of healthcare → own expectations of woman and support person (1) Healthcare profession likely to interpret pain according to norms of healthcare culture (2) Accept and respect that pain is whatever the woman says it is

VIII.

Fetal Response to Labor

A. Normal fetus → normal labor has no adverse effects B. Heart Rate Changes 1. Decelerations → intracranial pressures of 40 to 55 mm Hg 2. Early decelerations harmless in normal fetus

C. Acid–Base Status in Labor 1. Blood flow to fetus slowed during acme of contraction a) Slow decrease in fetal pH 2. Second stage → more rapid decrease in fetal pH 3. Persistent acid–base imbalance → multi-organ dysfunction in infant

D. Hemodynamic Changes 1. Adequate exchange of nutrients, gases → depends on fetal blood pressure

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Decreased fetal heart rate variability accompanies quiet sleep c) Quiet sleep state generally lasts less than 40 minutes

F. Fetal Sensation 1. 37 to 38 weeks’ gestation → fetus able to experience light, sound, touch 2. Hearing develops at 23 to 24 weeks → reliable at 28 weeks 3. Term baby aware of pressure sensations during labor

IX.

Focus Your Study

Activities 1. Individual Using Table 19–5: Factors Associated with a Positive Birth Experience, p. 439, have students interview two to three (or more) women who have given birth. Instruct the students to ask the women to identify factors they felt most affected them and those factors that least affected them. Have the students identify the cultural identity of the women interviewed. 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the pregnant woman. Assign each group a critical factor in labor or a specific stage of labor. The groups should use lay terms, diagrams, and pictures as appropriate in their teaching plans. 3. Large Group Show one of the short videos listed below that clearly shows the second stage of labor. Facilitate a class discussion based on the video. • http://www.medicanalife.com/watch_video.php?v=2803d92a3eac6ac • http://www.youtube.com/watch?v=u9xfu1qOJzs

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 20 Intrapartum Nursing Assessment Maternal Assessment...........................................................................................

Fetal Assessment..................................................................................................

Fetal Heart Rate Patterns.....................................................................................

Indirect Methods of Fetal Assessment................................................................

Focus Your Study..................................................................................................

Activities...............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Maternal Assessment

A. Accurate database 1. Goal → create an accurate database of information → healthcare providers to formulate an optimal plan of care 2. Patient history and screening 3. Varies with condition, stage of labor → triage a) Triage b) Vital signs, fetal heart rate (FHR) c) Contractions d) Abnormal symptoms or signs of distress 4. Suspected complications of labor, high risk, PROM, PPROM, preeclampsia, FHR abnormalities, vaginal bleeding → further assessment 5. No prenatal care → immediate complete assessment a) History and physical b) Obstetrical evaluation c) Laboratory tests d) Ultrasound e) Other indicated procedures 6. Well-being of mother and fetus primary concern

B. Prenatal Record 1. Perinatal guidelines a) Copy of prenatal record available → acute care facility at 36 weeks b) Foundation for intrapartum assessment

C. Historical Data 1. Pregnant patient the primary source 2. Foundation for intrapartum assessment 3. See Box 20–1: Historical Data for the Intrapartum Assessment, p. 457 a) Demographic information b) Socioeconomic factors c) Psychosocial assessment d) Medical, surgical histories e) Family history f) Obstetrical history (1) Past pregnancies (a) Complications during pregnancy (b) Labor complications 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Postpartum complications (d) High-risk factors (e) Previous abortions, etc. (f) Mode of birth (2) Current pregnancy (3) Gravidity, parity (4) High-risk factors (5) Blood type, Rh factor (6) Serology testing (7) Allergies (8) Drug, alcohol, smoking during pregnancy (9) Elevated blood pressure, bleeding problems, recurrent urinary tract infections (10) Medications (11) Method chosen for infant feeding (12) Type of prenatal education (13) Birth plan (14) Gestational age assessment (15) Fetal activity (16) Leopold maneuvers (17) Fetal positioning g) Clinical assessment (1) Maternal vital signs (2) Maternal weight, height, weight gain this pregnancy (3) Nutritional status (4) Uterine activity (5) Contraction assessment (6) Onset, duration, frequency of uterine contractions (7) Fetal response to uterine contractions (8) Membrane status (9) Status of membranes, color of amniotic fluid (10) Date and time of rupture (11) Vaginal examination (12) Vaginal bleeding and discharge (13) Cervical exam h) Biochemical examinations during pregnancy (1) Laboratory studies (2) CBC, blood type, Rh and antibody screen (3) Toxicology screening (if ordered) (4) Blood glucose screening (5) Urine for protein and sugar (6) Infectious disease evaluation (7) Chlamydia, gonorrhea, group beta strep, hepatitis B, rubella, syphilis (8) Optional infectious disease evaluation i) Fetal assessment 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Gestational age assessment (2) Last menstrual period (LMP) (3) Fetal movement (4) Ultrasound exams for dating (5) Fetal activity (6) Fetal movement by maternal report (7) Fetal movement by palpation (8) Antenatal assessments (9) Nonstress tests (NSTs) (10) Contraction stress tests (CSTs) (11) Biophysical profiles (BPPs) (12) Ultrasounds (13) Amniotic fluid index (AFI) (14) Method of monitoring (15) Auscultation (16) External (a) via ultrasound transducerPlaced on maternal abdomen over fetal back (17) Tocodynamometer (a) InternalVia fetal scalp electrode attached to fetal head (b) Cervix must be at least 2 cm dilated and membranes ruptured (c) Increases risk of infection transmission to fetus (18) Fetal spiral electrode (19) Intrauterine pressure catheter

D. Intrapartum High-Risk Screening 1. Integral part of assessment a) Physical conditions b) Psychosocial variables c) Cultural variables d) Communication problems e) Intimate partner violence 2. See Table 20–1: Intrapartum High-Risk Factors, p. 459 a) Abnormal presentation b) Multiple gestation c) Hydramnios d) Oligohydramnios e) Meconium staining of amniotic fluid f) Premature rupture of membranes (PROM) g) Induction of labor h) Abruptio placentae/placenta previa i) Failure to progress in labor j) Precipitous labor (less than 3 hours) k) Prolapse of umbilical cord 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

l) Fetal heart decelerations m) Uterine rupture n) Postdates (greater than 42 weeks) o) Diabetes p) Preeclampsia q) AIDS/STIs

E. Intrapartum Physical and Psychosociocultural Assessment 1. Physical exam → admission, ongoing 2. Physical assessment a) Critical assessments → maternal vital signs, labor status, fetal status, laboratory findings 3. Psychologic disorders a) Depression → fear, lack of energy, apathy, hopelessness, trouble concentrating, impaired immune function, impaired mother–baby interaction b) Panic disorder c) Obsessive-compulsive disorder d) Pregnancy further complicates psychiatric disorders 4. Psychosocial history a) Physical, sexual assault 5. Transcultural nursing assessment a) Starting point for plan → honors values, beliefs of laboring woman 6. Psychosocial a) Ideas, knowledge, fears about childbearing b) Adequacy of resources c) Information and resources 7. See Assessment Guide: Intrapartum—First Stage of Labor, p. 461

F. Evaluating Labor Progress 1. Ongoing accurate assessment → mother, fetus, responses 2. Method of monitoring a) Low tech b) Intermittent c) EFM d) Continuous 3. Guidelines with electronic fetal monitoring (EFM) a) Low-risk pregnancy (1) Nurse must perform a hands-on assessment, including auscultation of fetal heart tones (FHT) and palpation of uterine contractions (UC) 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Tracing reviewed every 30 minutes in first stage of labor (3) Every 15 minutes in second stage b) High-risk pregnancy (1) Every 15 minutes in first stage labor (2) Every 5 minutes in second stage labor c) See Table 20–3, p. 469 d) Document on same schedule 4. May be necessary to monitor more frequently a) Monitor before and after examination, rupture of membranes, certain procedures 5. EFM a) Originally in high-risk pregnancy, in 2002 85% of births used it 6. Intermittent assessment as appropriate a) Proper technique b) 1:1 nurse-to-patient ratio

G. Uterine activity assessment 1. Provides data regarding labor progress, fetal well-being a) Uterine contractions (UCs) reduce oxygen immediately available to fetus b) Adequate labor → 3 to 5 contractions in 10 minutes or a contraction every 2 to 3 minutes in active labor 2. UCs occur in wavelike patterns a) Begin at upper uterine segment → progress through lower segments of uterus b) Leads to cervical dilatation and effacement and the descent of the fetus c) Similar wave of relaxation d) During and between UCs → fundus changes shape, firmness e) Monitoring UCs (1) Palpation → fingertips of one hand on top of uterus (a) Frequency measured from beginning of one contraction to beginning of next (b) Duration from beginning of the contraction to end of same contraction (c) Acme (peak) evaluated subjectively (d) Benefits (i) Noninvasive (ii) Readily accessible (iii) Increases hands-on care (iv) Allows mother freedom of movement (e) Limitations (i) No quantitative measurement (ii) No permanent record (iii) Maternal size, positioning (2) Electronic monitoring with external tocodynamometer (a) Tocotransducer (toco) → pressure monitoring device 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Placed on maternal abdomen → at or near fundus (c) Held in place with elastic belt, belly band (3) Procedure (a) Palpation of uterus → locate fundus (b) Transabdominally (i) Frequency and duration (ii) Not accurate for UC intensity (c) Beltless tocodynamometer → remote telemetry (i) Adhesive transducer applied to abdomen (ii) More convenient (4) Advantages (a) Noninvasive (b) Easy to place (c) Before and after rupture of membranes (d) Intermittent (e) Permanent continuous recording (5) Disadvantages (a) Placement influences accuracy (b) Belt may be uncomfortable → need frequent readjustment (c) Nurse needs to palpate in addition (6) Electronic monitoring by internal pressure catheter (a) Intrauterine pressure catheter (IUPC) (i) Catheter inserted into uterine cavity → through cervical os (ii) Reflects pressure inside uterine cavity (iii) One of two types → fluid filled or solid tipped (iv) Can only be used after membranes have ruptured (7) Advantages (a) Near-exact pressure measurements (b) Accurate timing (c) Useful for vaginal birth after cesarean (VBAC) patients (d) Preferred when amnioinfusion indicated (e) Permanent record (8) Disadvantages (a) Membranes must be ruptured (b) Cervical dilation must be achieved (c) Invasive (d) Risk for infection, perforation, trauma (e) Contraindicated in known infections (f) Risk of placental puncture if low lying placenta 3. Cervical assessment a) Evaluated directly by vaginal exam (1) Dilatation (2) Effacement 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) See Clinical Skill 20–1: Performing an Intrapartum Vaginal Examination, p. 471

II.

Fetal Assessment

A. Determination of Fetal Position and Presentation 1. Position a) Inspection of woman’s abdomen (1) Observe abdomen for size and shape (2) Uterus projects up and down → longitudinal lie (3) Uterus projects left to right → transverse lie b) Palpation of the woman’s abdomen (Leopold maneuvers) (1) Systematic way to evaluate maternal abdomen (2) Procedure preparation (a) Empty bladder, positioned on back with abdomen uncovered (b) Shoulders raised slightly on pillow, knees drawn up little (c) Between contractions (d) Hands warm (3) Consider following questions: (a) Fetal lie longitudinal or transverse? (b) What is in fundus? Am I feeling buttocks or head? (c) Where is the fetal back? (d) Where are the small parts or extremities? (e) What is in the inlet? (f) Measuring the station of the fetal head while it is descending. (see Figure 19–8 in Chapter 19) (g) Is there fetal movement? (h) How large is the fetus? (i) Is there more than one fetus? (j) Is fungal height proportionate to estimated gestational age? (4) First maneuver (a) Nurse palpates upper abdomen with both hands (b) See Figure 20–4: Leopold maneuvers ..., p. 475 (c) Fetal head is firm, hard, round, moves independently of trunk (5) Second maneuver (a) Determine location of fetal back → palpates abdomen with deep but gentle pressure (b) Right hand steady → left hand explores right side of uterus (c) Repeat on other side (d) Fetal back firm smooth, connect with what was found in fundus (e) See Figure 20–4: Leopold maneuvers ..., p. 475 (6) Third maneuver (a) Grasp lower portion of abdomen just above symphysis pubis with thumb, fingers of right hand (b) Opposite information from what was found in fundus 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Validates presenting part (d) See Figure 20–4: Leopold maneuvers ..., p. 475 (7) Fourth maneuver (a) Fingers of both hands moved gently down sides of uterus toward pubis (b) Cephalic prominence (brow) located on side where there is greatest resistance to descent of fingers toward pubis (c) Opposite side from fetal back → head well flexed (d) Fetal head extended → located on same side as back (e) See Figure 20–4: Leopold maneuvers ..., p. 475 c) Vaginal examination (1) Reveals → presentation, position, station, degree of flexion of head, swelling present on fetal scalp d) Ultrasound (US) (1) Real-time US → assess fetal lie, presentation, position (2) Obtain measurements of biparietal diameter to estimate gestational age (3) Assess for anomalies (4) Assess placement of placenta (5) Pinpoint fetal heart location (6) Diagnose fetal demise (7) See Chapter 16 for further discussion of the use of ultrasound for fetal assessment.

B. Auscultation of Fetal Heart Rate 1. Direct auditory monitoring 2. FHR = number of fetal heart beats per minute 3. Handheld instrument a) Fetoscope → magnify actual fetal heart sounds b) Ultrasound Doppler → converts fetal myocardial movement into sound waves 4. FHR heard best → a) Cephalic presentation → lower quadrant of maternal abdomen b) Breech presentation → just above or below umbilicus 5. After located → counted for 30 to 60 seconds a) Listen before, during, just after contraction (1) FHR over 160 beats/min → tachycardia (2) FHR under 110 beats/min → bradycardia (3) Decelerations (4) See Clinical Skill 20–3: Auscultation of Fetal Heart Rate and Table 20–4: Frequency of Auscultation: Assessment and Documentation, p. 477 (5) Auscultation used for years → valuable assessment technique (6) Low risk status → no pregnancy risk factors, no meconium-stained fluid, normal labor patterns, labor without augmentation or induction (7) Learned skill, requires practice 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(8) Baseline, rhythms, increases, decreases in FHR (9) No permanent record b) Identify UCs, FHR simultaneously necessary → identify patterns c) Cannot determine baseline variability

C. Electronic Fetal Monitoring 1. EFM → provides continuous tracing of FHR a) Allows observation, evaluation (1) See Figure 20–7, Electronic monitoring by external technique, p. 478, and Clinical Skill 20–4: Electronic Fetal Monitoring, p. 479 b) Advanced assessment, clinical judgment skills c) Includes (1) Application of fetal monitoring components (2) Intermittent auscultation (3) Ongoing monitoring and interpretation of FHR data (4) Initial assessment of laboring woman and fetus (5) Ongoing clinical interventions and evaluations of woman, fetus d) Initiation of monitoring, ongoing clinical evaluation → healthcare professional with educations, skills (1) Registered nurse (2) Certified nurse midwives (CNMs) (3) Registered midwives (4) Other advanced practice nurses (nurse practitioners, clinical nurse specialists) (5) Physicians (6) Physician assistants (PAs) e) Standardized definitions for FHR tracings by ACOG, NICHD, and the Society for MaternalFetal Medicine (1) A three-tiered intrapartum categorization system was recommended 2. Indications for electronic fetal monitoring → see Table 20–5: Possible Indications for Electronic Fetal Monitoring, p. 480 a) Fetal factors (1) Decreased fetal movement (2) Abnormal auscultator FHR (3) Meconium passage (4) Abnormal presentations/positions (5) Intrauterine growth restriction (IUGR) or small–for-gestational-age (SGA) fetus (6) Postdates (greater than 41 weeks) (7) Multiple gestation b) Maternal factors (1) Fever (2) Infections (3) Preeclampsia (4) Disease conditions 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Anemia (6) Obesity (7) Rh alloimmunization (8) Previous perinatal death (9) Grand multiparity (10) Previous cesarean birth (11) Borderline/contracted pelvis c) Uterine factors (1) Dysfunctional labor (2) Failure to progress in labor (3) Oxytocin induction/augmentation (4) Uterine anomalies d) Complications of pregnancy (1) Prolonged rupture of membranes (2) Premature rupture of membranes (3) Preterm labor (4) Marginal abruptio placentae (5) Partial placenta previa (6) Occult/frank prolapse of cord (7) Amnionitis e) Regional anesthesia f) Elective monitoring 3. External monitoring a) Electronic monitoring can be done externally (1) Ultrasound transducer is a Doppler device (2) Placed on maternal abdomen over fetal back (3) Produces continuous graphic recording (4) Limited → susceptible to interference from maternal, fetal movement (5) Can show the baseline (BL), baseline variability (BL VAR), and changes in the FHR 4. Internal monitoring a) Internal fetal monitoring → fetal scalp electrode (FSE) (1) Fine surgical spiral wire attached to the fetal scalp b) Direct electrocardiogram (ECG) of FHR c) For spiral electrode to be inserted (1) Cervix must be dilated at least 2 cm (2) Presenting fetal part must be accessible by vaginal examination (3) Membranes must be ruptured (4) Electrode rotated clockwise → until attached to presenting part → disengaged from guide tube (5) See Figure 20–8: Techniques for internal, direct fetal monitoring, A, B, and C, p. 481 (6) Risk of transmission of known maternal infection exists (7) Spiral electrode provides instantaneous, continuous recording of FHR

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Telemetry a) FHR, uterine activity → may also be monitored by telemetry b) Less confining → US along with external uterine pressure transducers connected to a small battery-operated transmitter c) Direct, indirect monitoring of FHR, indirect monitoring of uterine pressure

III.

Fetal Heart Rate Patterns

A. Interval between two successive fetal heartbeats continually measured 1. Rate is displayed as if the beats occurred at the same interval for 60 seconds.

B. Fetal heart rate patterns → described by: 1. Baseline 2. Variability 3. Accelerations 4. Decelerations a) Categorized in three-tier system

C. Standardized terminology D. Baseline Fetal Heart Rate 1. BL FHR → determined by approximating mean FHR during 10-minute period → rounded to increments of 5 beats per minute a) Accelerations, decelerations, period of marked FHR variability excluded 2. Must be 2 minutes of identifiable baseline (BL) segments in any 10-minute window 3. Normal BL rate → 110 to 160 bpm a) As gestational age increases → FHR decreases as PNS matures

E. Tachycardia 1. Fetal tachycardia → BL FHR greater than 160 bpm for at least 10-minute period 2. Causes a) Idiopathic b) Maternal (1) Fever (2) Dehydration (3) Anxiety (4) Betasympathomimetic or sympathetic drugs (5) Maternal hyperthyroidism (6) Supraventricular tachycardia c) Fetal 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Early fetal hypoxia (2) Asphyxia (3) Fetal anemia (4) Infection (5) Prematurity (6) Prolonged fetal stimulation (7) Fetal heart failure d) Combined 3. Nonreassuring sign → accompanied by other FHR patterns a) Late decelerations b) Severe variable decelerations c) Decreased or absent variability 4. Intervention → treatment of underlying cause

F. Bradycardia 1. Fetal bradycardia → FHR baseline less than 110 beats/min for at least 10-minute period 2. FHR low as 90 beats/min → good variability → classified as benign, reassuring 3. Possible causes a) Maternal (1) Drugs that stimulate parasympathetic nervous system (PNS) or block sympathetic nervous system (SNS) (2) Maternal hypotension (3) Accidental monitoring of maternal pulse b) Fetal (1) Stimulation of vagus nerve (2) Prolonged umbilical cord compression (3) Fetal dysrhythmia associated with heart block in fetus (4) Hypoxemia or late fetal asphyxia (5) Occiput posterior or transverse position

G. Wandering baseline 1. Smooth, meandering, unsteady BL → fluctuates in the normal BL range without variability 2. Causes a) Congenital defect, metabolic acidosis

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

H. Sinusoidal fetal heart rate pattern 1. Visually apparent, smooth, wavelike, undulating sine pattern that fluctuates in FHR baseline 2. Sinusoidal patterns → benign or pathological 3. Causes a) Fetal anemia b) Chronic fetal bleeding c) Fetal isoimmunization d) Twin-to-twin transfusion e) Umbilical cord occlusion f) Central nervous system (CNS) malformations 4. Interventions if uncorrectable → notify healthcare provider, expeditious delivery

I. Arrhythmias and dysrhythmias 1. Interchangeable terms 2. Disturbances in FHR pattern not associated with abnormal electrical impulse formation or conduction in the fetal cardiac tissue 3. Three categories a) Irregular rhythms b) Sustained tachycardia c) Sustained bradycardia 4. FHR dysrhythmia estimated in 2% to 14% of pregnancies a) 90% benign b) 10% → life threatening, require consultation c) Accurately diagnose abnormal FHR patterns 5. See Table 20–6: Common Causes or Various Types of Fetal Dysrhythmias, p. 484

J. Baseline Variability 1. BL VAR → reliable indicator of fetal cardiac and neurological function, well-being 2. Fluctuations in baseline FHR that are irregular in amplitude and frequency over 2 cycles per minute 3. Measured in beats per minute 4. Classified as follows: a) Absent FHR variability-amplitude range undetected b) Minimal FHR variability-amplitude range detectable but 5 beats/min or less c) Moderate FHR variability-amplitude range of 6 to 25 beats/min d) Marked FHR variability-amplitude range greater than 25 beats/min

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) See Figure 20–12: A. and B. Moderate variability. C. Minimal variability. D. Absent variability and Figure 20–13: Marked variability, p. 485

K. Fetal Heart Rate Changes 1. FHR may exhibit intermittent, transient deviations → accelerations, decelerations a) Episodic changes → not associated with uterine contractions b) Periodic changes → occur with uterine contractions (1) If a periodic change occurs with > 50% of UCs in a 20-minute period → categorized as recurrent change/pattern c) Examine all changes in FHR → in relation to BL, uterine activity 2. Accelerations a) Acceleration (accel) → visually apparent increase in BL FHR (1) Onset-to-peak < 30 seconds, lasting less than 2 minutes overall (2) Peak must be 15 beats/min or more (3) Must last 15 seconds or more from onset to return to BL b) Prolonged acceleration → lasts 2 minutes or more, less than 10 minutes c) Episodic accelerations → not associated with contractions (1) Reassuring → fetal movement, stimulation, environmental stimulus d) Periodic accelerations → associated with uterine contractions (1) See Figure 20–14: Types of accelerations, p. 486 e) Generally associated with stimulation of autonomic nervous system (ANS) (1) Fetal movement, vaginal exams, application of fetal scalp electrode, occiput posterior presentation, uterine contractions, fundal pressure, abdominal palpation, VAS, scalp stimulation, other environmental stimuli f) Generally considered benign 3. Decelerations (decels) a) Decreases in the FHR below the BL b) Several components (1) Onset (2) Descent → time from onset to nadir (3) Nadir → lowest point of deceleration (4) Depth → level a deceleration reaches nadir (5) Recovery → time from nadir to return to BL (6) Duration → total length of time from onset to return to BL c) Classified (1) Early (2) Late (3) Variable (a) Accompanied by other characteristics (4) Prolonged (5) Based on shape, appearance, rate of decent, and timing in relation to uterine contractions 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Characteristics of decelerations (1) See Figure 20–15: Types and characteristics of early, late, and variable decelerations, p. 487 (2) Early deceleration (a) Visually apparent, usually symmetrical, gradual decrease and return of FHR associated with uterine contraction (b) Gradual FHR decrease defined as on from the onset to the FHR nadir of 30 seconds or more (c) Decrease in FHR calculated from onset to nadir of deceleration (d) Nadir of deceleration occurs at same time as the peak of the contraction (e) Onset, nadir, recovery of deceleration → coincident with beginning, peak, ending of contraction (3) Late deceleration (a) Visually apparent, usually symmetrical, gradual decrease, return to FHR to BL, associated with uterine contraction (b) Gradual FHR decrease → defined from onset to nadir of 30 seconds or more Decrease in FHR calculated from onset to nadir of the deceleration (c) Deceleration delayed in timing, with nadir of deceleration occurring after peak of contraction (d) In most cases → onset, nadir, recovery of the deceleration occurs after beginning, peak, and ending of contraction (4) Variable deceleration (a) Visually apparent abrupt decrease in FHR (b) Abrupt FHR decrease defined as from onset of deceleration to beginning of FHR nadir of 30 seconds of less (c) Decrease in FHR is 15 beats/min or more → lasting 15 seconds or more, less than 2 minutes (d) Associated with uterine contractions → vary with successive uterine contractions (5) Early decelerations (Figure 20–17, p. 488) (a) Result of vagal nerve stimulation (i) Caused by fetal head compression occurs during UC (ii) Not associated with loss of variability, tachycardia, other FHR changes → viewed as reassuring unless seen with lack of descent of fetal head (6) Late decelerations (a) Lates or late decels → uteroplacental insufficiency → decreased blood flow and/or oxygen transfer to fetus (b) Reflexive → normal physiologic chemical response to low oxygen levels (c) Myocardial → repetitive, chronic episodes → metabolic acidosis → myocardial depression (d) Decrease in heart rate → usually shallow, 10 to 20 beats/min (e) Baseline variability minimal or absent → fetal hypoxia (f) Supine position (g) Immediate interventions (i) Position change → elevate trunk or turn on side 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(ii) Increase intravenous fluids (iii) Oxygen via face mask (iv) Stop IV Pitocin if infusing (v) Notify physician, CNM immediately (7) Episodic or periodic decelerations (a) Episodic → without relationship to UCs, result of environmental stimuli (b) Periodic → direct association with UCs (i) Considered repetitive if they occur with 50% or more of UCs (8) Early or late decelerations (a) Periodic decelerations also classified by timing with respect to UCs (9) Prolonged decelerations (a) Visually apparent decrease in FHR (b) Lasts >2 minutes and <10 minutes (10) Variable decelerations (a) See Figure 20–22: Mechanism of variable deceleration, p. 491 (b) Have U or V shape, typically associated with cord compression (c) Not usually concerning unless: (i) Less than 70 beats/min (ii) Lasts more than 60 seconds (iii) Slow to return to baseline

L. Interpretation of Fetal Heart Rate Patterns 1. Systematic approach a) Determine uterine resting tone b) Assess contractions (1) What is the frequency? (2) What is the duration? (3) What is the intensity (if internal monitoring)? c) Evaluate FHR tracing (1) Determine baseline (a) Is the baseline within normal range? (b) Is there evidence of tachycardia? (c) Is there evidence of bradycardia? (2) Determine FHR variability (a) Is variability absent, minimal, or moderate? (b) Is variability minimal or marked? (3) Determine whether sinusoidal pattern present (4) Determine whether there are periodic changes (a) Are accelerations present? (b) Is there a reassuring tracing or FHR pattern? (c) Are decelerations present? (d) Are they uniform in shape? If so, determine if they are early or late decelerations. (e) Are they nonuniform in shape? If so, determine if they are variable decelerations.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Categorize tracing a) See Table 20–7: Three-Tier Fetal Heart Rate Interpretation System, p. 492 b) Three-Tier Fetal Heart Rate Interpretation System (1) Category I: FHR tracings are normal (a) Baseline 110 to 160 beats/min (b) Baseline FHR variability moderate (c) Late or variable decelerations absent (d) Early decelerations present or absent (e) Accelerations present or absent (2) Category II: FHR tracings are indeterminate (a) Baseline rate (i) Bradycardia not accompanied by absent baseline variability (ii) Tachycardia (b) Baseline FHR variability (i) Minimal (ii) Absent without decelerations (iii) Marked baseline variability (c) Accelerations (d) Episodic decelerations (i) Recurrent variable decelerations (ii) Prolonged deceleration ≥2 minutes but <10 minutes (iii) Recurrent late decelerations with moderate baseline variability (iv) Variable decelerations with other characteristics → slow return to baseline, overshoots, shoulders (3) Category III: FHR tracings are abnormal (a) Absent baseline FHR and any of the following (i) Recurrent late decelerations (ii) Recurrent variable decelerations (iii) Bradycardia (b) Sinusoidal pattern 3. Provide information to laboring woman regarding FHR pattern 4. Labor and birth nurses → skilled, competent in evaluating FHR patterns and respond a) See Key facts to Remember: Guidelines for Management of Variable, Late, and Prolonged Deceleration Patterns, p. 494

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Indirect Methods of Fetal Assessment A. Scalp stimulation, acoustic stimulation, maternal abdominal palpation 1. Ongoing scalp stimulation is not recommended and should not be used by nurses

B. Cord Blood Analysis at Birth 1. Indications → significant abnormal FHR patterns have been noted before birth, amniotic fluid is meconium stained, or the newborn is depressed at birth 2. Analyze immediately after birth to assess respiratory status 3. Cord clamped prior to first breath a) 8- to 10-inch segment double clamped, cut b) Blood collected from umbilical arteries in heparinized syringe c) Should not be allowed to remain in the segment of cord longer than 30 minutes

Focus Your Study

VI.

Activities 1. Individual Have students prepare a teaching plan for the laboring woman who does not understand fetal monitoring. 2. Small Group Divide the class into small groups of three to five students. Assign each small group a fetal heart rate pattern to describe and illustrate. The rubric should include the following: normal or abnormal patterns, causes, nursing interventions, and a teaching plan for the laboring woman who asks about the waveform pattern. The fetal heart rate patterns to include in the exercise are as follows: • Tachycardia • Bradycardia • Wandering baseline • Sinusoidal fetal heart rate pattern • Atrial dysrhythmias • Ventricular dysrhythmias • Accelerations • Decelerations 3. Large Group Review the monitor strip pictures from http://fetalmonitorstrips.com/learn_more.html or http://www.aafp.org/afp/990501ap/2487.html with the class. Project or print handouts for the students. Discuss reassuring and nonreassuring monitor strips.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 21 The Family in Childbirth: Needs and Care Reality of Childbearing and Childrearing............................................................

Nursing Diagnoses During Labor and Birth........................................................

Nursing Care During Admission……………………………………………………………………..

Nursing Care During the First Stage of Labor.....................................................

Nursing Care During the Second Stage of Labor................................................

Nursing Care During the Third Stage of Labor....................................................

Nursing Care During the Fourth Stage of Labor.................................................

Nursing Care of the Adolescent..........................................................................

Nursing Care During Precipitous Labor and Birth...............................................

Evaluation............................................................................................................

Focus Your Study.................................................................................................

Activities..............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Reality of Childbearing and Childrearing

A. Meaningful, stressful event B. Concerns about care 1. Look to nurse for support

II.

Nursing Diagnoses During Labor and Birth

A. General plan to encompass whole process 1. First-stage diagnoses a) Anxiety related to discomfort of labor and unknown labor outcome b) Knowledge, Readiness for Enhanced c) Coping: Family, Compromised d) Pain, Acute e) Knowledge, Deficient f) Fear related to unknown birth outcome and anticipated discomfort 2. Second- and third-stage diagnoses a) Pain, Acute b) Knowledge, Deficient c) Coping, Ineffective d) Fear related to outcome of birth process 3. Fourth-stage diagnoses a) Pain, Acute b) Knowledge, Deficient c) Family Processes, Readiness for Enhanced

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

III.

Nursing Care During Admission

A. Usually arrive at birth setting 1. Beginning of active phase of labor 2. Rupture of membranes (ROM) 3. Decreased fetal movement 4. Regular, frequent uterine contractions 5. Any vaginal bleeding

B. Patient teaching 1. What will occur during labor 2. Informed consent

C. Establishing a Positive Relationship 1. Initial interaction a) Increase or decrease anxiety 2. Create environment for family to ask questions a) Establish rapport, create supportive environment b) Provide opportunity for questions 3. Process of admission 4. Communicate in primary language 5. Cultural factors

D. Labor Assessment 1. Triage area, birthing room a) Admission history (1) Assist nurse in making effective nursing decisions (a) Is woman in labor or candidate to be sent home? (b) Are there factors that put woman or fetus at risk? (c) Should ambulation or bedrest be encouraged? (d) Is more frequent monitoring needed? (e) What are woman’s wishes and special requests? (f) Who will be with laboring woman for social support? b) Woman made comfortable c) Prenatal records 2. Intrapartum assessment a) Auscultate fetal heart rate (FHR) 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Vital signs c) Contraction status d) Cervical dilation and effacement e) Fetal presentation and station (1) Early latent (2) Nullipara → sent home or ambulate f) Share findings with couple g) Advanced labor → physician, CNM notified immediately h) Signs of excessive bleeding, painless bleeding in last trimester, placenta previa → no vaginal exam 3. Results of comprehensive assessment determine if admission is routine or urgent 4. Notify physician or CNM if high risk a) If high-risk or emergency data identified → before or after completing admission process b) See Table 21–1: Indicators of Normal Labor Process on Admission, p. 500 5. Report should include a) Cervical dilation and effacement b) Station c) Presenting part d) Status of membranes e) Contraction pattern f) Fetal heart rate g) Vital signs that are not normal h) Response to labor by woman

E. Collecting Laboratory Data 1. Clean-voided midstream urine specimen a) Dipstick prior to sending to lab 2. Hemoglobin and hematocrit 3. Blood is typed and cross-matched 4. Syphilis if not done in last 3 months 5. HIV if not screened during pregnancy

F. Social Assessment 1. Detailed social history a) Risk factors including (1) Family violence or sexual assault (2) Drug, alcohol, tobacco use (3) Presence of sexually transmitted infections b) Current living situation 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Resources available d) Preparedness for newborn e) Community resources f) Social support network 2. Provide information 3. Referrals to social services

G. Documentation of Admission 1. Nursing admission note a) Reason for admission b) Date, time, method of arrival c) Notification of physician/CNM d) Condition of woman and baby e) Labor and membrane status f) Current level of pain g) Pertinent social assessment information

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Interpreter 3. Comfort level

IV.

Nursing Care During the First Stage of Labor A. Plan of care to achieve nursing goals 1. Physical safety of woman and fetus 2. Emotional well-being of laboring couple 3. Support system 4. Continually assesses the effects and pattern of the UCs, FHR, and fetal well-being, maternal vital signs (VS), cervical changes, and intake and output

B. Labor support → primary role of nurse 1. Information 2. Pain management 3. Procedures and examinations 4. Reassurance 5. Positive reinforcement & praise 6. Assess individual preferences

C. Integration of Family Expectations 1. Assess expectations a) Birth plan 2. Expectations of nurse a) Highly involved b) Minimal involvement 3. Challenging to provide individualized care a) Cues from couple b) Direct questions

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Nurse serves as advocate for woman and support person

D. Integration of Cultural Beliefs 1. Values, customs, practices 2. Research → individual’s experiences in labor are highly dependent upon social and cultural norms 3. Cultural responses to labor a) Modesty b) Pain expression (1) Reactions (2) Korean culture → used to be important to be silent (3) European Americans → variety of behaviors 4. Examples of cultural beliefs a) Position b) Food and drink c) Hispancic women → partner with them (1) May fear loss of modesty, labor longer at home (2) Use less pain medications d) Muslim women (1) See case example on p. 462 5. European Americans demonstrate a wide variety of behaviors in response to pain 6. Need awareness of beliefs, values, practices → understand needs a) Demographics b) Stereotyping should be avoided

E. Provision of Care in the First Stage 1. Evaluate physical parameters of woman and fetus a) Maternal temperature every 4 hours unless elevated (1) 37.5°C (99.6°F) → taken every hour (2) Every 2 hours after amniotic fluid has ruptured b) Blood pressure, pulse, respirations → every hour c) BP > 30 systolic or 15 diastolic increase above prepregnancy readings or her pulse is more than 100 → notify provider Intrapartum vaginal examinations (1) To assess cervical changes, status of membranes, fetal position, and station (2) Increase risk of infection d) FHR every 30 minutes when between 110 and160 beats per minute (beats/min) without decels 2. Latent phase a) Anticipatory guidance b) Encourage ambulation 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) If no ROM, no vaginal bleeding c) Offer clear liquids, ice chips, snacks at frequent intervals with low-risk pregnancies d) Tour birthing facility 3. Active phase a) Contractions frequency → 2 to 3 minutes, a duration of 50 to 60 seconds, and moderate intensity (1) Palpate contractions every 15 to 30 minutes b) Intrapartum vaginal exam → assess cervical dilation, effacement, fetal station and position (1) Cervix dilates from 4 to 7 cm, vaginal discharge and bloody show increase c) Encourage woman to void d) Vital signs every hour → low risk (1) Every 30 minutes for high risk e) FHR is auscultated every 30 minutes for women without complications (1) Every 15 minutes for women with complications f) Slow labor, not tolerating fluids → intravenous (IV) may be started (1) Encourage voiding every 1 to 2 hours to prevent bladder distention g) Amniotomy if membranes not ruptured (1) Document color, odor, time (a) Meconium staining may indicate fetal compromise (b) Increased incidence of amnionitis after membranes ruptured 24 hours (c) Monitor for cord prolapse 4. Transition phase a) Increase contraction frequency (1.5–2 min), duration (60–90 sec), intensity strong (1) Cervical dilatation increases 8 to 10 cm (2) Effacement 100%-nulliparous vs multiparous b) Contractions are palpated at least every 15 minutes c) Sterile vaginal examination can be done during this stage of labor to assess rapid changes in status d) Maternal blood pressure, pulse, and respirations are taken at least every 30 minutes, and FHR is auscultated every 30 minutes for low-risk women and every 15 minutes for high-risk women e) Woman’s center of focus turns inward (1) Ability to speak in coherent sentences may be impaired (2) Follow cues f) Encourage woman to rest between contractions g) Assist with breathing during contraction (1) Encouragement (2) Encourage to refrain from pushing until cervix dilated (3) Short breaths, pant like puppy h) Involuntary passage of flatus, stool, deepening voice → end of transition, beginning of second stage (1) Increasing pressure, feel need to bear down 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

F. Promotion of Comfort in the First Stage 1. Initial step → identify goals of woman, partner a) Identify factors that contribute to discomfort 2. Responses to pain a) Increased pulse, respiratory rate, dilated pupils, increased blood pressure, muscle tension b) Sounds important part of labor and birthing process (1) Naturally make sounds such as moans and grunts and feel that it helps them cope and do the work of labor (2) Screams → loss of ability to cope c) Touch may be soothing d) Nonverbal cues e) Nursing measures to decrease pain include (1) Encouraging position changes (2) Assisting with personal comfort measures (3) Decreasing anxiety (4) Providing information (5) Using specific supportive relaxation techniques (6) Encouraging paced breathing (7) Administering pharmacologic agents as desired 3. Position changes a) Ambulatory → fetal head, electronic fetal monitoring (EFM) reassuring FHR pattern (1) In bed if membranes ruptured, presenting part not engaged, bedrest recommended (2) See Figure 21–1: Woman and her partner walking in the hospital during labor, p. 504 (3) Use pillows to help b) Assume any comfortable position in bed (1) Side lying generally most advantageous (2) Frequent position changes, every hour 4. Personal comfort measures a) Vaginal discharge increases → change underpads frequently (1) Wash perineum with warm soap and water (2) Standard precautions b) Diaphoresis, constant leaking of amniotic fluid (1) Fresh, smooth, dry linen (2) Replace underpads frequently c) Cool washcloth to forehead, behind neck d) Encourage to void every 1 to 2 hours e) Assess bladder for retention of urine f) Dry mouth (1) Clear fluids, ice chips (2) Encourage nose breathing (3) A & D ointment or lip emollient to moisten dry lips 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Lollipops (5) Rinse mouth if vomits g) Cold feet → slippers, socks h) Birthing balls (1) Balance, safety issue (2) See Figure 21–2: The laboring woman is encouraged to choose a position of comfort, p. 506 i) Family, support person can assist with comfort measures j) Encourage family members to maintain own comfort 5. Reducing anxiety a) Related to combination of factors b) Anxiety not related to pain (1) Give information (2) Establish rapport (3) Express confidence in couple’s ability (4) Remain with woman as is possible (5) Praise for correct actions (6) Partner anxiety (a) Feeling helpless (b) Lack of knowledge (c) See Figure 21–3: The woman’s partner provides support and encouragement during labor, p. 507 c) History of sexual abuse or rape (1) Nonverbal cues 6. Providing information a) Stress intermittent nature b) Maximum duration of contractions c) Explanation of surroundings, procedures, equipment 7. Supportive relaxation techniques a) Tense muscles increase resistance to descent of fetus (1) Contribute to maternal fatigue, anxiety (2) Encouraged to use the periods between contractions to rest and relax muscles b) Distractions c) Touch (1) Hand available for touch d) Effleurage → abdominal comfort during contractions e) Pressure on lower back → back discomfort f) Visualization g) Encouragement and support for controlled breathing techniques 8. Breathing techniques a) Avoid hyperventilation b) Prenatal classes 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Alternate relaxation and breathing exercises d) Hyperventilation → rapid breathing (1) Signs (a) Tingling, numbness nose, lips, fingers, toes (b) Dizziness (c) Spots before eyes (d) Spasms of hands, feet (2) Interventions (a) Encourage to slow breathing, shallow breaths (b) Relax (c) Count out loud (d) Remain with woman e) Assess interaction between woman and coach 9. Complementary and alternative therapies a) Hydrotherapy 10. Other comfort measures a) Analgesic agents, regional anesthesia blocks 11. See Evidence-Based Practice: Relaxation Therapies During Labor, p. 508

Nursing Care During the Second Stage of Labor A. Provision of Care in the Second Stage 1. Sterile vaginal exams to assess fetal descent 2. Maternal blood pressure, pulse, FHR every 5 minutes 3. Fetus FHR every 5 to 15 minutes 4. Sensitive to sounds, changes woman makes 5. When to push a) Studies → rest up to 90 min and wait until urge b) Uncomfortable urge to push (bear down) → normal (1) Splitting apart, ring of fire → normal c) When contraction begins → take two short breaths → third breath → hold it while pulling back on knees, pushing down with abdominal muscles (1) May prefer to exhale slightly while pushing 6. Encourage to rest between contractions a) Assist into comfortable position b) Comfort measures

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Woman may want to change position 8. Fatigue, frustration → short rest period a) Inform provider of time spent pushing b) Provide information regarding progress 9. Prepared for birth a) Nullipara → perineum begins to bulge b) Multipara → cervix at 7 to 8 cm dilated 10. Monitor contractions, blood pressure, FHR a) Assist with pushing 11. Assist physician or CNM in preparing for birth a) Sterile gown, gloves b) Drapes over abdomen, legs

B. Promotion of Comfort in the Second Stage 1. Second-stage comfort measures that are appropriate are same as in first stage a) Cool cloths b) Dry gown c) Remove clothing if hot 2. Additional measures a) Warm compresses (1) Perineum (2) Abdomen (3) Back b) Perineal massage 3. Encourage rest of all muscles between contractions 4. Visualization techniques

C. Assisting the Woman and Physician/CNM During Birth 1. Equipment and materials into birthing room, delivery room a) Family → same clothes for birthing room, scrubs for delivery room b) Handwashing by nurses, physician, CNM c) Protective clothing for nurses 2. Labor, delivery, and recovery (LDR) rooms a) May all be done in one room depending on facilities 3. Birthing room a) If woman moved from one bed to another → between contractions b) Preserve privacy c) Family still together 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Give simple directions on how to assist, be involved 4. Maternal birthing positions a) Bed, birthing chair, delivery table (1) Determined by woman and physician/CNM (2) Stirrups → padded, lift legs simultaneously (3) Upright position normal until modern times (a) women selected squatting, kneeling, standing, and sitting for birth b) See Table 21–4: Comparison of Birthing Positions, p. 513 c) Recumbent (1) Used to enhance asepsis, assessment of FHR, episiotomy and repair (2) Disadvantages (a) Decrease in blood pressure (b) Many women experience difficulty breathing (c) Uterine axis directed toward symphysis pubis instead of pelvic inlet (d) Increased risk of aspiration (e) May increase perineal pressure, making laceration more likely (f) Position may interfere with uterine contractions (g) Ensure stirrups do not cause excessive pressure on the legs (h) Woman works against gravity (i) Disadvantages lessened slightly if woman has back elevated 30 to 40 degrees d) Left lateral Sims (1) Left leg extended, right knee drawn against abdomen (2) Frequency of contractions may decrease → intensity increases (3) Increases overall comfort (4) Does not compromise venous return (5) Puts less stress and pressure on maternal neck (6) Diminishes chances of aspiration (7) Perceived as more natural (8) Fewer episiotomies → perineum tends to be more relaxed (9) Disadvantages (a) Difficult cutting, repairing episiotomies (b) Problems with difficult forceps births (c) Difficult for woman to see the birth (10) See Figure 21–5, Sidelying laboring or birthing position, p. 514 e) Squatting (1) Uses gravity (2) Abdominal wall relaxes (3) Aids in stretching cervix → stimulates myometrium to produce more intense uttering contractions (4) Birthing bar to increase balance, provide support (5) Increase size of pelvic outlet (6) Disadvantages (a) Difficult to control birth process 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Increases difficulty of administering analgesia (c) Increases difficulty of using instruments (d) Difficult to monitor fetal station (e) Perineal edema f) Semi-Fowler (1) Middle ground between recumbent & upright positions (2) Shorter first and second stages of labor (3) Enhances effectiveness of abdominal muscle efforts (4) Raising, supporting torso → helps woman view birth process (5) Birth attendant has access to perineum g) Sitting in birthing bed (1) Gravity aids descent and expulsion of the fetus. (2) Does not compromise venous return from lower extremities. (3) Woman can view the birth process. (4) Leg position may be changed at will. (5) Ensure legs and feet have support h) Sitting on birthing stool (1) Gravity aids descent and expulsion of the fetus. (2) Does not compromise venous return from lower extremities. (3) Woman can view the birth process. (4) Leg position may be changed at will. (5) Disadvantages (a) difficult to provide support to woman’s back (6) Encourage to sit in position that increases comfort i) Hands and knees (1) More comfortable for woman experiencing back labor (2) Extra pillows for forearms (3) Less pressure on perineum (4) Birth attendant has access to perineum for stretching (5) Access to fetal nose and mouth for suctioning (6) May increase placental and umbilical blood flow (7) May increase pelvic diameter → facilitate less traumatic birth of infant with shoulder dystocia (8) Disadvantages (a) Decreased eye contact between mother, birth attendant (b) Inability to use instruments (c) Necessity of repositioning mother for perineal repair (d) Maternal fatigue (e) Woman cannot view birth 5. Cleansing the perineum a) Position for birth b) Nurse washes hands c) Opens sterile prep tray 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Dons sterile gloves e) Cleans vulva, perineum with cleansing solution f) Mons pubis up to lower abdomen g) Second sponge → inner groin, thigh of one leg h) Third sponge → other leg, moving outward i) Last three sponges → labia and vestibule → one downward sweep each j) May use a spray bottle with cleansing agent 6. Support during the second stage a) Assess partner/support person for comfort, knowledge b) Assists in activities that will support woman c) Keep support team informed 7. Assisting with the birth of the baby a) With fetal head distending perineum → clinician may support perineum (1) Woman asked to breathe rapidly, pant, blow to avoid too-rapid birth of fetal head b) After infant’s head born → clinician palpates for neck for presence of cord c) Restitution and external rotation → after head born (1) Suctioning (2) Gentle pull to release anterior shoulder d) Grasp posterior shoulder with one hand, palm toward perineum 8. Assisting with clamping the umbilical cord a) Controversy about when to clamp and cut cord b) Birth plan may express a preference (1) Delayed cord clamping for > 30 seconds in preterm infant may reduce transfusions, intraventricular hemorrhage, sepsis c) Clamped with two Kelly clamps, cut between them d) May be double clamped → collection of cord blood gases e) Examine newborn’s stump for two arteries, one vein f) Clamp 0.5 to 1 inch from abdomen (1) See Figure 21–6: Hollister cord clamp, p. 515 9. Cord blood collection for banking a) Immediately after cord is clamped and cut → before placenta expelled → physician/CNM withdraws blood from umbilical cord (1) Blood placed in special container (2) Special directions with container b) Recommendations for banking (1) Stem cell transplants for family history if illness, children with nontraditional lineage (2) Stem cell transplants used to treat many different types of diseases (3) Cord blood has advantages over bone marrow (4) Universal cord blood collection does not exist (5) Cord blood transfusions utilized to treat a number of disorders (6) Written consent required for both collection and storage of cord blood (7) Considered no-risk procedure 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Nursing Care During the Third Stage of Labor

A. Provision of Initial Newborn Care 1. Physician/CNM places newborn on mother’s abdomen, chest for skin-to-skin, or radiantheated unit a) Skin-to-skin optimal for warmth, to promote breastfeeding, & fosters bonding 2. Respirations first priority a) Modified Trendelenburg to aid drainage of mucus b) Nasal pharyngeal suctioning (1) See Clinical Skill 21–1: Performing Nasal Pharyngeal Suctioning, p. 516 3. Provide, maintain warmth a) Dried immediately with warmed, soft blanket b) Dry head first c) Skin-to-skin contact with mother, both covered d) Stocking cap

B. Apgar scoring system 1. See Table 21–5: The Apgar Scoring System, p. 517 2. Evaluate physical condition of newborn a) 1 minute and 5 minutes after birth b) Total score of 0 to 10 based on five criteria 3. Five criteria evaluated a) Heart rate b) Respiratory effort c) Muscle tone d) Reflex irritability e) Skin color 4. Overall scores a) 7 to 10 → good condition, nasopharyngeal suctioning b) 4 to 7 → need for stimulation c) Less than 4 → need for resuscitation

C. Newborn physical assessment by the nurse 1. See Table 21–6: Initial Newborn Evaluation, p. 518 2. Abbreviated systematic physical assessment a) Size of newborn b) Contour, size of head in relationship to rest of body c) Posture, movements d) Muscle tone 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Palpation of fontanelles f) Inspect face, ears, neck g) Skin inspected for discoloration, presence of vernix caseosa, lanugo (1) Evidence of trauma, desquamation h) Observe nares for flaring i) Inspect palate j) Suction as needed with bulb syringe k) Inspect chest for respiratory rate, retractions l) Auscultation m) Normal respiratory rate (RR) 30 to 60 breaths per minute n) Heart auscultated → 110 to 170 beats/min o) Inspect umbilical cord, abdomen p) Genital area, buttocks, anus noted q) Extremities inspected for symmetry r) Reflexes assessed

D. Newborn identification 1. Nurse gives mother and newborn identification codes in birthing or delivery room a) Mothers wrist, sometimes wrist of partner b) Newborn → two, one on wrist, one on ankle c) Security device on cord clamp, id bracelet (1) See Figure 21–8: A newborn with a security device in place on one ankle, p. 518 2. Security measures a) Identification b) Parent education c) Do not leave baby in room unattended, send to nursery d) Footprinting

E. Initiation of attachment 1. Emotional time for family a) Touching baby b) Talking to baby, often high-pitched voice 2. Lights can be dimmed → newborn open eyes wide a) First hour, newborn quiet 3. Complete assessments while baby is on mother’s chest or abdomen 4. Breastfeeding can be encouraged 5. Enhance attachment a) Minimize assessments b) Delay instillation of ophthalmic antibiotic for first hour c) Keep room slightly darkened, avoid loud noises

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Provide privacy per parents’ request (1) Parents may want immediate contact (2) Parents may want to wait until placenta expelled, episiotomy repaired e) Support wishes of parents f) Encourage to delay phone calls and visits for first hour

F. Delivery of the Placenta 1. Physician/CNM observes for signs of placental separation a) Uterus rises upward in abdomen → placenta settles downward into lower uterine segment b) As placenta proceeds downward → umbilical cord lengthens c) Sudden trickle, spurt of blood d) Uterus changes from discoid to globular shape 2. Nurse palpates uterus gently to check for ballooning 3. Expelling placenta a) Maternal bearing-down effort b) Controlled cord traction c) Fundal pressure 4. To assist in expelling placenta a) Ensure separation has occurred b) Place one hand above symphysis pubis → palm against anterior surface of uterus c) Elevation of uterus straightens birth canal d) Gentle traction → excessive traction increases risk of uterine, inversion, snapping of cord 5. Fundal pressure not method of choice a) Uncomfortable b) May damage uterine supports c) May invert uterus d) Mother → relax abdominal muscles e) Hand of physician/CNM scoops downward → contracted uterus is pressed downward in an arc 6. Inspection of placental membranes a) All cotyledons present → especially with Duncan mechanism (1) If there is a defect or a part missing from the placenta, a digital uterine examination is done b) Time and mechanism noted c) Vagina and cervix inspected for lacerations d) Fundus palpated; normal position is at the midline and below the umbilicus

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

G. Use of Oxytocics 1. Stimulate uterine contractions after birth a) Reduce incidence of third-stage hemorrhage 2. May request 10 units of oxytocin be given intramuscularly to woman a) Anterior shoulder of infant at vaginal opening b) May be administered after placental expulsion 3. May add 10 to 20 units of oxytocin to IV fluids instead 4. Other medications a) Methylergonovine maleate (Methergine) b) Carboprost tromethamine (Hemabate) c) Misoprostol (Cytotec) → off-label use (1) Undesirable side effects including shivering, pyrexia, and diarrhea

VII.

Nursing Care During the Fourth Stage of Labor

A. Immediately after expulsion of placenta 1. Lasts 1 to 4 hours after birth until vital signs are stable 2. Episiotomy, vaginal lacerations repaired 3. Uterus palpated every 15 minutes → for hour, until firm and bleeding within normal limits a) Uterus sensitive to touch 4. Care of newborn next to mother 5. Behavioral characteristics of mother vary

B. Provision of Care in the Fourth Stage 1. After repairs completed, drapes removed 2. Clean absorbent pads beneath mother a) Maternity pads b) Cold pack on perineum c) Assist for shower as needed d) If stirrups used → clean perineum before removing legs from stirrups e) Legs removed from stirrups at same time f) Transfer to recovery room as appropriate 3. Encourage family celebration while assessing maternal bleeding, newborn stabilization a) Blood pressure, pulse → 5- to 15-minute intervals b) Firmness and position of fundus (1) Firm at the umbilicus or lower and in the midline c) Boggy uterus → feels soft → kneading motions → fundus will tighten to firm, hard object 19 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) See Clinical Skill 21–2: Assessing the Uterine Fundus Following Vaginal Birth, p. 522 d) Inspect bloody vaginal discharge (1) Lochia (a) See Clinical Skill 32–2: Evaluating Lochia, p. 871 (2) Minimal, moderate, or heavy amount (3) Weigh maternity pads (a) 1 g is equivalent to approximately 1 mL of blood e) Continuous observation if perineal pad soaked in 15 minutes, or blood pools f) If fundus rises, displaces to right → palpate bladder for distension (1) Decreased sensations to void as a result of the decreased tone of the bladder (2) Catheterize if unable to void (3) Distended bladder → uterine atony → increasing postpartum bleeding g) Inspect perineum for edema, hematoma 4. Report the following to physician/CNM a) Hypotension b) Tachycardia c) Uterine atony d) Excessive bleeding e) Temperature > 38°C (100.4°F)

C. Promotion of comfort in the fourth stage 1. Tremors, shivering common a) Heated blanket b) Warm drink 2. Tired, hungry, thirsty a) Meal b) Sleep 3. Transfer to postpartum unit a) Per policy b) Vital signs stable c) Stable lochia d) Nondistended bladder e) Firm fundus f) Sensations fully recovered from any anesthetic agent received

VIII.

Nursing Care of the Adolescent

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) What are her attitudes and feelings about the pregnancy? c) How does her developmental stage influence her behavior, and how are her specific needs different? d) Who will support her during birth, and what is person’s relationship to her? e) What preparation has she had for the experience? f) What are her expectations and fears regarding labor and birth? g) How has her culture influenced her? h) What are her usual coping mechanisms? i) Does she have adequate social support? j) Does she plan to keep the newborn? If so, does she need to learn parenting skills? k) Will the father of the baby be involved in the labor and birth experience? 3. Highest risk for pregnancy and labor complications a) If no prenatal care → close observation during labor b) Review record for risks c) More likely to have poor nutritional intake, preeclampsia, cephalopelvic disproportion (CPD), anemia, prematurity, drugs ingested during pregnancy, sexually transmitted infections, fetal death, and size–date discrepancies (gestation appears to be less than dates indicate because of minimal weight gain) 4. Support role depends on support system a) Establish trusting relationship b) Positive reinforcement c) Younger the adolescent → less able she may be to participate in process

B. Age-Related Responses to Labor and Birth 1. Very young adolescent (under age 14) → fewer coping mechanisms a) Needs someone to rely on at all times during labor b) More childlike and dependent c) Transition → withdrawn (1) Needs touching, soothing encouragement, nurturing 2. Middle adolescent (ages 14 to 16) a) May try to remain calm, unflinching 3. Older adolescent (ages 16 to 19) a) May feel they “know it all” b) Nurse needs to use reinforcement and nonjudgmental manner

C. The Adolescent Father 1. Important part of labor and birthing care 2. Early labor a) Talk about expectations for parenting, resources available b) May need encouragement to provide supportive care

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Use lay terms to answer questions honestly

D. Other Members of the Support Team 1. Adolescent mother may want parents, friends a) May want her parents b) May look to friends 2. Respect young woman’s privacy, honor her wishes 3. Advocate

E. Teaching the Adolescent Mother 1. Latent phase of labor a) Explain changes in body sensations, emotional reactions b) Teaching about possible procedures c) Assess for resources for infant, postpartum supplies, transportation, child care 2. Infant care information a) Breastfeeding information b) Support decision making 3. May relinquish newborn a) Seeing infant can facilitate grieving process, but is her choice

IX.

Nursing Care During Precipitous Labor and Birth A. Rapid labor → labor and birth last < 3 hours → nurse must manage birth of baby 1. Woman may feel disappointed, frightened, cheated, abandoned if physician/CNM not present 2. Keep woman informed

B. Imminent birth 1. Do not leave woman alone 2. Direct auxiliary personnel to retrieve precip pack and contact physician/CNM a) Pack contains (1) Small drape (2) Bulb syringe (3) Two sterile clamps (Kelly or Rochester) to clamp the umbilical cord before applying a cord clamp (4) Sterile scissors to cut the umbilical cord (5) Sterile umbilical cord clamp, either Hesseltine or Hollister (6) Baby blanket (7) Package of sterile gloves

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Remain calm a) Will reassure woman

C. Birth of the Baby 1. Encourage woman to assume comfortable position 2. Scrub hands, sterile gloves as time permits 3. Clear instructions to woman 4. Most vertex → when crowning instruct to blow, pant 5. If amniotic sac intact → tear with clamp 6. Index finger inside lower portion of vagina → stretching, “ironing the perineum” 7. Gentle pressure on head to maintain flexion a) Slows birth b) Do not force head back forcibly 8. Support perineum with the other hand and allow the head to be delivered between contractions 9. Woman continues to blow, pant → insert one or two fingers along back of fetal head to check for umbilical cord a) Grasp cord, pull over head, loosen, slip over shoulder b) If too tight → clamp with two clamps, cut between 10. Head typically rotates → nurse needs to let it rotate 11. After delivery of head → suction mouth, throat, then nose 12. Hand on each side of head of newborn → instruct mother to push down gently 13. Support as it emerges

D. Breech vaginal delivery 1. Rare (3%) 2. Most scheduled for cesarean birth 3. Primary concern → entrapment of head in cervix 4. Avoid intervention until buttocks born a) Pull loop of cord, support breech in both hands b) Lift slightly upward, shoulder passes under symphysis pubis c) Then lower and the anterior shoulder and arm will pass under the symphysis pubis d) Suprapubic pressure applied → maintain the normal flexion of the baby’s head → continued until the baby is born

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. After birth 1. Newborn held at level of uterus to facilitate blood flow through cord 2. Infant slippery 3. Dry quickly 4. Head slightly lower to aid drainage of fluid, mucus 5. Apgar score assessed at 1 and 5 minutes 6. Alert for signs of placental separation a) Gentle downward traction on cord while instructing mother to push b) Inspect placenta 7. Assess firmness of uterus a) No palpation of uterus before separation of placenta 8. Cut umbilical cord a) Two clamps → 2 to 4 inches from newborn’s abdomen b) Cut between clamps with sterile scissors 9. Clean under mother’s buttocks a) Inspect for lacerations b) Bleeding from lacerations → pressing a clean perineal pad against the perineum → instruct woman to keep her thighs together

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

10. Transport newborn to nursery if arrival of physician/CNM delayed, signs of respiratory distress

F. Record Keeping 1. Position of fetus at birth 2. Presence of cord around neck or shoulder (nuchal cord) 3. Time of birth 4. Apgar scores at 1 and 5 minutes 5. Gender of newborn 6. Time of expulsion of placenta 7. Method of placental expulsion 8. Appearance and intactness of placenta 9. Mother’s condition 10. Any medications that were given to mother or newborn (per agency protocol)

G. Postbirth Interventions 1. Same as those discussed in Nursing Care During the Third Stage of Labor section

Evaluation A. Determine effectiveness of nursing care B. Anticipated 1. Mother’s physical needs and psychologic well-being of family have been maintained and supported 2. Baby’s physical and psychologic well-being has been protected and supported 3. Family has had input into birth process, and members have participated as much as they desired 4. Birth was safe and promoted family cohesiveness

XI.

Focus Your Study

XII.

Activities 1. Individual Have students prepare drug cards for the following medications, which are frequently used in labor:

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

• • • •

Oxytocin Methylergonovine maleate Carboprost tromethamine Misoprostol

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the adolescent in early labor. Instruct the students to include fetal heart rate (FHR) monitoring and potential interventions after delivery. 3. Large Group Show a video from the following link http://childbirthvideo.biz/. Stop as necessary to identify phases of the delivery process.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 22 Pharmacologic Pain Management Medicated Birth....................................................................................................

Systemic Analgesia................................................................................................

Regional Anesthesia and Analgesia......................................................................

General Anesthesia...............................................................................................

Analgesic and Anesthetic Considerations for the High-Risk Mother and Fetus……………………………………………………………………………………………………..

Focus Your Study...................................................................................................

Activities................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Medicated Birth

A. Unmedicated versus medicated decisions involves many factors 1. Caregiver preference 2. Availability of analgesia & anesthesia 3. Fear of risks, complications 4. Past experiences 5. Previous pain experience 6. Culture

B. Increasing levels of pain 1. Interfere with coping

C. Decisions regarding medicates/unmedicated birth 1. Many factors 2. Support decision a) Offer alternatives if they do not want pharmacologic remedies 3. 2/3 of U.S. births receive regional anesthesia like an epidural 4. Offer alternative comfort measures 5. Pharmacologic agents affect fetus 6. Response to pain and stress also affects fetus

D. Unprepared for intense pain 1. Physiological and emotional responses to labor a) Increased respiratory rate b) Increased oxygen consumption c) Metabolic acidosis d) Release of catecholamines, leading to constriction of maternal blood vessels e) Fear and anxiety f) Feeling of being out of control g) Stalled labor progression.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Goal is healthy, satisfying outcome for family

II.

Systemic Analgesia

A. Goal → maximum pain relief with minimal risk B. Systemic analgesia → pain medication given intravenously, intramuscularly, or via inhalation that does not result in complete loss of sensation or a reduction of motor functioning C. Multiple factors to consider 1. Effects on woman a) Adequate functioning of maternal cardiopulmonary system b) Fetal well-being dependent on woman 2. Effects on fetus a) All systemic analgesics → cross placental barrier by simple diffusion b) Crosses blood-brain barrier c) Fetal liver enzymes and renal systems are inadequate to metabolize analgesic agents (1) High doses remain active in fetal circulation for a prolonged period of time 3. Effects on labor contractions a) Lack of research and evidenced-based practice on pain management during labor for women with opioid dependencies b) Most physicians do not offer analgesics, direct to use an epidural 4. Medical status of woman 5. History of substance abuse; current use of substances, including alcohol 6. Progress of labor

D. Administration of Analgesic Agents 1. Optimal time determined after complete assessment of many factors a) In past → labor well established b) Current thinking → woman’s request for pain medications c) Too early → prolong labor d) Too late → no value e) Nurse observes woman for cues f) NO can be given at any point in labor, requires physician order 2. Maternal assessment a) Critical prior to administration (1) Woman willing to receive medication after being advised about it (2) Vital signs are stable (3) Contraindications are not present 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Knowledge of other medication being administered (5) See Box 22–1: What Women Need to Know About Pain Relief Medications, p. 531 3. Fetal assessment a) Fetal heart rate (FHR) is between 110 and 160 beats per minute b) Variability is present c) Late decelerations or recurrent variable decelerations are absent 4. Assessment of labor a) Contraction pattern b) Cervical dilatation c) Cervical effacement d) Fetal presenting part e) Station of the fetal presenting part 5. Routes of administration a) Oral analgesic not used b) Intramuscular (IM), intravenous (IV), subcutaneous (SC) c) IV preferred → prompt smooth predictable action d) IM, SC → takes a few minutes for effect to be felt e) NO self-administered by woman → rapid onset → leaves body quickly during exhalation

E. Sedatives 1. Primarily in early latent phase a) When the cervix is long, closed, and thick b) Relaxation and sleep for the expectant woman 2. Benzodiazepines a) Lorazepam (Ativan), midazolam (Versed) (1) No longer used for pain management in labor (2) May be used to treat anxiety after birth (3) Primary use in intrapartum setting → anticonvulsant (4) Flumanzenil → reverse benzodiazepine sedative effects b) H1-receptor antagonists → block action of histamines (1) Sedative effects (2) Anti-Parkinson, antiemetic effects (3) Seven subtypes (4) Used to promote sleep, decrease anxiety (5) Promethazine (Phenergan) (a) Often combined with opiates, antiemetic effects (b) Cross placental barrier → decreased beat-to-beat variability (c) IM injections painful (d) Does not cause lower APGAR scores (e) Can decrease variability

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(f) Binds to bilirubin → increases incidence of neonatal hyperbilirubinemia and jaundice (6) Diphenhydramine (Benadryl) (a) Over-the-counter to treat allergic rhinitis, urticaria (b) Sedative, antiemetic properties (c) Short half-life (d) Can cause agitation in some women 3. Nursing care a) Assessment before administering medications (1) Stage of labor (2) Frequency, duration, intensity of contractions (3) Vaginal exam (4) Fetal well-being established b) Education c) Ensure safe environment

F. Narcotic Analgesics 1. Injected into circulation → primary action at sites in brain 2. See Table 22–1: Analgesics Used in Labor, p. 533 3. Fentanyl (Sublimaze) a) Short-acting synthetic opioid, moderate analgesia, mild sedation b) Rapid onset c) Limited placental transfer d) Short half-life e) 50 to 100 mcg every hour f) Very useful in active labor, 5 cm dilated → helps over the hump to transition and second stage 4. Nursing care a) Prior to administration, confirm woman does not have any opioid dependency or addiction b) Evaluate respiratory and cardiac status (1) Vital signs, pulse oximetry (2) Level of consciousness checked frequently (3) Continuous EFM c) Naloxone (Narcan) can improve respiratory depression in mother, fetus/newborn 5. Nalbuphine hydrochloride (Nubain) a) Synthetic agonist-antagonist analgesic (1) May precipitate withdrawal if woman is physically dependent on narcotics b) Crosses placenta to fetus c) IM, SC, IV → most frequently IV in birth setting d) 10 mg/70 kg → onset 2 to 3 minutes → peak 15 to 20 minutes → 3 to 6 hour duration 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Nursing care (1) Assess history for contraindications (a) Current narcotic drug dependence, sensitivity to sulfites, history of asthma (2) IV route frequently used during labor (a) Directly into tubing of running IV (b) 10 mg, over 3 to 5 minutes (3) Respiratory rate, quality of respirations, FHR (4) Urinary urgency (5) Experience dizziness and sedation 6. Opiate antagonist: Naloxone (Narcan) a) Antagonist with little or no agonistic effect b) Exhibits little pharmacologic activity in the absence of narcotic agent c) Can reverse mild respiratory depression, sedation, hypotension following small doses of opiates (1) Drug of choice when the depressant is unknown because it will cause no further depression d) Nursing care (1) When administered → resuscitative measures and trained personnel should be present as precaution additional respiratory support is needed (2) Inject undiluted, 0.4mg over seconds into tubing of running IV (a) Obtain maternal vital signs every 5 minutes until respiratory rate stable, then every 30 minutes (3) Neonatal dose can be given IV, IM, or ET (a) Dose 0.01mg/kg (4) Duration shorter than analgesics, monitor for return of respiratory depression 7. Nitrous oxide a) Making comeback in obstetrics b) Safe, effective and inexpensive c) Has not been shown to impact on rate of vaginal births, uterine activity, or risk of complication, breastfeeding, or Apgar scores d) Given in mixed concentration of 50% NO & 50% oxygen for obstetrics e) Apparatus uses a demand valve (1) Completely controlled by the woman f) Also has anxiolytic properties g) Rapid onset and offset h) Crosses placenta (1) Does not impact FHR pattern, depression i) Contraindications (1) Few (2) Inactives vitamin B12, do not give to women with B12 deficiency, Crohn’s, celiac, pernicious anemia, alcoholism, anorexia, recent bariatric surgery (3) Pneumothorax or obstructed bowel (4) Inability of woman to hold her own mask or tolerate potential side effects 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

j) Nursing Care (1) Assess (2) Consents and order (3) Education (4) Involve partner to cue to use NO with contraction use (5) No one else should hold mask for patient (6) Woman fall risk (7) Assess woman’s vital signs, FHR pattern (8) Document

III.

Regional Anesthesia and Analgesia

A. Regional anesthesia → temporary and reversible loss of sensation 1. Produced by injecting anesthetic agent into area that will bring agent into direct contact with nervous tissue 2. Local agent stabilizes cell membrane → prevents initiation, transmission of nerve impulses 3. Common in childbearing → epidural, spinal, combined a) Epidural → labor, vagina birth, cesarean birth (1) Relieves pain associated with first stage of labor (2) Can also be used in second stage, birth 4. See Figure 22–1: Schematic diagram showing pain pathways and sites of interruption, p. 536 5. See Table 22–2: Summary of Commonly Used Regional Blocks, p. 537 6. Regional anesthesia → less risk than general 7. Regional analgesia → temporary and reversible pain relief a) Inject analgesic into nervous tissue supplying region b) Using same agent as anesthesia problematic c) Use narcotic agent such as fentanyl along with small amount of local anesthetic (1) Pain relieved, blood pressure stable 8. Intrathecal injection a) Subarachnoid (spinal) space (1) Fentanyl citrate, preservative-free morphine (2) Pain relieved, urinary retention may occur 9. Informed consent a) Answer questions, address concerns early

B. Action and Absorption of Anesthetic Agents 1. Block nerve conduction by: a) Impairing propagation of action potential in axons b) Impairing transmission of nerve impulses by stabilizing cell membrane 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Absorption depends on vascularity of area of injection a) Increase blood flow → cause vasodilation b) Higher concentration → greater vasodilation

C. Types of Local Anesthetic Agents 1. Esters a) Procaine hydrochloride (Novocain) b) Chloroprocaine hydrochloride (Nesacaine) c) Tetracaine hydrochloride (Pontocaine) d) Rapidly metabolized → toxic levels less likely to be reached 2. Amides a) Bupivacaine hydrochloride (Marcaine) b) Mepivacaine hydrochloride (Carbocaine) c) Ropivacaine hydrochloride (Naropin) d) Levobupivacaine (Chirocaine) e) Lidocaine hydrochloride (Xylocaine) f) More powerful, longer acting than ester types g) Readily cross placenta, affect fetus for prolonged period 3. Opiates a) Morphine (Duromorph) b) Fentanyl (Sublimaze) c) Used alone epidurally → less pain relief d) Combination achieves better pain control e) Pruritus f) Common with cesarean → effective with postpartum pain g) Fentanyl may interfere with early breastfeeding (1) Dose dependent

D. Adverse Maternal Reactions to Anesthetic Agents 1. Mild a) Palpitations, vertigo, tinnitus, apprehension, confusion, headache, metallic taste in the mouth 2. Common side effects a) Pruritus, vertigo, dizziness, urinary retention 3. Moderate reactions a) More severe degrees of mild symptoms plus b) Nausea, vomiting, hypotension, muscle twitching (may lead to convulsions and loss of consciousness)

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Severe reactions a) Sudden loss of consciousness, coma, severe hypotension, bradycardia, respiratory depression, cardiac arrest 5. Systemic toxic effects a) Most common with excessive dose 6. Women in labor a) Generally require less medication → hormonal factors, uterine compression, increased cardiac output, increased sensitivity of neural axons b) Imperative → close supervision with IV line in place 7. Epinephrine in anesthetic → differentiate reaction 8. Psychogenic reactions a) Severe anxiety, hallucinations, inability to move or speak, catatonic appearance 9. Allergic reactions a) Antigen-antibody reaction b) Urticaria, laryngeal edema, joint pain, swelling of the tongue, bronchospasm 10. Treatment of systemic toxicity a) Oxygen by mask, IV injection of short-acting barbiturate to decrease anxiety 11. Treatment of convulsions a) Establish airway, administer 100% oxygen b) Benzodiazepines or propofol c) Small doses to help avoid cardiorespiratory depression 12. Treatment of sudden cardiovascular collapse a) Airway, cardiopulmonary resuscitation, IV fluids, emergency cesarean birth b) Displace uterus during CPR c) After 4 minutes of resuscitative measures, a bedside cesarean birth must be started in order for delivery of the baby within 5 minutes

E. Lumbar Epidural Block 1. Injection of local anesthetic into epidural space a) See Figure 22–2: The epidural space lies between the dura mater and the ligamentum flavum, extending from base of the skull to the end of the sacral canal, p. 539 b) Space accessed through lumbar area c) Continuous block d) Complete pain relief → 85% of women 2. Common during labor and birth a) U.S. rates rising b) Demographic differences c) Does not pass through placenta to affect fetus

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Administration a) Single dose with epidural needle b) Single dose through epidural catheter with additional doses as needed c) Continuous epidural infusion via pump 4. Many women equate quality of labor to satisfaction with anesthesia 5. Guidelines a) Should be performed when woman experiences pain b) Asks for epidural 6. Complications a) Urinary catheterization b) Pitocin augmentation of labor c) Intrauterine pressure catheter use d) Fetal malpresentation associated with decreased maternal movement during labor e) Increased rates of assisted vaginal deliveries (forceps or vacuum assistance) f) Spinal headaches 7. Advantages a) Good analgesia b) Fully awake c) Adjustable d) Once pump off → wears off in 2 hours 8. Disadvantages a) Maternal hypotension → peripheral vasodilation (1) Preload with rapid infusion of IV fluids (2) Approaches (3) Single dose → gradual onset, less medication b) Postdural puncture seizures, meningitis, cardiorespiratory arrest, vertigo c) Onset of analgesia → 30 minutes d) Skilled personnel e) FHR → Variability may decrease f) Costly g) Decreased sensation and movement 9. Contraindications → absolute a) Maternal refusal b) Local or systemic infection c) Uncorrected hypovolemia d) Coagulation disorders e) Actual or anticipated maternal hemorrhage f) Increased intracranial pressure g) Allergy to a specific class of local anesthetic agents

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

10. Contraindications → relative a) Platelet count less than 100,000/mm3 b) Severe anatomic abnormalities of the spine c) Uncooperative patient d) Sepsis e) Hypertension 11. Individual evaluation a) Previous back surgery b) Suspicion of neurologic disease c) Long-term use of aspirin, anti-inflammatory agents d) Abruptio placentae e) Acute infection at the epidural site f) Heart failure, aortic stenosis → may need invasive monitoring 12. Technique for continuous lumbar epidural block a) Maternal and fetal status, labor progress assessed b) Oxygen and resuscitative equipment readied c) IV infusion begun, preload of 500 to 1000 mL IV fluid given over 15 to 30 minutes d) Woman positioned on left or right side, at edge of bed, knees flexed or (1) Sitting on the edge of the bed, shoulders dropped, back rounded, chin on chest (2) Arch back like a cat (3) Assist with breathing, alert anesthesia provider when contraction occurs (4) See Figure 22–3: Positioning woman for epidural anesthesia block, p. 541 e) Skin prepared with antiseptic agent by the anesthesia provider f) Skin wheal of a small amount of local anesthesia given intradermally by anesthesia provider g) Anesthesia provider inserts short, beveled 16- to 18-gauge needle with stylet → to ligamentum flavum in widest interspace below second lumbar vertebra h) Anesthesia provider injects 5 mL preservative-free saline in order to pass catheter into epidural space more easily i) Catheter inserted approximately 1 to 2 cm into epidural space by anesthesia provider (1) Needle removed (2) Aspiration for blood or cerebrospinal fluid attempted j) If aspiration tests are negative → test dose injected (1) 1.5% lidocaine with epinephrine 1:200,000 concentration or (2) 3 mL of 0.23% bupivacaine with 1:200,000 concentration of epinephrine (3) Usually injected after aspiration, after a uterine contraction (4) If subarachnoid space has been entered → sensory and motor changes occur in woman’s extremities (5) If no untoward effects → additional anesthetic agent is injected (6) Catheter securely taped k) Nurse assists woman into semireclining position with lateral tilt of uterus → allows for distribution of block (1) Maintained in side-lying position to maximize uteroplacental perfusion 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

l) Anesthesia provider or nurse → monitor maternal blood pressure every 1 to 2 minutes for first 10 minutes (1) Every 5 to 15 minutes until block wears off (2) Nurse is responsible for documentation of assessment data obtained throughout the procedure m) Woman attended by nurse, nurse anesthetist, anesthesiologist for first 20 minutes following initial dose, after administration of any additional dose n) If hypotension (20% to 30% fall in systolic pressure, or below 100 mm Hg) → nurse ensures left lateral displacement of uterus maintained, IV fluids infused more rapidly (1) Oxygen by face mask (2) 10- to -20 degree Trendelenburg may be used (3) If blood pressure not restored within 1 to 2 minutes → vasopressor may be administered IV (a) Ephedrine, 5 to 15 mg o) Maternal blood pressure, pulse, FHR continue to be monitored by nurse p) If epidural not being administered by continuous pump → anesthesiologist aspirates catheter before administering subsequent doses 13. Technique for single-dose lumbar epidural block a) Same as lumbar block → instead of injecting 5 mL saline → test dose of 2 to 3 mL anesthetic agent to make sure dura mater has not been penetrated b) After checking again to confirm dura mater not perforated → clinician injects single dose of 10 to 12 mL to provide anesthesia for birth c) Subsequent care continues as for the procedure just described, from step 11 14. Problems and adverse effects a) Major (1) Maternal hypotension → results in uteroplacental insufficiency in fetus, manifested as late decelerations (a) Minimize risk → hydrating with 500 to 1000 mL IV solution before procedure (b) Intervention is to think of flip, flush, and O (i) Reposition to other side (ii) Increase fluids (iii) 10 L oxygen by non-rebreather facemask b) Inadequate block, unilateral block, block failure (1) One-sided block → have woman lie on unanesthetized side, inject more of local anesthetic agent (2) Continuous pump → turn from side to side (3) May have window of pain (4) Breakthrough pain c) Nurse assesses woman → calls anesthesia provider for additional medication d) Pruritus → diphenhydramine (Benadryl) e) Maternal temperature may be elevated to 37.8°C (100.4° F) or higher f) Headache, migraine headaches, neck aches, tingling of hands, fingers g) Short-term tenderness at puncture site 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

h) Urinary retention, shivering, nausea, vomiting 15. Complications a) Serious (1) Systemic toxic reaction → unintentional placement of drug in arachnoid, subarachnoid space, excessive amount of drug in epidural space, accidental intravascular injection (2) Likelihood of toxic reactions is higher than with some of the other regional procedures b) Pain during cesarean birth c) Spinal headaches 16. Nursing care a) Assess maternal vital signs, FHR for baseline information → within normal limits b) Document on EFM strips, nursing notes c) Labor progress assessed d) Procedure, expected results, questions answered (1) Nurse acts as advocate e) Nurse starts IV infusion, preloads per physician’s order or agency protocol (1) Usually dextrose free f) Void prior to block g) Support person present h) After block → semireclining position, head at 23 degrees, lateral uterine tilt (1) Then side-lying position i) Maternal blood pressure, pulse every 5 minutes → 30 minutes (1) Every 30 minutes thereafter (2) FHR monitored, assessed by continuous EFM j) Hypotension → corrective measures (1) Observe FHR k) Repeat regimen of assessing maternal blood pressure, etc. → additional local anesthetic agents injected l) If legs in stirrups → assess blood pressure when legs taken out m) Frequent bladder assessment n) Catheterization as necessary o) Shivering sensation suppressed → warmed blankets p) Assess level of pain relief q) Respiratory rate, quality of respirations assessed at least every 15 to 30 minutes r) Nurse asks if woman experiencing pruritus → alert for scratching (1) Benadryl as ordered s) Woman may require assistance pushing in second stage of labor → not feel contractions, urge to push t) Return of sensation prior to ambulation

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

F. Spinal Block 1. Local anesthetic agent injected directly into spinal fluid in subarachnoid space to provide anesthesia for cesarean birth → blockade to the T4 dermatome a) Much higher level of anesthesia in pregnant woman than nonpregnant b) Low failure rate (1) Spinal blocks allow the anesthesia to mix directly with the cerebrospinal fluid → eliminates “windows” c) See Figure 22–5: Levels of anesthesia for vaginal and cesarean births, p. 546 2. Advantages a) Immediate onset of anesthesia b) Relative ease of administration c) Smaller drug volume d) Maternal compartmentalization of drug e) Frequently regional block or choice in acute obstetrical emergencies 3. Disadvantages a) Primary is intense blockade of sympathetic fibers → high incidence of hypotension b) Uterine tone maintained → manipulation difficult c) Short acting 4. Contraindications a) Severe hypovolemia b) Central nervous system disease c) Infection over the site of puncture d) Maternal coagulation problems e) Allergy to local anesthetic agents f) Sepsis, active genital herpes → relative contraindications g) Women who do not wish to have spinal procedure 5. Technique a) Nurse assists woman into sitting or left lateral position b) IV infusion checked for patency c) Nurse helps woman into same position as for lumbar epidural block d) Anesthesiologist/nurse anesthetist prepares skin carefully → maintaining sterility e) Skin wheal made over L3 or L4 f) 18- or 19-gauge needle introduced through the skin → into interspinous ligament (1) 24- to 27-gauge pencil-point needle introduced inside the larger needle → inserted into ligamentum flavum→ epidural space through dura mater → subarachnoid space g) The appropriate amount of anesthetic agent injected slowly → both needles removed h) Upon removal → drop of cerebrospinal fluid can be seen in hub of needle if subarachnoid space entered i) Hyperbaric solutions → woman sitting up for 45 seconds j) Nurse assists woman onto back with pillow under head 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Position changes can alter dermatome level if done within 3 to 5 minutes (2) After 10 minutes → position change will not affect level of anesthesia k) Nurse monitors blood pressure, pulse, respirations every 1 to 2 minutes for first 10 minutes, then every 5 to 10 minutes l) No direct effect on fetus 6. Complications a) Hypotension b) Drug reaction c) Total spinal neurologic sequelae d) Spinal headache e) Side effects (1) Nausea (2) Shivering (3) Urinary retention f) Prehydrate with 500 to 2000 mL of non–dextrose-containing fluids (1) Positioning woman in lateral, head-down position (2) Rapid IV fluids (3) Early detection → supplemental oxygen, assisted ventilation, measures to maintain blood pressure (a) Lateral, head-down position (b) If maternal hypotension has been reversed → delay the birth for 4 to 5 minutes to allow the fetus to recover (c) If doesn’t resolve → ephedrine IV g) Anesthesia in phrenic nerve or higher (1) Respiratory function impaired h) Complete spinal → respiratory assistance needed, loss of consciousness i) Total spinal → paralysis of respiratory muscles (1) Within 30 seconds to 45 minutes (2) Resuscitative treatment, airway control j) Inadequate anesthesia coverage → discomfort k) Neurologic complications → coincidental with preexisting disease l) Headache from leakage of spinal fluid (1) Postural headaches can last up to 7 days (2) Blood patch with severe headache 7. Nursing care a) Assist in positioning b) Provide oxygen c) Assess, record baseline vital signs of mother, fetus d) Start IV infusion with bolus e) Continue to monitor maternal blood pressure, pulse, respiration f) Monitor FHR at least every 5 minutes g) Positioning h) Detect contractions 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

i) Wedge pillow under right hip to displace uterus j) Inform woman of what is going on k) Continue to monitor maternal blood pressure, pulse, respiration l) Monitor FHR at least every 5 minutes m) Raising legs facilitates venous return n) Keep woman flat following birth (1) May avoid headache o) Monitor breathing and for hypotension closely

G. Combined Spinal–Epidural Block 1. CSE used for labor analgesia and cesarean a) Epidural needle into epidural space b) Pencil-point anesthesia needle through epidural needle through dura → into cerebrospinal fluid c) Small amount of local anesthetic agent, opioid, or both injected d) Epidural catheter through epidural needle into epidural space e) Needle removed → catheter securely placed against woman with tape 2. Advantages a) Spinal agent faster onset b) Medication can be added 3. Disadvantages a) Higher incidence of pruritus, urinary retention b) CSEs not as commonly used

H. Pudendal Block 1. Perineal anesthesia a) Second stage of labor b) Birth c) Episiotomy repair 2. Anesthetic agent injected below pudendal plexus a) See Figure 22–7: A. Pudendal block by the transvaginal approach. B. Area of perineum affected by pudendal block, p. 548 3. Advantages a) Ease of administration b) Absence of maternal hypotension c) Allows use of forceps or vacuum extraction 4. Disadvantages a) Urge to bear down decreased b) Burning sensation

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Complications a) Systemic toxic reaction from accidental vascular injection b) Broad ligament hematoma c) Perforation of the rectum d) Trauma to sciatic nerve 6. Nursing care a) Explain procedure, expected effect, answer questions

I. Local Infiltration Anesthesia 1. Injecting anesthetic agent into intracutaneous, subcutaneous, intramuscular area of perineum a) Usually at time of birth for episiotomy and repair b) After birth if laceration occurred c) See Figure 22–8: Local infiltration anesthesia, p. 549 2. Advantages a) Involves least amount of anesthetic agent b) Just before birth for episiotomy 3. Disadvantages a) Large amount of solution must be used b) Burning sensation at time of injection 4. Nursing care a) Explain procedure, expected effect, answer any questions

J. Transversus Abdominis Plane Block 1. TAP block → growing in use for postop pain after cesarean birth 2. Ultrasound guided local anesthetic injected into the space between the transverse abdominus and internal oblique muscles 3. AKA “fill block” 4. Advantages a) Provide up to 12 hours of analgesia without need for opioids b) Useful women who cannot or should not use opioids after surgery c) Reduce opioid-related side effects, use d) Improve woman's satisfaction with pain control 5. Contraindications a) Infection at site b) Refusal or inability to consent c) Allergies

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

General Anesthesia A. Induced unconsciousness 1. Cesarean birth, surgical interventions with some obstetric complications 2. Use declining 3. Decrease exposure of fetus → woman fully prepped and OB fully ready before administering 4. Most common indication a) Perceived lack of time for regional anesthesia b) Contraindications to regional anesthesia c) Failure of regional anesthesia d) Patient refusal of regional anesthesia

B. Intravenous Anesthetics 1. Propofol (Diprivan) a) Short-acting sedative b) Narcosis within 30 seconds after IV administration c) Initiating unconsciousness → intubation 2. Ketamine → intermediate-acting barbiturate a) Effects typically last 20 to 60 minutes b) Contraindicated in women with preeclampsia or chronic hypertension c) Supplement spinal block d) Given with midazolam (Versed) → known hallucinogen

C. Inhales Anesthesia Agents 1. Nitrous oxide a) No significant uterine relaxation b) Fetal tissue uptake → 20 minutes after administration c) Dosage decreased to 50%, mixed with 50% oxygen 2. Halogenated agents a) Isoflurane, sevoflurane, desflurane b) Often combined with nitrous oxide c) Sevoflurane has been associated with uterine relaxation d) Increased maternal inspired oxygen 3. In combination with spinal, epidural techniques a) Ineffective regional b) Severe maternal anxiety

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Complications of General Anesthesia 1. Fetal respiratory depression a) Directly proportional to depth, duration of anesthesia b) Most anesthetics reach fetus in about 2 minutes 2. Uterine relaxation 3. Risk of aspiration a) Chemical pneumonitis → Mendelson syndrome

E. Care During General Anesthesia 1. Prophylactic antacid therapy 2. Wedge under hip → displace uterus 3. Preoxygenated with 3 to 5 minutes 100% oxygen 4. IV fluids 5. Nurse applies cardiac monitors, blood pressure cuff, oxygen saturation device; holds face mask for oxygenating the woman while anesthesiologist draws up needed medication 6. Emotional support 7. Rapid induction → nurse applies cricoid pressure until anesthesiologist has placed cuffed ET tube 8. See Figure 22–9: Proper position for fingers in applying cricoid pressure until cuffed endotracheal tube is placed …, p. 551

F. Neonatal Neurobehavioral Effects of Anesthesia and Analgesia 1. Neurobehavioral effects influenced by other factors a) Hunger, degree of hydration, time within the sleep–wake cycle, gestational age, birth weight

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Analgesic and Anesthetic Considerations for the High-Risk Mother and Fetus A. Skill required 1. Difficult to separate maternal and fetal complications 2. Team approach

B. Preterm Labor 1. Immature fetus → more susceptible to depressant drugs 2. Analgesia avoided whenever possible 3. Emotional support to woman

C. Preeclampsia 1. Potential for chronic placental insufficiency or preterm birth is also present 2. Incidence of hypotension with epidural anesthesia increased a) Further stress on an already compromised cardiovascular system 3. Regional anesthesia preferred with severe hypotension a) IV fluids to raise CVP b) Woman at risk for heart failure c) Invasive cardiovascular monitoring d) Monitor fluid intake and output e) Vasopressors considered 4. General anesthesia may aggravate maternal hypertension a) Intubation safest → may cause hypertensive episode b) May be more difficult due to mucosal edema

D. Diabetes Mellitus 1. Fetus may have reduction in placental blood flow a) Continuous epidural 2. Cesarean birth → woman more likely to experience cardiovascular depression with regional block a) Acute hydration b) Left uterine displacement

E. Cardiac Disease 1. Mitral stenosis → continual epidural with low forceps birth a) Avoids Valsalva

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. IV fluids, central venous pressure monitoring → avoid hypotension 3. Epidural, general anesthesia → cesarean 4. Ketamine avoided → tachycardia

F. Bleeding Complications 1. Trend → schedule cesarean 2. Epidural if maternal cardiovascular system stable 3. Treat hypovolemia immediately 4. Regional blocks contraindicated during active bleeding a) General anesthesia recommended b) Oxytocin should not be given IV bolus → dilute infusion 5. Resources on hand a) Large-bore IV catheters b) Fluid warmer c) Forced-air body warmer d) Woman’s specific blood type or O negative e) Trained personnel f) Equipment to infuse blood products rapidly

VI.

Focus Your Study

VII.

Activities 1. Individual Have students prepare drug cards for the following medications: Seconal Fentanyl Zolpidem Morphine sulfate Promethazine Naloxone Hydroxyzine Procaine hydrochloride Diphenhydramine Chloroprocaine hydrochloride Meperidine Bupivacaine hydrochloride Nalbuphine Lidocaine hydrochloride Butorphanol 2. Small Group Divide the class into small groups of three to five students. Ask each group to prepare teaching plans for the laboring woman who will be receiving anesthesia from the following list. For each anesthesia, the groups must include the advantages and disadvantages to the mother and the fetus or newborn. Instruct each group to include the expected nursing interventions needed for each anesthesia and to cite resources using APA format. • Spinal block 21 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

• • • •

Pudendal block Epidural block General anesthesia Local anesthesia

3. Large Group Invite a nurse anesthetist or perinatal nurse to speak to the students in your class about anesthesia. Ask your speaker to include the perioperative nursing care considerations of the postpartum woman, and both vaginal delivery and cesarean delivery in the presentation.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 23 Childbirth at Risk: Prelabor Onset Complications Care of the Woman at Risk Due to Preterm Labor.........................................

Care of the Woman with Premature Rupture of Membranes.......................

Care of the Woman and Fetus at Risk Because of Placental Problems.........

Care of the Woman with Cervical Insufficiency.............................................

Care of the Woman with a Multiple Gestation..............................................

Care of the Woman and Fetus at Risk Because of Amniotic Fluid-Related Complications.......................................................................................

Focus Your Study.............................................................................................

Activities..........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman at Risk Due to Preterm Labor

A. Early-term birth between 37 and 38 weeks 6 days B. Full-term birth between 39 and 49 weeks 6 days C. Late-term birth occurring after the 41st week D. Postterm birth occurring after 42 weeks E. Preterm labor (PTL) → labor that occurs between 20 and 37 completed weeks of pregnancy 1. Number one cause of neonatal mortality and long-term neurological disability 2. African American women 17.7%, 10% of Native American/Alaskan Native, and a little less than 10% of Caucasian American and Asian American 3. See Table 23–1: Risk Factors for Spontaneous Preterm Labor, p. 555

F. Maternal Risks 1. Previous preterm birth 2. Screening for risk factors help eliminate modifiable risk factors a) Smoking, substance abuse, stress, alcohol use, other behavioral factors b) Preconception teaching c) Prenatal teaching d) Monitoring

G. Fetal-Neonatal Risks 1. Mortality increases before 37 weeks’ gestation 2. Neonates < 32 gestational weeks are nine times more likely to die in the neonatal period compared to those at 39–40 weeks 3. Preterm birth accounts for 25% of neonatal deaths and 36% of infant death 4. Maturational deficiencies a) Respiratory system most critical b) Greater the gestational age the lower the incidence of RDS c) Periviable → 20 0/7 to 25 6/7 weeks’ gestation → 40% of infant deaths d) Extremely preterm births → prior to 28 weeks → 0.5% of all live births (1) Inform parents, consider palliative care vs resuscitation efforts (2) Realistic expectations on prognosis e) Severe maternal diabetes, serious isoimmunization → continuation of the pregnancy may be more life-threatening to the fetus than the hazards of prematurity (1) See Genetic Facts: Genetic Patterns and the Risk of Preterm Birth, p. 556 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Tocolytic drug therapy a) Primary goal to delay birth for maximum benefit of glucocorticoids (1) Reduction in RDS, necrotizing enterocolitis, intraventricular hemorrhage, neonatal jaundice, admission NICU when given prior to 34 weeks’ gestation (2) See Table 23–2 Selected Interventions for Periviable Fetus in Preterm Labor, p. 557 6. Prompt diagnosis of PLT difficult a) Symptoms common in normal pregnancy (1) Uterine contractions that occur every 10 minutes or less, with or without pain (2) Menstral-like cramps felt low in abdominal (3) Constant or intermittent feelings of pelvic pressure that may feel like the (4) baby pressing down Rupture of membranes Low, dull backache, which may be constant or intermittent A change in vaginal discharge (an increase in amount, a change to more clear and watery, or a pinkish tinge)Urinary frequency, urgency, hesitancy, or hematuria Abdominal cramping with or without diarrhea b) No attempt is made to stop labor (1) Fetal demise (2) Lethal fetal anomaly (3) Severe preeclampsia/eclampsia (4) Hemorrhage/abruptio placentae (5) Chorioamnionitis (6) Severe fetal growth restriction (7) Fetal maturity (8) Category III fetal heart rate tracing (9) Gestational age less than 24 weeks (10) Oligohydramnios (less than normal amount of amniotic fluid) (11) Absent or reversed diastolic flow upon Doppler examination of umbilical blood flow (12) Repetitive severe variable decelerations (13) Significant vaginal bleeding consistent with abruption c) Some women have frequent contractions without cervical changes d) fFN in cervicovaginal fluid → normal first half of pregnancy (1) After 20 weeks → abnormal (2) Also in amniotic fluid (3) False positives (a) Recent sexual intercourse, vaginal examination, bacterial vaginosis, vaginal bleeding e) Contraction frequency alone not diagnostic of preterm labor (1) Electronic fetal monitoring (EFM) to detect uterine contractions for at least 1–2 hours (2) Digital exam after ROM ruled out (3) Endovaginal ultrasound exam for cervical length (a) Cervical length of 3 cm good evidence that woman not in PTL (b) Cervical length <20mm, 2 cm or more dilated, 50% or more effaced in presence of regular contractions → diagnostic of PTL 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Interventions a) Primary (1) Diagnosis and treatment of infections (2) Cervical cerclage (a) Previous history of painless cervical dilatation that has resulted in a secondtrimester birth or a fetal loss that occurred in a previous pregnancy (3) Progesterone supplementation b) Secondary prevention (1) Antibiotics (2) Emergency cervical cerclage placement (3) Tocolysis 8. Bacterial infection → implicated as causative factor of PTL a) Sexually transmitted infection (STI), group B streptococcus (GBS), bacterial vaginosis (BV) b) BV (1) Most common lower genital tract infections (2) Associated with (a) Increased risk of PTL (b) Increased PPROM (c) Miscarriage (d) Chorioamnionitis (e) Endometritis (f) Cesarean section wound infection c) GBS can cause neonatal infection (1) Not associated with preterm birth d) Urinary tract infections (UTIs) associated with PTL (1) Positive culture → retest after therapy e) Preterm, low-birth-weight infants linked with gum disease f) Progesterone → promote uterine relaxation, suppress contractions, prevents gestational immune intolerance (1) Can be given prophylactically, not after labor has started 9. Tocolysis → use of medications in attempt to stop labor a) May delay 24 to 48 hours (1) May permit the administration of betamethasone for fetal surfactant induction or allow for the transport of the mother to a tertiary care facility b) Beta-adrenergic agonists (1) Magnesium sulfate (a) Do not use with calcium channel blockers, if mother has myasthenia gravis, or neuromuscular disorders (b) Loading dose of 4 to 6 g/hr intravenous (IV) in 100 mL IV fluid over 20 minutes (i) Maintenance 2 to 4 g/h titrated to deep tendon reflexes, serum magnesium levels (ii) Maternal serum level 5.5 to 7.5 mg/dl (iii) Side effects 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Flushing, warmth, headache, nystagmus, nausea, dry mouth, dizziness (b) Lethargy, sluggishness, risk of pulmonary edema (iv) Fetal side effects (a) Hypotonia for 1–2 days after birth, lethargy, hypoglycemia, lethargy (2) Calcium channel blockers (a) Nifedipine (i) Inhibits contractile activity (ii) Side effects (a) Hypotension, tachycardia, facial flushing, headache (iii) Coadministration with ritodrine or terbutaline may be beneficial (a) Not with magnesium sulfate (3) Prostaglandin synthetase inhibitors (a) Suppress muscle contraction (b) Maternal side effects are few (i) Dyspepsia, nausea, vomiting, depression, dizzy spells (ii) Not used in women with asthma, coagulation disorders, hepatic or renal insufficiency, peptic ulcer disease (c) Indomethacin, sulindac, celecoxib (d) Crosses placenta to fetus (e) Not used after 34 weeks → oligohydramnios, premature closure of fetal ductus arteriosus 10. National Institute of Child Health and Human Development (NICHD) a) Recommends corticosteroids be administered antenatally to women at risk of preterm birth

H. Nursing Management for the Woman at Risk for Preterm Labor 1. Nursing Assessment and Diagnosis a) Assessment (1) Predisposing factors (2) Educational needs b) Diagnoses include (1) Knowledge, Readiness for Enhanced (2) Fear (3) Coping, Ineffective (4) Anxiety 2. Nursing Plan and Implementation a) Community-based nursing care (1) Continued pharmacologic therapy b) Home care (1) Frequent office visits (2) Patient education (3) Ability to care for self, impact of changes 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Nursing management plan c) Health promotion (1) Signs and symptoms of preterm labor (a) Uterine contractions that occur every 10 minutes or less with or without pain for 1 hour (b) Mild menstrual-like cramps felt low in abdomen (c) Constant or intermittent feelings of pelvic pressure that may feel like the baby is pressing down (d) Rupture of membranes, leaking of clear fluid from vagina (e) Low, dull backache, which may be constant or intermittent (f) Change in the vaginal discharge (g) Urinary frequency, urgency, hesitancy or hematuria (h) Abdominal cramping with or without diarrhea (2) Taught to evaluate contraction activity one or twice a day (3) Taught when to report signs and symptoms (a) Any PTL symptoms for more than 15 minutes: (i) Empty her bladder (ii) Lie down tilted toward her side (iii) Drink 3 to 4 (8 oz) cups of fluid (iv) Palpate for uterine contractions, and if contractions occur 10 minutes apart or less for 1 hour, notify healthcare provider (v) Soak in a warm tub bath with the uterus completely submerged (vi) Rest for 30 minutes after the symptoms have subsided, and gradually resume activity (vii) Call healthcare provider if symptoms persist, even if uterine contractions not palpable d) Woman knowledgeable, attuned to changes in body → caregivers need to take her call seriously e) See Table 23–4: Self-Care Measures to Prevent Preterm Labor, p. 561 3. Hospital-based nursing care a) Supportive nursing care (1) Promoting rest (2) Monitoring vital signs (3) Measuring intake and output (4) Continuously monitoring FHR, uterine contractions (5) Place woman on left side (6) Vaginal examinations minimal b) Intense stress of woman and partner (1) Keep informed (2) Consultations as indicated or requested 4. Evaluation a) Woman can discuss cause, diagnosis, treatment of PTL b) Woman affirms that fears about early labor are decreased 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Woman states she feels comfortable in ability to cope with situation and has resources to call on if needed d) Woman can identify signs and symptoms of PTL that need to be reported to her caregiver e) Woman can describe appropriate self-care measures to initiate in the event that she experiences any symptoms of PTL f) Woman successfully gives birth to a healthy infant

II.

Care of the Woman with Premature Rupture of Membranes

A. Spontaneous rupture of membranes before onset of labor → premature rupture of membranes (PROM) 1. After 37 weeks 2. Before 37 weeks → preterm PROM (PPROM) 3. Prolonged rupture of membranes → more than 24 hours before birth

B. PPROM → more frequently in lower socioeconomic status, previous preterm birth or PPROM 1. Multiple interrelated factors a) Cervicitis b) Urinary track infections c) Gonorrhea infections d) Asymptomatic bacteriuria e) Amniocentesis f) Placenta previa g) Abruptio placenta h) Hydramnios i) History of LEEP procedure j) Multiple pregnancy k) Maternal genital tract anomalies l) Smoking m) Substance abuse n) Connective tissue disorders o) Fetal anomalies 2. Unknown etiology

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Abruptio placentae

D. Fetal-neonatal risks 1. Associated complications: respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage 2. Infection (sepsis) 3. Fetal hypoxia 4. Early prolonged PPROM → fetal pulmonary hypoplasia, facial anomalies, limb position defects, fetal growth restriction 5. Clinical therapy a) Assessment (1) Time of initial loss of fluid (2) Continuous leaking (3) Color, consistency, amount, odor (4) Presence of blood, meconium, vernix b) Nitrazine testing of fluid (1) Amniotic fluid more alkaline (pH 7 to 7.5) than normal vaginal secretions (2) Blue-green, blue → suggestive of ruptured membranes c) Sterile speculum exam (1) Avoid digital exam d) Microscopic examination → ferning e) Fetal well-being (1) Fetal heart rate (FHR) tracing (2) Biophysical profile (3) Calculation of fetal age 6. Management a) No evidence of infection, gestation < 37 weeks → conservative (1) Hospitalized on bedrest (2) Fetal lung maturity studies near 34 weeks (3) Lab work (4) Non-stress tests (NSTs) every shift (5) Biophysical profile (BPP) every 24 hours b) Fetus not at viable stage (1) Home on bedrest (2) Monitor temperature 4x/day (3) Fetal movement record (4) Pelvic rest (5) Instructions on when to contact physician (6) Twice-weekly NSTs, complete blood counts (CBCs) (7) Weekly ultrasound, cervical visualization c) Prophylactic antibiotics 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Prevent ascending infection (2) Allow time for corticosteroids to enhance fetal lung maturity d) Immediate birth → fluid studies show (1) Low glucose level (2) High white blood cell (WBC) count (3) Positive Gram stain (4) Organisms in fluid e) Betamethasone (1) Decreases likelihood of several complications (a) Neonatal respiratory distress syndrome (b) Necrotizing enterocolitis (c) Intraventricular hemorrhage (d) Perinatal death (2) Single course → 12 mg IM with second dose in 24 hours (a) Or 6 mg every 12 hours for 2 doses f) Tocolytics (1) Generally not indicated (2) May be used to allow course of steroids 7. Health promotion education a) Counseling b) Accurate information about grave outcomes of very premature births

E. Nursing Management for the Woman with PROM or PPROM 1. Nursing Assessment and Diagnosis a) Assessment (1) Time, amount, color, odor, duration of ROM (2) Gestational age determined (3) Observe mother for signs and symptoms of infection (4) If fever, check hydration status (5) Fetal heart rate tracings monitored (6) Evaluate childbirth preparation, coping abilities of woman and partner b) Diagnoses may include (1) Infection, Risk for (2) Gas Exchange, Impaired (3) Coping, Ineffective 2. Nursing Plan and Implementation a) Focus on woman, partner, fetus (1) Uterine activity, fetal response to labor evaluated (2) Encourage to rest on side (3) Vaginal exams are not done unless absolutely necessary (4) Comfort measures (5) Ensure hydration is maintained 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Health promotion education a) Education, implication of PROM/PPROM b) Treatment methods c) Accurate information about neonatal outcomes d) Provide psychologic support 4. Evaluation a) Woman’s risk of infection and cord prolapse decreased b) Couple is able to discuss implications of PROM/PPROM and treatment options c) Pregnancy is maintained without trauma to the mother or fetus

III.

Care of the Woman and Fetus at Risk Because of Placental Problems

A. Abruptio Placentae 1. Premature separation of a normally implanted placenta from the uterine wall a) More common in pregnancies complicated with (1) Smoking (2) PROM (3) Multiple gestation (4) Advanced maternal age (5) Cocaine use (6) Chorioamnionitis (7) Hypertension (8) Risk of recurrence is 10 times higher if a previous abruption has occurred 2. Cause unknown a) Hypertension b) Presence of fibroids c) Maternal trauma d) Domestic violence e) Abdominal trauma f) Overdistention of uterus g) Fetal growth restriction h) Alcohol consumption i) Short umbilical cord j) High parity k) More common in white and African American women than Asian and Latin American women 3. Pathophysiology a) See Figure 23–1: Abruptio placentae, p. 566 b) Types (1) Marginal (2) Central (3) Partial 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Complete c) Severe cases of central abruptio placentae → blood clot forms behind placenta (1) Blood invades myometrial tissue (2) Uterus contracts with difficulty → Couvelaire uterus → may necessitate hysterectomy (3) Large amounts of thromboplastin released into maternal blood supply → triggers disseminated intravascular coagulation (DIC) d) Grading (1) Grade 1 (mild) (2) Grade 2 (moderate) (3) Grade 3 (severe) 4. Maternal risks a) DIC b) Hypofibrinogenemia c) Moderate to severe hemorrhage → shock (1) Fatal if not reversed (2) Renal failure (a) Vascular spasm (b) Intravascular clotting 5. Fetal-neonatal risks a) Perinatal mortality 25% b) Complications: preterm labor, anemia, hypoxia (1) Irreversible brain damage, fetal demise 6. Clinical therapy a) Evaluate coagulation tests for DIC (1) Fibrinogen levels, platelet counts decreased (2) Prothrombin (PT), partial prothrombin (PTT) normal to prolonged b) Maintain cardiovascular status of mother (1) IV access with large-gauge cannula c) Continuous EFM d) Birth method depends on condition of woman and fetus (1) Induction of labor if separation mild, gestation near term (a) If rupture of membranes and oxytocin infusion by pump do not initiate labor within a short time, cesarean birth usually done (b) Supportive treatment (2) Moderate to severe separation → cesarean birth after hypofibrinogenemia treated (a) IV cryoprecipitate (b) IV fresh frozen plasma (FFP) (c) Vaginal birth impossible with Couvelaire uterus → cannot contract e) Hypovolemia (1) Life threatening → whole blood (2) Emergency cesarean with living fetus 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Stillborn fetus → vaginal birth preferable unless shock uncontrollable (4) IV fluids through 16- to 18-gauge cannula (5) Central venous pressure monitoring (6) Two venous lines if evidence of hypovolemia (7) Monitor urine output with indwelling catheter (8) DIC may preclude invasive hemodynamic monitoring (9) Laboratory testing for ongoing data (a) Hemoglobin, hematocrit, coagulation status (b) Clotting study f) Stimulate labor (1) Amniotomy, oxytocin stimulation (2) Kleihauer-Betke to determine amount of fetal–maternal hemorrhage in Rh-negative women → calculate appropriate dose of Rh D immunoglobulin

B. Nursing Management for the Woman with Abruptio Placentae 1. Nursing Assessment and Diagnosis a) Electronic monitoring of uterine contractions b) Uterine resting tone (1) Often increased with abruptio placentae c) Abdominal girth measurements hourly 2. Nursing diagnoses include a) Fluid Volume: Risk for Deficient b) Tissue Perfusion: Peripheral, Ineffective c) Anxiety d) Gas Exchange, Impaired 3. Nursing Plan and Implementation a) Factual reassurance b) Explanation of procedures c) Reinforce positive aspects 4. Evaluation a) Woman and baby have a safe labor and birth without further complications for the mother or child b) Woman and family verbalize understanding of reasons for medical therapy and risks

C. Placenta Previa 1. Placenta improperly implanted in the lower uterine segment a) See Figure 23–2: Grades of placenta previa, p. 569 b) Villi torn from uterine wall as lower uterine segment contracts and dilates in later weeks of pregnancy 2. Cause a) Unknown 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) 1:200 pregnancies c) Factors (1) Previous placenta previa (2) Multiparity (3) Increasing age (4) Placenta accreta (5) Defective development of blood vessels in the decidua (6) Prior cesarean birth (7) Cocaine use (8) Smoking (9) Recent spontaneous or induced abortion (10) Large placenta 3. Classifications a) Grade 1 → placenta lies over lower uterine segment but is lower edge does not abut the internal cerivical os b) Grade 2 → placental tissue raches the margin of the internal cervical os, but does not cover it c) Grade 3 → placenta partially covers the internal cervical os d) Grade 4 → placenta completely covers the internal cervical os 4. Vasa previa a) Fetal vessels course through amniotic membranes b) Present at cervical os 5. Clinical therapy a) History of abnormal placental placement diagnosed during pregnancy b) Review prenatal records c) Identify cause of bleeding d) Transabdominal scan to localize placenta e) Direct diagnosis → feeling placenta inside os → may cause profuse bleeding (1) Vaginal exam contraindicated f) If no ultrasound available (1) Double setup (a) Delivery room set up for vaginal exam, vaginal birth, cesarean birth (b) Adequate personnel g) Differential diagnosis (1) See Table 23–10: Differential Signs and Symptoms of Placenta Previa and Abruptio Placenta, p. 570 h) Care of woman with painless late gestational bleeding (1) Week of gestation (2) Amount of bleeding (3) Expectant management (a) Bedrest with bathroom privileges only as long as woman is not bleeding (b) No vaginal examinations 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Monitoring of blood loss, pain, uterine contractility (d) Evaluation of FHR with external monitor (e) Monitoring of maternal vital signs (f) Complete laboratory evaluation: hemoglobin, hematocrit, Rh factor, urinalysis (g) Administration of IV fluid (lactated Ringer’s solution) with drip rate monitored (h) Availability of two units of cross-matched blood for possible transfusion (i) Administration of betamethasone to facilitate fetal lung maturity (j) Administration of Rh D immunoglobin in Rh D negative women

D. Nursing Management for the Woman with Placenta Previa 1. Nursing Assessment and Diagnosis a) Ongoing to prevent, treat complications b) Painless, bright red vaginal bleeding best diagnostic sign of placenta previa c) No vaginal examinations d) Uterus soft, if labor begins, relaxed between contractions e) FHR stable unless profuse hemorrhage, maternal shock occurs f) Appraise blood loss, pain, uterine contractility g) Monitor maternal vital signs, results of blood and urine tests h) FHR monitoring with EFM 2. Diagnoses may include a) Fluid Volume, Deficient b) Tissue Perfusion: Peripheral, Ineffective c) Anxiety d) Gas Exchange, Impaired e) Fear 3. Nursing Plan and Implementation a) Monitor woman and fetus b) Emotional support for family c) Physical support with active bleeding d) Newborn assessment (1) Hemoglobin, cell volume, erythrocyte count → checked immediately after birth, monitored closely 4. Evaluation a) Cause of hemorrhage is recognized promptly, corrective measures are taken b) Woman’s vital signs remain in the normal range c) Woman and her baby have a safe labor and birth d) Family understands what has happened and the implications and associated problems of placenta previa

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Care of the Woman with Cervical Insufficiency A. Definition 1. Painless dilatation of the cervix without contractions because of a structural or functional defect of the cervix

B. Etiology multifactorial 1. Congenital 2. Acquired 3. Biochemical (hormonal)

C. Obstetric history may give risk indications 1. Multiple gestation 2. Repetitive second-trimester losses 3. Previous preterm birth 4. Progressively earlier births with each subsequent pregnancy 5. Short labors 6. Previous elective abortions or cervical manipulations 7. Diethylstilbestrol (DES) exposure 8. Other uterine anomaly

D. Endovaginal ultrasound measurements 1. Cervical length between 15 and 28 weeks identifies groups at risk a) At 16 to 24 weeks if at risk 2. Cerclage does not reduce risk of prematurity 3. Medical therapies used are serial cervical ultrasound assessments, progesterone supplementation, antibiotics, anti-inflammatory drugs

E. Cerclage Procedures 1. Surgical procedure a) Stitch placed in cervix to prevent spontaneous abortion, premature birth b) Elective (1) Placed in late first trimester, early second trimester (2) 93% success rate c) Emergent → dilation, effacement already occurred (1) Graver outcomes 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Preterm rupture of membranes (a) See Figure 23–3: A cerclage or purse-string suture is inserted in the cervix to prevent preterm cervical dilatation and pregnancy loss, p. 573 d) Uncomplicated (1) Outpatient and discharge when able to ambulate and void (2) Emergency → 5- to 7-day hospitalization or longer e) Serial ultrasounds weekly to monitor f) Cut sutures at 36–37 weeks’ gestation

Care of the Woman with a Multiple Gestation A. Incidence of twins 1. 33 per 1000 live births 2. Increasing with advances in reproductive technologies 3. Twin birth most common

B. Pregnancy Loss in Multiple Gestation 1. 25% lost before end of first trimester a) Environmental factors b) Infectious organisms c) Trophoblast dysfunction d) Poor embryo quality e) Lower concentration of placentally produced substances f) Loss of one twin → more common in first trimester 2. Pregnancy loss in second trimester a) Congenital anomalies b) Growth restriction c) Chromosomal abnormalities d) Cervical insufficiency 3. Incidence of preterm birth higher a) 58.8% of twins b) 94.4% of triplets c) 98.3% quadruplets d) See Table 23–12: Guidelines for Timing of Birth in Multiple-Gestation Pregnancies, p. 575 4. Potential complications a) Spontaneous abortions are more common b) Gestational diabetes occurs more often in multiple gestations c) Hypertension is a major maternal complication d) Multiple gestations are more likely to acquire HELLP (hemolytic anemia, elevated liver enzymes, and low platelet count) syndrome 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Women with multiple gestations more likely to develop acute fatty liver f) Pulmonary embolism six times more likely to develop during pregnancy with multiple gestations g) Maternal anemia occurs because of demands of the multiple gestation h) Hydramnios may be due to increased renal perfusion from cross-vessel anastomosis of monozygotic twins i) Premature rupture of membranes cervical insufficiency, and intrauterine growth restriction more common j) Rare complications associated with twins include twin-to-twin transfusion, conjoined twins, acardia k) Complications during labor include preterm labor, uterine dysfunction due to overstretched myometrium, abnormal fetal presentations, instrumental or cesarean birth, postpartum hemorrhage l) Pulmonary edema more common in multiple gestations m) Dermatologic complications n) Multiple births account for 21% of low-birth-weight infants o) More physical discomfort during pregnancy 5. Clinical therapy a) Goal → promote normal fetal development, prevent maternal complications and preterm birth, diminish fetal trauma during labor b) Ultrasound plays crucial role (1) Identification of multiple pregnancy (2) Detecting anomalies (3) Chorionicity (a) Essential in differentiating twin-to-twin transfusion from fetal growth restriction (4) Amnionicity (a) Ultrasound visualization or the lack of visualization of an intertwin membrane c) Preventing preterm labor (1) Early prenatal care, more frequent visits (2) Assessing cervical status (a) A cervical length < 25 mm between 14 and 20 weeks is associated with PTB prior to 32 weeks. (b) Cervical length < 25 mm for triplets between 15 and 20 weeks is associated with a 100% delivery rate by 28 weeks (3) fFN (4) Corticosteroids (a) 24 to 34 weeks if risk to deliver within next 7 days (b) Repeat dose if < 34 weeks and last dose was > 14 days prior (5) Insufficient evidence to support routine bedrest, cervical cerclage, reduced activity and work d) Intrapartum management and assessment (1) IV with large-bore needle (2) Anesthesia, cross-matched blood available 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Dual EFM (4) Method of birth depends on variety of factors (a) Presence of maternal complications (b) Fetal factors (c) Presentation (d) Three or more fetuses → cesarean (5) See Figure 23–5: Twins may be in any of these presentations in utero, p. 577 (6) Placentas examined after birth → laboratory for examination

C. Nursing Management for the Woman with Multiple Gestation 1. Nursing Assessment and Diagnosis a) Identify family history of twinning b) Medication taken to enhance fertility c) Each visit → measure fundal height (1) Growth, fetal movement, heart tone auscultation out of proportion to gestational age by dates → indicative of twins (2) See Figure 23-6: Leopold maneuvers in twin pregnancy …, p. 578 d) Determine family’s level of preparation e) Monitor each fetus during labor f) After multiple birth → mother closely monitored for postpartum hemorrhage 2. Diagnoses include a) Fear b) Coping, Ineffective c) Knowledge, Deficient d) Gas Exchange, Impaired 3. Nursing Plan and Implementation a) Community-based nursing care (1) Antepartum (a) Counseling about diet and daily activities (b) Meal plans (c) Prenatal vitamin and 1 mg folic acid, iron daily (d) Weight gain of 35 to 45 lb recommended (e) Prenatal vitamins with folic acid (f) Maternal hypertension treated with bedrest, lateral position (g) Pelvic rocking to alleviate back discomfort (h) Community support systems b) Hospital-based nursing care (1) Prepare to receive multiple newborns (a) Equipment, identification papers, bracelets (b) Staff 4. Evaluation a) Woman able to discuss implications and problems associated with multiple gestation 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Woman feels she is able to cope with the pregnancy and birth c) Woman understands treatment plan and how to gain further information d) Mother, father, babies have a safe prenatal course, labor, and birth and safe postpartal and newborn course

VI.

Care of the Woman and Fetus at Risk Because of Amniotic Fluid-Related Complications

A. Hydramnios 1. Polyhydramnios → over 2000 mL of amniotic fluid a) Cause unknown b) Often occurs in cases of major congenital anomalies c) Anencephaly → fetus thought to urinate excessively d) Monozygotic twin manifests hydramnios → possible that twin with increased blood volume urinates excessively 2. Chronic → fluid gradually increases a) Problem of third trimester b) Most cases 3. Acute → volume increases rapidly a) Over a few days b) Usually between 20 and 24 weeks’ gestation 4. Amount of amniotic fluid over 3000 mL a) Shortness of breath and edema in lower extremities b) Can experience severe pain 5. Fetal malformation, preterm birth common a) Prolapsed cord can occur when membranes rupture 6. Clinical therapy a) Supportive treatment (1) Maternal dyspnea and pain → hospitalization, removal of excessive fluid (a) Artificial rupture of membranes → dangers (b) Needle amniotomy → slower release of fluid b) Prostaglandin synthesis inhibitor

B. Nursing Management for the Woman with Hydramnios 1. Nursing Assessment and Diagnosis a) Suspected when fundal height increases out of proportion to the gestational age b) Difficulty palpating fetus, auscultating FHR c) Abdomen tense, tight

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Diagnoses include a) Gas Exchange, Impaired b) Fear c) Pain, Acute 3. Nursing Plan and Implementation a) Amniocentesis (1) Sterile technique (2) Support (3) Education b) Fetus diagnosed with congenital defect (1) Psychologic support 4. Evaluation a) Woman and her partner can discuss the procedure, implications, risks and characteristics that need to be reported to the caregiver

C. Oligohydramnios 1. Less than normal amount of amniotic fluid → 500 mL considered normal a) Diagnosed when largest vertical pocket of amniotic fluid visible on ultrasound examination is 5 cm or less 2. Cause → unknown a) Cases of postmaturity b) Intrauterine growth restriction (IUGR) c) Fetal conditions with major renal malformations d) In first part of pregnancy (1) Fetal adhesions e) Fetal skin and skeletal abnormalities f) Pulmonary hypoplasia 3. Clinical therapy a) Suspected when uterus does not increase in size according to gestational dates b) Fetus easily palpated, not ballottable c) Biophysical profile d) NSTs e) EFM f) Amnioinfusion to replace some fluid volume

D. Nursing Management for the Woman with Oligohydramnios 1. Nursing Assessment and Diagnosis a) Fundal height less than gestational age b) Fetal parts easily palpated c) Continuous EFM in labor and birth d) Evaluate EFM tracing for nonreassuring signs 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Position changes f) Newborn evaluated after birth g) Amniotic fluid index on ultrasound less than 5 cm 2. Diagnoses include a) Gas Exchange, Impaired b) Fear 3. Nursing Plan and Implementation a) Continuous monitoring during labor and birth b) Amnioinfusion c) Cesarean with nonreassuring FHR tracing 4. Evaluation a) Woman and her partner can discuss the diagnosis, implications, and risks to the caregiver b) Fetus remains uncompromised during labor and birth

VII.

Focus Your Study

VIII.

Activities 1. Individual Have each student prepare drug cards for the following medications: • Betamethasone • Ritodrine hydrochloride • Magnesium sulfate • Nifedipine • Cryoprecipitate • Fresh frozen plasma 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the woman with one of the following nursing diagnoses: • Fear related to unknown outcome of pregnancy • Knowledge, Deficient related to lack of information about the problems associated with − Multiple gestation − Placenta previa − Oligohydramnios − Hydramnios 3. Large Group Invite a perinatal nurse or certified nurse-midwife (CNM) to speak to the students in your class, giving case studies related to prelabor complications.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 24 Childbirth at Risk: Labor-Related Complications Care of the Woman Experiencing Dystocia Related to Dysfunctional Uterine Contractions.............................................................................................

Care of the Woman with Postterm Pregnancy..................................................

Care of the Woman and Fetus at Risk Because of Fetal Malposition...............

Care of the Woman and Fetus at Risk Because of Fetal Malpresentation ………………………………………………………………………………..

Care of Woman and Fetus at Risk Because of Macrosomia..............................

Care of the Woman and Fetus in the Presence of Nonreassuring Fetal Status………………………………………………………………………………………………….

Care of the Woman Experiencing Placental and Umbilical Cord Problems ……………………………………………………………………………………………

Care of the Woman and Fetus with a Prolapsed Umbilical Cord......................

Care of the Woman and Fetus at Risk Because of Anaphylactoid Syndrome of Pregnancy...........................................................................

Care of the Woman with a Uterine Rupture......................................................

Care of the Woman with Cephalopelvic Disproportion.....................................

Care of the Woman at Risk Because of Complications of Third and Fourth Stages of Labor……………………………………………………………………………………

Focus Your Study................................................................................................

Activities.............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman Experiencing Dystocia Related to Dysfunctional Uterine Contractions

A. Dystocia → abnormal labor pattern 1. Abnormalities occur with power, passenger, passage 2. Dysfunctional uterine contractions → prolongation of labor 3. See Figure 24–1: Comparison of labor patterns. A. Normal uterine contraction pattern … B. Tachysystole uterine contraction pattern C. Hypotonic uterine contraction pattern. p. 584 4. Risk factors a) Advanced maternal age b) Maternal obesity c) Nulliparity d) Short maternal height e) Pregnancy complications f) Labor induction g) Premature rupture of membranes h) Prolonged latent phase i) Epidural anesthesia j) Chorioamnionitis k) Postterm gestation l) Large-for-gestational-age (LGA) fetus m) Malposition n) Malpresentation

B. Tachysystole Labor Patterns 1. Contraction frequency of more than five contractions in a 10-minute period with less than 60 seconds of relaxation between contractions or uterine contractions lasting greater than 2 minutes 2. Risk factors a) High-dose oxytocin titration regimens b) Oxytocin incremental intervals less than 30 minutes c) Cocaine use d) Uterine rupture e) Placental abruption 3. Fetal-neonatal risks include a) Nonreassuring fetal status b) Category II and III fetal tracings c) Prolonged pressure on fetal head

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Clinical therapy a) Continuous fetal monitoring b) Oxytocin (Pitocin) infusion stopped immediately

C. Nursing Management for the Woman Experiencing Tachysystole Labor 1. Nursing Assessment and Diagnosis a) Monitor frequency, duration, intensity of labor contractions 2. Diagnoses include a) Pain, Acute b) Coping, Ineffective c) Anxiety 3. Nursing Plan and Implementation a) Comfort and support (1) Position change, sitting or left sidelying (2) Continuous fetal monitoring (3) Comfort measures (4) Oxytocin stopped immediately (5) Breast stimulation stopped (6) Relaxation exercises → quiet environment (7) Physician/CNM advised of patient status and contraction pattern (8) Maintain calm, understanding approach b) Patient education c) Nonreassuring fetal status often occurs with a tachysystole contraction pattern → intrauterine resuscitation measures may become warranted (1) Position the woman on her left side (2) Apply oxygen via face mask (3) Increase intravenous fluids by at least 500 mL bolus (4) Call for anesthesia provider for support (5) Call the physician/CNM to the bedside d) Evaluation e) Woman’s labor pattern normalizes with contractions of normal frequency, duration, and intensity f) Woman and partner able to cope with abnormal labor pattern and interventions g) Woman’s level of pain becomes tolerable

D. Hypotonic Labor Patterns 1. First stage and occur in nulliparous women, common 2. Clinical therapy a) Arrest of progress → irregular contractions, low amplitude (1) Commonly less than 1 cm cervical dilation per hour (2) Or no change of dilation for 2 hours b) Evaluate for cephalopelvic disproportion (CPD) 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Station (2) Size of maternal pelvis (3) Position, presentation of fetus (4) Fetal weight c) CPD ruled out → amniotomy (artificial rupture of membranes [AROM]) if membranes intact d) Other causes: induced labor with unripe cervix, false labor, early amniotomy, premature rupture of membranes e) Clinical therapy (1) Amniotomy (a) Active labor has been established (b) The presenting part is well applied to the cervix (c) Hypotonic labor patterns are present (d) Hypercontractibility is present (2) Oxytocin augmentation (a) Low-dose regimen → less uterine tachysystole (b) High-dose regimen → shorter length of labor, decreased second stage, reduced chorioamnionitis and neonatal sepsis, and reduced incidence of cesarean births related to dystocia → increased uterine tachysystole and adverse FHR changes (3) Continuous electronic fetal monitoring (EFM)

E. Nursing Management for the Woman Experiencing Hypotonic Labor 1. Nursing Assessment and Diagnosis a) Maternal vital signs, contractions, dilation, fetal descent, fetal heart rate (FHR) b) Signs and symptoms of infection, dehydration c) Vaginal exam → presenting part assessed d) See Figure 24–2: Effects of labor on the fetal head, p. 586 e) Woman’s stress and coping f) Adequate fluids and nourishment 2. Nursing diagnoses include a) Pain, Acute b) Coping, Ineffective c) Anxiety 3. Nursing Plan and Implementation a) Frequent maternal vital signs b) Note duration, frequency, strength of contractions c) FHR d) Assess amniotic fluid for meconium, blood, amount e) Intake and output f) Assess bladder every 2 hours for distention g) Ongoing evaluation for symptoms of infection h) Information 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Address the woman and her partner’s concerns and questions (2) Provide clear, accurate information (3) Keep the woman and her partner informed of labor progress (4) Advise the woman and her partner of possible treatment measures (5) Discuss disadvantages and treatment alternatives 4. Evaluation a) Woman and partner understand labor pattern and possible implications b) Woman and partner able to cope with labor c) Woman’s comfort increases and anxiety decreases d) Woman experiences more effective labor pattern

II.

Care of the Woman with Postterm Pregnancy

A. Extends more than 294 days or 42 completed weeks 1. 7th day of 42nd week elapsed 2. Associated with primiparity, previous postterm pregnancy, placental sulfatase deficiency, fetal anencephaly, male fetus, maternal obesity, genetic predisposition 3. Most causes related to inaccurate pregnancy dating a) Error in determining the time of ovulation and conception according to first day of last menstrual period b) Ultrasound in early pregnancy

B. Maternal Risks 1. Labor and birth may be affected a) Increased discomforts during pregnancy b) Maternal anxiety c) Insomnia d) Cesarean birth e) Operative vaginal birth f) Perineal trauma and damage g) Maternal hemorrhage 2. Fetal-neonatal risks a) Complications (1) Reduced placental blood supply (2) Decreased fetal oxygenation (3) Reduced nutritional supply (4) Oligohydramnios (5) Risk of umbilical cord compression (6) Small for gestational age (SGA) (7) Large for gestational age (LGA) (8) Macrosomia 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(9) Higher incidence of birth trauma (10) Risk of shoulder dystocia (11) Cephalopelvic disproportion (CPD) (12) Meconium, which can be associated with nonreassuring fetal status and meconium aspiration at birth (13) Low umbilical artery pH (14) Low 5-minute Apgar scores (15) Nonreassuring fetal status (16) Increased category II and III FHR tracings (17) Hypoglycemia (18) Seizures (19) Respiratory distress b) Approximately 20% of all postterm infants experience dysmaturity syndrome associated with uteroplacental insufficiency 3. Clinical therapy a) Non-stress test (NST) b) Biophysical profile (BPP) c) Anytime tests indicate fetal problems or there is decreased amniotic fluid volume, induction of labor is recommended

C. Nursing Management for the Woman with Postterm Pregnancy 1. Nursing Assessment and Diagnosis a) Establish estimated date of birth (EDB), type of antenatal testing b) Continuous EFM c) Assess fluid for meconium d) Ongoing assessments of labor progress 2. Diagnoses include a) Fear b) Coping: Family, Compromised c) Injury, Risk for (Fetus) d) Injury, Risk for (Mother) e) Pain, Acute 3. Nursing Plan and Implementation a) Community-based nursing care (1) Education (a) Fetal activity monitoring b) Hospital-based nursing care (1) Continuous electronic monitoring (2) Assist with procedures c) Evaluation (1) Woman able to explain implications of postterm pregnancy (2) Woman and partner and family feel supported, able to cope with labor and birth 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Fetal problems identified quickly

III.

Care of the Woman and Fetus at Risk Because of Fetal Malposition

A. Persistent occiput posterior (OP) position 1. Head remains in direct OP position throughout labor 2. To rotate to occiput anterior (OA) position → rotate 135 degrees a) In most cases rotation is accomplished

B. Maternal-Fetal-Neonatal Risks 1. Fetal a) None unless protracted labor, operative birth 2. Maternal a) Intense pain in small of back b) Third- or fourth-degree perineal laceration c) Higher rates of cesarean birth d) Prolonged first and second stage of labor e) Oxytocin augmentation f) Anal sphincter injury g) Severe perineal lacerations h) Episiotomy i) Blood loss greater than 500 mL j) Postpartum infection k) Accidental lacerations of the lower uterine segment during cesarean l) Instrument delivery 3. Clinical therapy a) Close monitoring b) Vaginal versus cesarean birth safest (1) Spontaneous birth (2) Forceps-assisted birth with occiput directly posterior (3) Forceps rotation of the occiput to the anterior position and birth (Scanzoni maneuver) (a) See Figure 24–3, Scanzoni maneuver... (4) Manual rotation to the anterior position followed by spontaneous or forcepsassisted birth (a) See Figure 24–4, Manual rotation of ROP to OA, p. 590 c) If pelvis is larger diameter, relaxed perineal muscles fetus may emerge spontaneously 4. Prolonged second stage with arrest of descent a) Lasts more than an hour in multiparas, > 2 hours nulliparas b) Forceps, manual rotation if no CPD c) Cesarean birth 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Nursing Management for the Laboring Woman with a Fetus in Occiput Posterior Position 1. Nursing Assessment and Diagnosis a) First sign of OP position → intense back pain in first stage of labor b) Dysfunctional labor pattern c) Prolonged active phase d) Secondary arrest of dilatation e) Arrest of descent f) Depression in maternal abdomen above symphysis pubis g) FHR auscultated far laterally on maternal abdomen h) Vaginal exam → anterior fontanelle i) Intrapartum ultrasound, Leopold maneuvers 2. Diagnoses include a) Pain, Acute b) Coping, Ineffective 3. Nursing Plan and Implementation a) Forward leaning, hands and knees, straddling, kneeling, or side-lying positioning Pelvic rocking b) Whirlpool or shower c) Adequate fluid and hydration during labor d) Judicious use of anesthesia e) Oxytocin infusion f) Amniotomy g) Anticipate need for vacuum or forceps h) Use of birthing ball 4. Evaluation a) Woman’s discomfort is decreased b) Woman and her partner apply comfort measures and position changes to assist her c) Woman’s coping abilities are strengthened d) Woman and her partner state that they feel supported and encouraged

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Care of the Woman and Fetus at Risk Because of Fetal Malpresentation A. Normal cephalic presentation 1. Occiput presenting, head flexed 2. See Figure 24–5: Types of cephalic presentations, p. 591

B. Malpresentation 1. Military presentation → least difficult

C. Brow Presentation 1. Forehead is presenting part 2. Causes a) High parity, placenta previa, uterine anomaly, hydramnios, fetal anomaly, low birth weight, CPD, large-for-gestational-age (LGA) fetus 3. Prolonged labor, secondary arrest 4. Cesarean in presence of CPD 5. Episiotomy with vaginal birth 6. Clinical therapy a) No active intervention if dilation and descent occurring b) Expectant management → cesarean birth frequent

D. Nursing Management for the Laboring Woman with the Fetus in Brow Presentation 1. Nursing Assessment and Diagnosis a) Leopold maneuvers b) Vaginal examination → palpation of anterior fontanelle, orbital ridges c) See Figure 24–6: Brow presentation. A. Descent. B. Internal rotation in the pelvic cavity, p. 592 2. Nursing diagnoses include a) Anxiety or Fear b) Knowledge, Deficient c) Injury, Risk for (Fetus) 3. Nursing Plan and Implementation a) Close observation b) Education c) Reassurance d) Explanation of facial edema, excessive molding

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Evaluation a) Woman and partner understand the implications and associated problems of brow presentation b) Mother and baby have safe labor and birth c) Woman and baby initiate bonding process

E. Face presentation 1. Fetal head → hyperextended a) Multiparous, pendulous abdomen b) Macrosomia, nuchal cord, anencephaly, fetal malformations 2. Risks a) CPD b) Prolonged labor c) Infection d) Edema e) Petechiae, bruising 3. Clinical therapy a) If no CPD, mentum anterior, labor pattern effective → vaginal birth b) Oxytocin for hypotonic labor patterns c) Manual rotation should not be attempted d) If mentum wedged on anterior surface, or CPD → cesarean birth (1) See Figure 24–7: Face presentation. Mechanism of birth in mentoanterior position, p. 593 (2) See Figure 24–8: Face presentation. Mechanism of birth in mentoposterior position, p. 593

F. Nursing Management for the Laboring Woman with the Fetus in Face Presentation 1. Nursing Assessment a) Leopold maneuvers → fetus difficult to outline, furrow palpated b) Fetal heart tones on side where fetal feet palpated c) Vaginal exam → palpation of saddle of nose, gums should be attempted (1) See Figure 24–9: Face presentation. A. Palpation of the maternal abdomen with the fetus in right mentum posterior (RMP). B. Vaginal examination …, p. 594 2. Nursing diagnoses include a) Fear b) Injury, Risk for 3. Nursing Plan and Implementation a) Same as for brow presentation 4. Evaluation a) Woman and partner understand implications and problems of face presentation

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Mother and baby have safe labor and birth c) Woman and baby initiate bonding process

G. Breech Presentation 1. Most common of malpresentations a) Frank breech → 50% to 70% of breech presentations → flexed hips and extended knees b) Footling breech → 10% to 30% of breech presentations, preterm fetuses → single or double → one or both hips extended and foot presenting (1) See Figure 24–10: Breech presentation. A. Frank breech. B. Incomplete (footling) breech. C. Complete breech … D. On vaginal examination …, p. 594 c) Associated with (1) Placenta previa, implantation of placenta in cornual area, hydramnios, high parity, oligohydramnios, hydrocephaly, anencephaly, previous breech presentation, uterine anomalies, pelvic tumors, multiple gestation, fetal anomalies (2) Cord prolapse more likely (3) Neuromuscular disorders (4) Head trauma during vaginal birth (5) Entrapment of fetal head (6) Higher risks of meconium aspiration, fetal asphyxia d) Planned cesarean birth → lower risk of perinatal morbidity and mortality 2. Clinical therapy a) External cephalic version (ECV) usually attempted at 37 to 38 weeks b) Complementary and alternative therapies (1) Moxibustion (a) Acupoint BL67 → may increase fetal activity (2) Maternal positioning exercises 2 to 3 times daily → hips higher than torso c) Unsuccessful version, spontaneous return to breech (1) Evaluate possibility of vaginal birth versus cesarean (2) Cesarean in nulliparas d) Contraindications to labor and vaginal birth (1) Fetal weight less than 1500 g or more than 3800 g (2) Hyperextension of the fetal neck more than 90 degrees (3) Extension of the fetal arms over head (4) Anomalies such as hydrocephalus (5) Diminished maternal pelvic measurements e) Attempted vaginal birth → pain relief (1) Prevent sensation to push before full dilation → fetal head entrapped

H. Nursing Management for the Laboring Woman with the Fetus in Breech Presentation 1. Nursing Assessment and Diagnosis a) Leopold maneuvers → hard vertex in fundus, ballottement of head b) Fetal heart tones (FHTs) usually auscultated above umbilicus 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Passage of meconium may occur d) Prolapsed cord if membranes ruptured 2. Nursing diagnoses include a) Self-Health Management, Readiness for Enhanced b) Injury, Risk for (Fetus) 3. Nursing Plan and Implementation a) Risk for cord prolapse b) Continuous EFM c) Ongoing assessments of labor progress d) Emotional support e) Assess FHR during vaginal birth 4. Evaluation a) Woman and partner can describe the implications and associated problems with breech presentation b) Mother and baby have a safe labor and birth c) Major complications are recognized early, and corrective measures are instituted

I. Transverse Lie (Shoulder Presentation) of a Single Fetus 1. Long axis lies across woman’s abdomen a) Associated conditions (1) Grand multiparity with lax uterine musculature, obstructions, hydramnios, preterm fetus b) Vaginal birth impossible (1) No labor attempted (2) Cesarean birth done quickly (3) See Figure 24–11: Transverse lie. A. Shoulder presentation. B. On vaginal examination, the nurse may feel the acromion process of the fetal presenting part, p. 596 2. Clinical therapy a) Leopold maneuvers → confirmed by ultrasound b) Management varies depending on length of gestation (1) ECV if close to term (2) No contraindication to vaginal birth (3) Fetal lung maturity confirmed (4) Tocolytics for procedure

J. Nursing Management for the Laboring Woman with the Fetus in Transverse Lie 1. Nursing Assessment and Diagnosis a) Inspection, palpation of abdomen b) FHTs in midline c) Vaginal examination 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nursing diagnoses a) Gas Exchange, Impaired b) Powerlessness, Risk for c) Fear 3. Nursing Plan and Implementation a) Evaluate fetal presentation b) Provide information, support to couple c) Interventions for induction if ECV accomplished 4. Evaluation a) Transverse lie is recognized promptly, crucial assessments are completed b) Measures to perform and ECV or cesarean birth are completed c) Mother and baby have a safe birth d) Couple can describe implications and associated problems of transverse lie

K. Compound Presentation 1. Two presenting parts a) Hand → generally not difficult birth 2. Cesarean birth indicated in presence of uterine dysfunction, nonreassuring fetal status

Care of Woman and Fetus at Risk Because of Macrosomia A. Fetal macrosomia → weight more than 4000 g 1. Mean birth weight varies throughout world 2. Obese woman twice as likely to have macrosomic fetus 3. Association with pregestational, gestational diabetes 4. Other risk factors postterm pregnancy, multiparity, grand multiparity, previous macrosomic newborn, previous shoulder dystocia, male sex, and maternal birth weigh 5. Adequate pelvis may be small for oversized fetus 6. Complications a) Dysfunctional labor b) Postpartum hemorrhage c) Risk of perineal lacerations d) Infection e) Vacuum and forceps birth f) Shoulder dystocia (1) Obstetric emergency (2) Anterior shoulder does not emerge spontaneously g) Other injuries to fetus, brachial plexus injury

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Clinical therapy a) Identification of macrosomia before onset of labor (1) Diagnosis not precise (2) Fetus greater than 4500 g → cesarean (3) Fetus between 4000 and 4500 g → debated b) Vaginal birth attempted, shoulders not delivering (1) McRoberts maneuver (a) See Figure 24–12: McRoberts maneuver, p. 596 (b) Suprapubic pressure (2) Episiotomy (3) Woods screw maneuver (4) Elective clavicular break

B. Nursing Management for the Laboring Woman and the Fetus at Risk for Macrosomia 1. Nursing Assessment and Diagnosis a) Identifying factors associated with macrosomic infants b) FHR assessment c) Evaluation of cervical dilation, fetal descent 2. Nursing diagnoses a) Injury, Risk for (Fetus) b) Infection, Risk for c) Injury, Risk for (Mother) 3. Nursing Plan and Implementation a) Monitor labor closely for dysfunctional pattern b) Support for laboring woman, partner c) Provide information d) Additional staff if shoulder dystocia anticipated e) Evaluate newborn for cephalhematoma, Erb palsy, fractured clavicles f) Check uterus for potential atony, maternal vital signs 4. Evaluation a) Woman and partner can describe implications of macrosomia and possible associated problems b) Mother and baby have safe labor and birth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Care of the Woman and Fetus in the Presence of Nonreassuring Fetal Status

A. Oxygen supply insufficient to meet physiologic demands of fetus B. Nonreassuring fetal status is the term used to identify data describing the fetal status C. Factors 1. Cord compression 2. Uteroplacental insufficiency 3. Preexisting maternal or fetal disease

D. Initial signs 1. Meconium-stained amniotic fluid 2. Changes in FHR a) Late, severe variable deceleration b) Decrease in or lack of variability c) Progressive acceleration in FHR baseline

E. Clinical therapy 1. Relieving hypoxia 2. Change mother’s position 3. Increase intravenous rates 4. Administer oxygen by mask 5. EFM if not in use 6. Oxytocin discontinued 7. See Table 24–1: Management of Nonreasssuring Fetal Status, p. 599

F. Nursing Management for the Laboring Woman and Fetus in the Presence of Nonreassuring Fetal Status 1. Nursing Assessment and Diagnosis a) Review prenatal history to anticipate possibility b) Assess FHR, observe for meconium staining when membranes rupture c) Assess changes in fetal movement activity 2. Nursing diagnoses a) Cardiac Output, Decreased (Fetus) 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Anxiety 3. Nursing Plan and Implementation a) Assess fetal status b) Initiate corrective measures c) Provide explanations and emotional support to woman, partner, family 4. Evaluation a) Woman and family become less anxious and more able to cope with situation b) FHR remains in normal range, or alternatively, supportive measures maintain FHR as normal as possible

VII.

Care of the Woman Experiencing Placental and Umbilical Cord Problems

A. Placental Problems 1. Developmental a) Placental lesions, succenturiate placenta, circumvallate placenta, battledore placenta b) See Table 24–2: Placental and Umbilical Cord Variations, p. 601 2. Degenerative a) Infarcts, placental calcifications 3. Succenturiate placenta a) One or more accessory lobes of fetal villi have developed on placenta (1) Vascular connections of fetal origin (2) Risk of minor lobe being retained during third stage of labor b) Risks (1) Maternal → postpartum hemorrhage (2) Fetal/newborn → if vascular connections rupture → fatal fetal hemorrhage (a) Inspect newborn at birth for pallor, cyanosis, retractions, tachypnea, tachycardia, feeble pulse 4. Circumvallate placenta a) Fetal surface of placenta exposed through a ring opening around umbilical cord (1) Increased incidence of late abortion, fetal death (2) Antepartum hemorrhage (3) Prematurity (4) Abnormal maternal bleeding 5. Battledore placenta a) Umbilical cord inserted at or near placental margin b) Chances of preterm labor high c) Nonreassuring fetal status, bleeding during labor likely 6. Placental infarcts and calcifications a) Large enough → interfere with uterine–placental–fetal exchange b) Severe preeclampsia, women who smoke 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Umbilical Cord Abnormalities 1. Congenital absence of umbilical artery a) Infants born with two vessel cords have increased rate of anomalies b) 15% have IUGR c) Inspect all cords after cut for three vessels at delivery 2. Insertion variations a) Velamentous insertion (1) Umbilical cord vessels divide some distance from placenta in placental membranes (2) More frequently in multiple gestations (3) Other placental anomalies accompany this condition (4) More easily compressed → lack of Wharton’s jelly (a) Increased risk of vessels tearing during birth (5) Risk of vasa previa b) Cord length variations (1) Average length 55 cm (2) Short cord associated with umbilical hernias, abruptio placentae, cord rupture (3) Long cords tend to twist, tangle around fetus (4) True knots 3. Clinical therapy a) Continuous EFM with any vaginal bleeding b) Nonreassuring heart rate pattern → report immediately c) Fetal hemorrhage → vaginal, cesarean birth, correct anemia d) Identify and treat neonatal complications

C. Nursing Management for the Laboring Woman and the Fetus with Umbilical Abnormalities 1. Nursing Assessment and Diagnosis a) May not be evident until birth of fetus b) Observe during labor 2. Diagnoses include a) Gas Exchange, Impaired (Fetus) b) Knowledge, Deficient 3. Nursing Plan and Implementation a) Alert for unusual amount of bleeding b) Inspect placenta c) Repositioning of woman 4. Evaluation a) Mother and baby have safe labor and birth b) Woman’s bleeding is assessed quickly, corrective measures taken c) Family is able to cope successfully with fetal or neonatal anomalies, if they exist 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VIII.

Care of the Woman and Fetus with a Prolapsed Umbilical Cord

A. Umbilical cord that precedes fetal presenting part 1. Cord falls, washed down through cervix into vagina 2. Trapped between presenting part and maternal pelvis 3. Presenting part not firmly against cervix a) See Figure 24–13: Prolapse of the umbilical cord, p. 603 4. Occult cord prolapse 5. Incidence higher with a) 20x greater with abnormal axis lie, footling, shoulder presentations b) Low birth weight c) Multipara with more than five previous births d) Multiple gestation e) Polyhydramnios f) Unengaged presenting part g) Obstetric manipulation h) Long cord i) 80% occur in second stage of labor

B. Maternal-Fetal-Neonatal Risks 1. Maternal a) Reaction may cause stress 2. Fetus a) Compression of umbilical cord (1) Bradycardia (2) Persistent variable decelerations (3) Cord compressed further with each contraction (4) Pressure not relieved, fetus will die

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Clinical therapy 1. Prevention 2. Bedrest after rupture of membranes 3. Nurse usually finds, relieve pressure on cord 4. Knee-to-chest position (Figure 24–14)

D. Nursing Management for the Laboring Woman and the Fetus with a Prolapsed Umbilical Cord 1. Nursing Assessment and Diagnosis a) Review nursing history b) Is presenting part engaged c) Spontaneous or artificial rupture of membranes d) Assess FHR 2. Nursing diagnoses a) Gas Exchange, Impaired (Fetus) b) Fear 3. Nursing Plan and Implementation a) Few outward signs b) Call physician/CNM when membranes rupture c) Sterile vaginal examination d) Presenting part well engaged → risk minimal e) Membranes not ruptured → FHR monitored after spontaneous rupture, amniotomy f) EFM tracings show bradycardia, decelerations → vaginal exam g) Vaginal exam (1) Loop of cord → nurse’s gloved fingers in vagina, pushing presenting upward to lift fetal part off the cord (2) Oxygen administered (3) Large-gauge IV cannula inserted (4) Notify anesthesiology and neonatology (5) Insert indwelling bladder catheter → fill bladder with 500 mL warmed, sterile normal saline (6) Woman in side-lying position, assumes the knee-chest position (7) Maintain pressure on presenting part until fetus born via cesarean birth 4. Evaluation a) FHR remains in normal range with supportive measures b) Fetus is born safely c) Woman and partner feel supported d) Woman and partner understand problem and corrective measures that are undertaken

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IX.

Care of the Woman and Fetus at Risk Because of Anaphylactoid Syndrome of Pregnancy A. Amniotic fluid embolism, fetal cells, hair, other debris enters maternal circulation, then maternal lungs 1. Obstetric emergency

B. Clinical therapy 1. IV access quickly 2. Crash cart available 3. Stabilize mother, emergency cesarean birth 4. Symptoms occur rapidly a) Shortness of breath b) Hypoxia c) Cyanosis d) Cardiovascular and respiratory collapse 5. Supportive nursing measures a) Prepare for emergency birth b) Transfer of mother to ICU

C. Nursing Management for the Woman and Fetus at Risk Because of Anaphylactoid Syndrome of Pregnancy 1. Nursing Assessment and Diagnosis a) Gas Exchange, Impaired (Fetus) b) Gas Exchange, Impaired (Mother) c) Fear 2. Nursing Plan and Implementation a) Administer oxygen under positive pressure until medical help arrives b) IV line c) Cardiopulmonary resuscitation (CPR) d) Obstetrician, anesthesiologist, perinatologist, hospital intensivist called e) Prepare equipment for blood transfusion, insertion of central venous pressure (CVP) line f) Fetus continually monitored g) Emergent cesarean birth to save fetus (1) CPR continues through the cesarean procedure 3. Evaluation a) Mother treated with appropriate interventions to achieve stabilization b) Fetus is delivered safely via cesarean birth c) Family is informed and supported during emergency procedures 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman with a Uterine Rupture A. Nonsurgical disruption of uterine cavity 1. 1:2000 births 2. Complete → endometrium, myometrium, and serosa separated 3. Incomplete or partial → not all layers disrupted

B. Factors 1. Previous uterine incision 2. Uterine manipulation (version) 3. Operative vaginal delivery 4. Abdominal trauma 5. Interval of birth between deliveries less than 18 months 6. Postpartum fever during previous cesarean birth 7. One-layer closure performed with a previous cesarean birth

C. Clinical therapy 1. Only diagnosed via surgical incision 2. Pad count → vaginal bleeding 3. Preparations for emergency birth 4. Neonatal resuscitation should be anticipated

D. Nursing Management for the Woman with a Uterine Rupture 1. Nursing Assessment and Diagnosis a) Nonreassuring FHR commonly earliest sign b) Loss of fetal station on abdominal palpation c) Constant abdominal pain, uterine tenderness, change in uterine shape, cessation of contractions, hematuria, signs of shock 2. Nursing Plan and Implementation a) Nonreassuring fetal pattern identified → physician/CNM immediately contacted b) History of cesarean birth, uterine surgery at risk c) Maternal signs and symptoms assessed d) Leopold maneuvers, maternal vital signs e) Prepare woman for emergency cesarean birth f) Anesthesiologist called immediately

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Diagnoses a) Gas Exchange, Impaired (Fetus) b) Gas Exchange, Impaired (Mother) c) Fear d) Anxiety e) Coping, Ineffective 4. Evaluation a) Mother remains hemodynamically stable throughout emergency cesarean birth b) Fetus retains optimal oxygenation until safe birth is achieved

XI.

Care of the Woman with Cephalopelvic Disproportion

A. Birth passage 1. Bony pelvis through maternal soft tissues a) Contracture (narrowing) in any part of passage → CPD b) Abnormal fetal presentations and positions occur 2. Gynecoid, anthropoid pelvic types usually adequate for vertex birth 3. Android, platypelloid types predispose to CPD 4. See Table 24–3: Clues Suggesting Contractures of Maternal Pelvis, p. 605 a) Diagonal conjugate less than 11.5 cm, outlet less than 8 cm b) Unengaged fetal head in early labor in primigravidas c) Hypotonic uterine contraction pattern d) Deflexion of fetal head e) Uncontrollable pushing before complete dilation of cervix f) Failure of fetal descent g) Edema of anterior portion of cervix

B. Types of Contractures 1. Inlet a) Contracted if shortest anterior–posterior diameter < 10 cm b) Or greatest transverse diameter < 12 cm c) Bulging perineum and crowning indicate obstruction has been passed 2. Outlet a) Interischial tuberous diameter < 8 cm → outlet contracture b) Possibility of vaginal birth → depends on diameters and fetal posterosagittal diameter

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Implications of Pelvic Contractures 1. Labor prolonged 2. Premature rupture of membranes (PROM) can result 3. Obstructed labor can result in uterine rupture 4. Necrosis of maternal soft tissue → fistulas 5. Difficult forceps-assisted births a) Damage to fetus and mother

D. Clinical therapy 1. Fetopelvic relationships assessed a) Estimated weight of fetus from ultrasound measurements b) Pelvic measurements by manual examination and/or CT scan 2. If diameters borderline or questionable a) Trial of labor (TOL) b) Continued progress → TOL continues c) Progress ceases → decision for cesarean birth made

E. Nursing Management for the Woman with Cephalopelvic Disproportion 1. Nursing Assessment and Diagnosis a) Adequacy of maternal pelvis assessed intrapartum, antepartum b) Prolonged cervical dilation, effacement slow, delayed engagement 2. Nursing diagnoses a) Knowledge, Deficient b) Fear 3. Nursing Plan and Implementation a) During TOL → similar to care during any labor b) More frequent assessment of dilation, fetal descent c) Contractions monitored d) Positioning to increase pelvic diameters (1) Sitting, squatting e) Assist with coping with stresses f) Keep couple informed 4. Evaluation a) Woman’s fear is lessened b) Woman has additional knowledge regarding problems, implications, and treatment plans

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

XII.

Care of the Woman at Risk Because of Complications of Third and Fourth Stages of Labor

A. Retained Placenta 1. Placenta retained beyond 30 minutes after birth 2. 2 to 3% of births 3. Manual removal by physician/CNM attempted 4. Failure to retrieve → surgical removal by curettage a) May be a symptom of an accreta, increta, percreta 5. General anesthesia if no epidural in place

B. Lacerations 1. Bright red blood in presence of well-contracted uterus 2. Incidence 3. Categorized in terms of degree a) First degree → limited to fourchette, perineal skin, vaginal mucous membrane b) Second degree → perineal skin, vaginal mucous membrane, underlying fascia, muscles of perineal body; may extend upward on one or both sides of vagina c) Third degree → through perineal skin, vaginal mucous membranes, perineal body and involves anal sphincter; may extend up the anterior wall of rectum d) Fourth degree → same as third and extends through rectal mucosa to lumen of rectum

C. Placenta Accreta 1. Chorionic villi attach directly to myometrium of uterus a) Placenta increta → myometrium invaded b) Placenta percreta → myometrium penetrated 2. Can be life threatening a) 1:2000 births 3. Risks a) Previous cesarean birth 4. Complications a) Maternal hemorrhage b) Failure of placenta to separate following birth of infant

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Abdominal hysterectomy may be necessary treatment

XIII.

Focus Your Study

XIV.

Activities 1. Individual Have each student prepare a teaching plan for the primigravida who is experiencing a postterm pregnancy. 2. Large Group Utilizing equipment from the skills lab, run an emergency drill/mock code for the woman with uterine rupture, amniotic fluid embolism, or placenta accreta with hemorrhage. Have students plan interventions. Evaluate and provide feedback on how they worked together.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 25 Birth-Related Procedures Care of the Woman During Version....................................................................

Care of the Woman During Cervical Ripening....................................................

Care of the Woman During Induction or Augmentation of Labor…………………..

Care of the Woman During an Amniotomy........................................................

Care of the Woman During Amnioinfusion........................................................

Care of the Woman During an Episiotomy.........................................................

Care of the Woman During Forceps-Assisted Birth............................................

Care of the Woman During Vacuum Extraction.................................................

Care of the Family During Cesarean Birth..........................................................

Care of the Woman Undergoing Trial of Labor After Cesarean and Vaginal Birth After Cesarean....................................................................

Focus Your Study.................................................................................................

Activities..............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman During Version

A. Procedure used to change fetal presentation 1. External cephalic version (ECV) a) Fetus changed from breech, transverse, oblique lie (1) See Figure 25–1: External (or cephalic) version of the fetus, p. 609 (2) Success rates highest with transverse lie (3) Overall success rate 60% 2. Podalic version (internal version) a) Used only with second twin during a vaginal birth (1) Obstetrician places hand inside the uterus (a) See Figure 25–2: Use of podalic version and extraction of the fetus to assist in the vaginal birth of the second twin, p. 610

B. External Cephalic Version 1. If breech or shoulder presentation detected in later weeks of pregnancy a) ECV may be attempted b) May increase risk of intrapartum cesarean birth 2. Usually done after 36 to 37 weeks’ gestation a) Time for spontaneous change to vertex b) Risk of prematurity eliminated 3. Higher success rates a) Fetal weight estimated < 2500 g b) Higher parity c) Adequate amniotic fluid d) Lack of fetal engagement e) Transverse lie f) Palpable fetal head g) Relaxed uterus h) Anterior placenta i) Low station j) Maternal obesity k) Decreased amniotic fluid volume l) Anterior or posterior positioning of fetal spine 4. Criteria for external cephalic version a) Single fetus b) Fetal breech is not engaged c) Adequate amount of amniotic fluid must exist d) Reactive non-stress test (NST) should be obtained immediately before performing the version 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Fetus must be 36 to 37 or more weeks’ gestation 5. Contraindications for external cephalic version a) Absolute contraindications (1) Suspected intrauterine growth restriction (2) Fetal anomalies (3) Presence of an abnormal fetal heart rate (FHR) tracing (4) Rupture of membranes (5) Planned cesarean birth (6) Maternal problems (7) Amniotic fluid abnormalities b) Relative contraindications for ECV (1) Previous lower uterine segment cesarean birth (2) Nuchal cord (3) Multiple gestation (4) Evidence of uteroplacental insufficiency (5) Significant third-trimester bleeding (6) Uterine malformation 6. External cephalic version procedure a) In birthing unit in case further intervention necessary b) Fasting for 8 hours preceding c) Ultrasound to confirm (1) Single fetus (2) Amount of amniotic fluid (3) Location of placenta (4) Position of umbilical cord (5) Breech presentation d) Maternal vital signs e) Continuous electronic fetal monitoring (EFM) f) Reactive NST g) Evaluate presence of uterine activity h) Blood work i) Explain procedure, patient signs consent form j) Intravenous line k) Beta-mimetic agent or magnesium sulfate administered to achieve uterine relaxation (1) Epidural or spinal analgesia increases success rate l) Woman positioned in supine or slight Trendelenburg m) Warmed ultrasound gel applied to abdomen n) Physician grasps fetal breech (1) Index finger, thumb o) Presenting part gently pushed out of maternal pressure p) Head and breech rotated or moved in opposite directions q) Direction similar to forward roll attempted initially r) Fails → opposite direction attempted 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

s) Procedure concluded when: (1) Fetal head is moved to a head-down position (2) Repeated failures have occurred (3) Woman has indicated that procedure has become too painful or stressful (4) Signs of maternal or fetal problems occur (a) Nonreassuring FHR pattern t) Beta-mimetic discontinued u) Nurse or physician holds fetus in new presentation until uterus regains tone v) Ultrasound performed to confirm fetal position

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Tocolysis likely to increase success rates of ECV 8. If failed, repeat attempt can be made within 1 week if tolerated well by mother and fetus

C. Nursing Management for the Expectant Woman During External Cephalic Version 1. Ensure that expectant woman understands procedure 2. Possibility of failure, slight risk to fetus discussed 3. Initial maternal, fetal assessments 4. Ongoing evaluation of FHR, NST 5. Blood work 6. Psychologic support 7. Monitor vital signs every 2 minutes during beta-mimetic use, 30 minutes after 8. FHR monitored for at least 30 minutes or longer 9. Provide information → aftercare instructions

II.

Care of the Woman During Cervical Ripening

A. Contraindications for ripening 1. Prematurity 2. Active herpes 3. Fetal malpresentation 4. Nonreassuring fetal surveillance 5. History of prior traumatic delivery 6. Regular contractions 7. Unexplained vaginal bleeding 8. Placenta previa 9. Vasa previa 10. Prior uterine myomectomy involving the endometrial cavity or classic cesarean delivery

B. Use of Misoprostol (Cytotec) 1. For cervical ripening 2. Synthetic prostaglandin PGE1 analogue a) Soften, ripen cervix, induce labor b) Tablet inserted into vagina 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Oral or sublingual 3. More effective than oxytocin or prostaglandin agents, less costly 4. Adverse outcomes associated with doses beyond recommended 25 mcg 5. Guidelines a) Initial dosage should be 25 mcg b) Recurrent administration should not exceed dosing intervals of more than 3 to 6 hours c) Pitocin should not be administered less than 4 hours after the last Cytotec dose d) Misoprostol should only be administered where uterine activity and FHR can be monitored continuously for initial observation period 6. Contraindications a) Nonreassuring FHR tracing b) Frequent uterine contractions of moderate intensity c) Prior cesarean section or uterine scar d) Placenta previa e) Undiagnosed vaginal bleeding

C. Use of Prostaglandin Agents (Cervidil, Prepidil) 1. Prostaglandin gel a) Prepidil gel → 0.5 mg dinoprostone (1) Placed intracervically 2. Cervidil → intravaginal insert a) Resembles 2-cm-square piece of cardboard-like material b) Left in posterior vagina → slow release of 10 mg dinoprostone over 12 hours 3. Advantages and disadvantages of prostaglandin administration a) Cervidil → easily removed if uterine hyperstimulation occurs b) Both cause cervical ripening c) Shorten labor d) Lower requirements for oxytocin during labor induction e) Vagina birth achieved within 24 hours for most women f) Incidence of cesarean birth is reduced g) Complications (1) Uterine hyperstimulation (2) Nonreassuring fetal status (3) Hypotonous 4. See Table 25–1: Contraindications to Labor Induction or Augmentation, p. 614 a) Vasa previa or complete placenta previa b) Transverse fetal lie c) Umbilical cord prolapse d) Previous classical cesarean delivery e) Active genital herpes infection 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Previous myomectomy entering endometrial cavity

D. Prostaglandin agent insertion procedure 1. Recommended that prostaglandin gel be used in hospital birthing unit a) Physician readily available in case of emergency cesarean birth b) Prepidil → introduced by means of prefilled syringe c) Dinoprostone available as gel or suppository d) Cervidil → insert placed in posterior vagina 2. Monitoring of contractions and fetal status 3. Hyperstimulation of uterus → insert removed 4. Active labor established → insert removed 5. Oxytocin started to facilitate birth

E. Mechanical Methods of Cervical Ripening and Labor Induction 1. Balloon catheters a) Promote mechanical dilatation b) Foley catheter with 30 to 50 mL balloon passed through undilated cervix, then inflated c) Weighted balloon applies pressure on internal os of cervix, ripens d) Can be used with other induction methods e) Extra-amniotic saline infusion (1) Additional saline inserted into Foley bulb, pulled snugly against cervical os

F. Use of Nitric Oxide Donor Agents 1. Being studied for their ripening of the cervix without producing contractions 2. Isosorbide mononitrate, isosorbide dinitrate, nitroglycerin, sodium nitroprusside 3. Use leads to little or no difference in the labor process and delivery outcomes 4. Associated with dizziness, nausea

G. Nursing Management for the Expectant Woman During Cervical Ripening 1. Administration of agents for cervical ripening a) Physicians, CNMs, labor and delivery nurses with special education and training 2. Baseline vital signs, EFM for 30 minutes 3. Reactive NST 4. Woman lying down after insertion a) Blanket or hip wedge under right hip b) 30 to 60 minutes c) Monitor for uterine tachysystole, FHR abnormalities 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) 30 minutes to 2 hours if prostaglandin gel agent used d) More than five contractions in 10 minutes → woman positioned on left side, oxygen administered if fetal stress noted e) Gel removed for uterine tachysystole, severe nausea, vomiting, cardiac tachysystole develops 5. Balloon catheter → intermittent monitoring with maternal vital signs a) Do not need continuous fetal monitoring b) Note placement of catheter c) Avoid ambulation, woman should remain in a recumbent position d) No vaginal exams

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

III.

Care of the Woman During Induction or Augmentation of Labor

A. Induction 1. Stimulation of uterine contractions before spontaneous onset of labor, with or without ruptured fetal membranes, for purpose of accomplishing birth

B. Labor augmentation 1. Artificial stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of fetus

C. May be indicated in presence of following 1. Maternal medical conditions 2. Preeclampsia, eclampsia 3. Premature rupture of membranes (PROM) 4. Chorioamnionitis 5. Fetal demise 6. Postterm pregnancy 7. Fetal compromise 8. Risk of rapid labor or extensive distance from hospital setting 9. Mild abruptio placentae 10. Nonreassuring FHR

D. Contraindications to Labor Induction or Augmentation 1. All contraindications to spontaneous labor, vaginal birth are contraindications to the induction or augmentation of labor

E. Assessment of individual patient, clinical situation 1. Fetal maturity 2. Amniotic fluid studies 3. See Table 25–2: Confirmation of Gestational Age, p. 615 a) Ultrasound measurement at less than 20 weeks b) Fetal heart tones (FHTs) documented for at least 30 weeks by Doppler ultrasonography c) 36 weeks since positive serum or urine human chorionic gonadotropin pregnancy test result 4. Bishop score a) Bishop prelabor scoring system 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) See Table 25–3: Prelabor Status Evaluation Scoring System, p. 616 (2) Higher score → more likely labor will occur (3) Favorable cervix is most important criterion

F. Methods of Inducing or Augmenting Labor 1. Most frequent a) Stripping amniotic membranes b) Amniotomy c) Intravenous oxytocin infusion d) Complementary methods 2. Stripping the membranes a) CNM/physician inserts gloved finger into internal cervical ox b) Rotated finger 360 degrees, twice (1) Thought to release prostaglandin F2oc (PGF2oc) from the amniotic membranes or prostaglandin E2 (PGE2) from the cervix c) Discomfort d) Typically labor begins within 24 to 48 hours 3. Oxytocin infusion a) Effective method of initiating uterine contractions (1) Goal to achieve adequate uterine contraction pattern without tachysystole b) Augmentation of arrested labor → IV (1) Assessment of fetal station, maternal pelvis, fetal position before starting infusion c) Primary bottle of IV fluid prepared (1) Piggyback oxytocin solution into primary tubing port closest to catheter insertion with a device permits precise control of flow rate (2) 10 to 20 units oxytocin added to 1 L 5% dextrose in lactated Ringer’s solution (a) 10 or 20 milliunits of oxytocin per mL (b) High-dose and low-dose regimen d) Associated risks (1) Tachysystole of uterus with/without FHR changes (2) Uterine rupture (3) Water intoxication 4. Complementary health approaches a) Sexual intercourse/lovemaking (1) Female orgasm stimulates uterine contractions (2) Male ejaculate contains natural prostaglandins b) Self/partner stimulation of nipples, breasts (1) Stimulates release of endogenous oxytocin (2) Stimulate uterine contractions (3) Initiate spontaneous labor c) Herbs (1) Blue, black cohosh 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Evening primrose oil → oral, intravaginal (3) Red raspberry leaf teas d) Homeopathic solutions (1) Pulsatilla (2) Castor oil (3) Enemas (4) Acupressure/acupuncture

G. Nursing Management for the Expectant Woman During Labor Induction 1. Close observation 2. Accurate assessments a) Maternal vital signs b) Fetal monitoring (1) 20- to 30-minute electronic fetal monitor recording demonstrating a reassuring FHR c) Reactive NST d) Contraction status e) Physician should be readily available 3. Patient teaching a) Blood-tinged discharge from membrane stripping 4. Assess contraction pattern 5. EFM while breast pumping to stimulate breasts 6. Expected outcomes a) Woman and family fully informed; understand induction process; able to relate advantages, disadvantages, risks, possible outcomes; and have had opportunity to have questions answered b) Woman’s labor is successfully induced c) Labor progresses at normal rate, maternal vital signs remain in normal range d) Fetal status remains reassuring throughout the labor period

H. See Nursing Care Plan: For Induction of Labor, p. 619

IV.

Care of the Woman During an Amniotomy A. Artificial rupture of amniotic membranes (AROM) 1. Cervix must be dilated at least 2 cm 2. Stimulate or augment labor a) If labor progressing normally, not suggested as can increase risk of infection

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Advantages and Disadvantages of Amniotomy 1. Advantages a) Contractions similar to those of spontaneous labor b) Usually no risk of hypertonus or rupture of the uterus c) Woman does not require same intensive monitoring as with intravenous oxytocin d) EFM facilitated because once membranes ruptured: e) Fetal scalp electrode may be applied f) Intrauterine catheter may be inserted g) Scalp blood sampling for pH determinations may be done h) Color and composition of amniotic fluid can be evaluated i) Amniotomy less costly procedure 2. Disadvantages a) Once amniotomy done, risk of infections rise if labor proceeds beyond 24 hours b) Danger of prolapsed cord increased, especially if fetal presenting part not firmly pressed down against cervix c) Compression and molding of fetal head increased because of loss of cushioning effect of amniotic fluid d) Fetal injury can occur if amniohook causes laceration on presenting part e) Bleeding can occur if undiagnosed vasa previa present f) Severe variable decelerations can occur, which increases likelihood of cesarean birth g) Intervention can cause pain increase

C. Amniotomy Procedure 1. Fetus assessed for presentation, position, station, FHR before 2. Sterile vaginal examination → introduce amniohook into vagina against amniotic membrane 3. Small tear made in membrane made by provider with amnihook

D. Nursing Management for the Woman Undergoing Artificial Rupture of the Amniotic Membranes 1. Procedure explained 2. Fetal presentation, position, station assessed 3. Positioned in semireclining position, draped to provide privacy 4. Disposable underpads and/or towels to absorb amniotic fluid 5. FHR assessed before and after a) If markedly different, assess for cord prolapse

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Assess fluid for color, amount, odor, presence of meconium or blood 7. Clean and dry perineal area 8. Advise that fluid will continue 9. Patient comfort 10. Strict sterile technique 11. Minimize number of vaginal examination 12. Monitor vital signs every 2 hours 13. Provide information

Care of the Woman During Amnioinfusion A. Amnioinfusion (AI) → volume of warmed, sterile, normal saline, Ringer’s lactate solution introduced into uterus through use of intrauterine pressure catheter (IUPC) 1. Increase volume of amniotic fluid volume 2. Relieve pressure on umbilical cord 3. Promote increased perfusion to fetus 4. Meconium dilution in presence of medium to heavy meconium staining

B. Contraindications 1. Contraindication to vaginal delivery 2. Amnionitis 3. Hydramnios 4. Uterine hypertonus 5. Multiple gestation 6. Known fetal anomaly 7. Uterine anomaly 8. Nonreassuring fetal status requiring immediate birth 9. Nonvertex presentation 10. Scalp pH below 7.2 11. Placenta previa 12. Vasa previa 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

13. Abruptio placentae

C. Can be associated with rare risk factors 1. Umbilical cord prolapse, amniotic fluid embolism, and uterine rupture

D. No one, accepted protocol 1. Infuse bolus of 500 to 800 mL of warmed saline through intrauterine catheter a) Infusion pump b) Approximate rate 3 mL per minute c) Repeat until indication resolves

E. Nursing Management for the Woman Undergoing Amnioinfusion 1. Suspect cord compression a) Assist woman into another position b) Apply O2 via face mask 2. Amnioinfusion considered 3. Monitor vital signs, contraction status 4. Continuous EFM 5. Provide ongoing information 6. Should not cause pain or discomfort 7. Ensure that fluid infused is being expelled 8. Advise that fluid will leak from vagina 9. Change absorbent pads, pericare on regular basis

VI.

Care of the Woman During an Episiotomy

A. Surgical incision of perineal body 1. Traditionally performed to prevent damage to soft tissues a) Prevent jagged tears from lacerations b) Reduce mechanical, metabolic risks to fetus/newborn c) Protect maternal bladder d) Prevent future perineal relaxation 2. Research indicates no maternal benefits a) Major perineal trauma more likely to occur if midline episiotomy is performed b) Additional complications associated with episiotomy (1) Blood loss (2) Infection (3) Pain 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Perineal discomfort (5) Dyspareunia (6) Flatal incontinence c) No evidence to support that it promotes shorter second stage, improved Apgar scores, or a decrease in perinatal asphyxia

B. Risk Factors That Predispose Women to Episiotomy 1. Overall factors a) Primigravid status b) Large or macrosomic fetus c) Occiput-posterior (OP) position d) Use of forceps or vacuum extractor e) Shoulder dystocia f) White race g) Physician provider h) Private practice physician i) Nocturnal birth times. j) Use of lithotomy position, other recumbent position k) Encouraging or requiring sustained breath holding during second-stage pushing l) Time limit placed on second stage

C. Episiotomy Procedure 1. Sharp scissors with rounded points a) Just before birth b) Approximately 3 to 4 cm of the fetal head is visible during a contraction 2. Two types a) Midline (1) Vertical incision that begins at the vaginal opening, extends downward to rectum (2) Vaginal orifice to fibers of rectal sphincter b) Mediolateral (1) Short perineum, macrosomia, instrument-assisted birth (2) Midline of posterior fourchette → 45-degree angle downward to right or left c) See Figure 25–3: The two most common types of episiotomies are midline and mediolateral. A. Right mediolateral. B. Midline, p. 624 3. Usually performed with regional or local anesthesia a) As crowning occurs

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Repair after birth before expulsion of placenta, or after expulsion of placenta

D. Nursing Management for the Woman Underoing an Episiotomy 1. Support 2. Distract from pain 3. Act as advocate 4. Note type of episiotomy on birth record, in report 5. Pain relief measures a) Ice pack b) 20 to 30 minutes, removed for at least 20 minutes before being reapplied 6. Inspect site every 15 minutes for first hour a) Redness, swelling, tenderness, and hematomas 7. Instructions on perineal hygiene

VII.

Care of the Woman During Forceps-Assisted Birth

A. Instrumented delivery, operative delivery, or operative vaginal delivery 1. Different types for specific functions

B. Criteria for Forceps Application 1. Outlet forceps application a) Forceps applied when fetal skull reaches pelvic floor and is at or on perineum b) Scalp is visible between contractions without separating labia c) Sagittal suture not more than 45 degrees from midline 2. Low forceps application a) Leading edge of fetal skull at +2 or below (+3) but not on pelvic floor b) Rotation of fetal head is less than 45 degrees 3. Midforceps application a) Fetal head engaged b) Leading edge of fetal skull is above +2 (+1, 0, –1, –2) c) Goal is to apply traction d) Rotate head, facilitate vaginal birth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. High forceps not indicated in current obstetric practice 5. See Figure 25–4: Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve, p. 625

C. Indications for Use of Forceps 1. Presence of any condition that threatens mother or fetus → can be relieved by birth 2. At risk a) Heart disease b) Acute pulmonary edema c) Pulmonary compromise d) Certain neurologic conditions e) Intrapartum infections f) Prolonged second stage g) Exhaustion h) Premature placental separation i) Prolapsed umbilical cord j) Nonreassuring fetal status k) Shorten second stage and spare pushing in exhausted mother, mother with heart disease 3. Risk factors a) Nulliparity b) Maternal age (35 and older) c) Maternal height of less than 150 cm (4 ft 11 in) d) Pregnancy weight gain of more than 15 kg (33 lb) e) Postdates gestation (41 weeks of more) f) Epidural anesthesia g) Fetal presentation other than occipitoanterior h) Presence of dystocia i) Presence of midline episiotomy j) Abnormal FHR tracing

D. Neonatal and Maternal Risks 1. Neonatal risks a) Ecchymosis or edema b) Forceps marks c) Caput succedaneum, cephalhematoma d) Hyperbilirubinemia e) Transient facial paralysis f) Low Apgar scores g) Retinal hemorrhage h) Corneal abrasions i) Descemet membrane tear j) Ocular trauma 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

k) Erb palsy l) Fractured clavicle m) Elevated neonatal bilirubin levels n) Prolonged infant hospital stay 2. Maternal risks a) Third- or fourth-degree Lacerations b) Extension of median episiotomy into the anus c) Increased bleeding or bruising d) Hematomas e) Pelvic floor injuries f) Increased perineal pain g) Sexual dysfunction in the postpartum period h) Postpartum infections i) Prolonged hospital stays j) Urinary and rectal incontinence, anal sphincter injury

E. Prerequisites for Forceps Application and Birth 1. Physician knowledgeable about advantages, disadvantages of different types of forceps and use 2. Cervix must be completely dilated 3. Fetal head must be engaged, stations, presentation, exact position of head must be known a) Vertex or face presentation, chin anterior 4. Amniotic membranes must be ruptured 5. Type of pelvis should be identified a) No disproportion between fetal head and maternal pelvis

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Maternal bladder should be empty 7. No obstructions to birth below fetal head 8. Adequate anesthesia

F. Trial or Failed Forceps Procedure 1. Attempts forceps with knowledge there could be degree of CPD 2. Setup for immediate cesarean birth available 3. If good application cannot be obtained, no descent → vacuum technique can be attempted 4. If yields no descent, cesarean birth method of choice

G. Nursing Management for the Woman Undergoing a Forceps-Assisted Birth 1. Variables a) Dystocia → maternal position b) FHR abnormalities → support ambulation, position changes, adequate fluids, monitoring 2. Forceps-assisted birth required a) Explain procedure b) Encourage to avoid pushing c) Monitor contractions d) With contraction, after forceps are in place, physician/CNM provides traction on forceps as woman pushed 3. Following birth a) Newborn assessed for facial edema, bruising, caput succedaneum, cephalhematoma, corneal abrasion, sign of cerebral edema b) Woman assessed for perineal swelling, bruising, hematoma, excessive bleeding, hemorrhage, signs of infection

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Answer questions 5. Provide reassurance

VIII.

Care of the Woman During Vacuum Extraction

A. Applying suction to fetal head 1. Soft suction cup placed against occiput of fetal head 2. No cervical or vaginal tissue trapped under cup

B. Negative pressure 50–60 mmHG suction applied for more than 10 minutes → associated with greater incidence of scalp injury 1. 20 to 30 minutes time limit on use 2. More than three pop-offs → discontinue

C. Indications 1. Prolonged second stage of labor, nonreassuring heart rate pattern 2. Preferred to forceps with borderline CPD

D. Contraindications 1. True CPD 2. Nonvertex presentations 3. Maternal or suspected fetal coagulation defects 4. Known or suspected hydrocephalus 5. Fetal scalp trauma 6. Relative contraindications a) Suspected fetal macrosomia b) High fetal station c) Face or breech presentation d) Gestation less than 34 weeks e) Incompletely dilated cervix f) Previous fetal scalp blood sampling 7. Complications a) Scalp lacerations b) Bruising c) Subgaleal hematomas d) Cephalhematomas e) Intracranial hemorrhages 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Subconjunctival hemorrhages g) Neonatal jaundice h) Fractured clavicle i) Erb palsy j) Damage to sixth, seventh cranial nerves k) Retinal hemorrhage l) Fetal death 8. Maternal complications a) Perineal trauma b) Edema c) Third-, fourth-degree lacerations d) Postpartum pain e) Infection 9. Guidelines a) Same criteria as used to evaluate appropriateness of forceps birth b) Same indications and contraindications should be used for both forceps and vacuum births c) Presenting part must be vertex and must be at 0 station or below d) Vacuum-assisted births should be performed only by experienced practitioners e) Procedure should be terminated immediately if descent does not occur or if vacuum device pops off more than three times

E. Nursing Management for the Woman Undergoing a Vacuum-Assisted Birth 1. Inform woman about what is happening during procedure 2. Pump vacuum to appropriate level 3. FHR auscultated at least every 5 minutes, or continuous EFM 4. Inform parents that caput will disappear within 2 to 3 days 5. See Figure 25–6: Vacuum extractor traction, p. 628 6. Continue to assess newborn for complications

IX.

Care of the Family During Cesarean Birth A. Birth of infant through abdominal and uterine incision 1. One of oldest surgical procedures 2. 32% of all births in 2015 a) American College of Obstetricians and Gynecologists (ACOG) task force (1) Recommendations

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Factors affecting cesarean birthrate a) Rising number of nulliparous women b) Rise in maternal age c) Changing philosophies d) Interpretations of EFM tracings e) Decrease in use of forceps, vacuum extractors f) Rise in obesity g) Vaginal birth after cesarean h) Use of epidural anesthesia i) Physician convenience j) Type of provider k) Medical malpractice litigation l) Mother request over fear of labor, convenience, concern about pelvic floor damage

B. Indications 1. Complete placenta previa 2. Cephalopelvic disproportion (CPD) 3. Placental abruption 4. Active genital herpes 5. Umbilical cord prolapse 6. Failure to progress in labor 7. Proven nonreassuring fetal status 8. Benign, malignant tumors that obstruct birth canal 9. Previous cesarean birth 10. Breech presentation 11. Major congenital anomalies 12. Cervical cerclage 13. Severe Rh isoimmunization 14. Maternal preference 15. Dystocia

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Excessive blood loss c) Injury to maternal organs d) Increased hospital stay e) More negative emotions f) Lower Apgar scores g) Neonatal respiratory problems h) Reactions to anesthesia i) Blood clots

D. Surgical Techniques 1. Skin incision a) Transverse (Pfannenstiel) (1) Lowest, narrowest part of abdomen (2) Less bleeding, better healing (3) More time required b) Vertical (1) Quicker (2) Rapid birth indicated (3) In obese women 2. Uterine incisions a) See Figure 25–8: Uterine incisions for a cesarean birth, p. 631 b) Lower uterine segment (1) Transverse (2) Vertical incision (a) Lower uterine segment in certain circumstances c) Classic incision (1) Upper uterine segment (2) More blood loss, difficult to repair (3) Nearly never performed in modern obstetrics (4) Increased risk of uterine rupture in subsequent pregnancies (5) See Table 25–4: Types of Uterine Incisions for Cesarean Birth, p. 632

E. Analgesia and Anesthesia 1. Safety, comfort, emotional satisfaction

F. Nursing Management for the Woman Undergoing a Cesarean Birth 1. Preparation for Cesarean Birth a) Encourage all pregnant women, partners to discuss with physician/CNM 2. Possible preferences a) Participating in choice of anesthetic b) Presence of partner during procedure c) Audio or video recording/photographing birth 23 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Delayed instillation of eye drops to promote eye contact between parent, newborn e) Physical contact or holding newborn while on operating table, recovery room f) Breastfeeding immediately after surgery completed g) Preparation that may be done h) Description or viewing operating room i) Types of anesthesia j) Sensations that may be experienced k) Roles of significant others l) Interaction with the newborn m) Immediate recovery phase n) Postpartum phase 3. Communication with couple 4. Preoperative teaching a) Nothing taken by mouth status b) Antacids c) Anesthesia d) Assist, monitor blood pressure e) Continuous EFM f) Prep g) Positioning on operating table h) “Time-out” i) Grounding source secured j) Suction k) Instrument count 5. Preparation for Repeat Cesarean Birth a) Encourage to identify what they would like altered b) Reassurance and support c) Provide opportunity to discuss anxieties, fears 6. Preparation for Emergency Cesarean Birth a) Time for privacy to assimilate information if possible b) Give couple opportunity for further clarification c) Before procedures explain (1) What is going to happen (2) Why it is going to happen (3) What sensation she may experience 7. Supporting the Father/Partner a) Include in the experience b) Gown and mask c) Sterile drape can be partition if viewing procedure not wanted d) Allow to be near operating room to hear first cry e) Encourage to carry/accompany infant to nursery for initial assessment 24 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Involve in postpartum care in recovery room 8. Immediate Postpartum Recovery Period a) Assess Apgar score, complete initial assessment, identification procedures as after vaginal birth b) Assist with bonding c) Vital signs every 5 minutes until stable d) Every 15 minutes for 1 hour e) Every 30 minutes until discharged to postpartum unit f) Dressing, perineal pad checked every 15 minutes for at least an hour g) Fundus palpated to determine if remaining firm (1) Support fundus while palpating h) IV oxytocin i) If general anesthesia → positioned on side (1) Position on side (2) Assist with cough, deep breathing every 2 hours for 24 hours j) Check level of anesthesia every 15 minutes k) Monitor intake and output

Care of the Woman Undergoing Trial of Labor After Cesarean and Vaginal Birth After Cesarean A. VBAC 1. Nonrecurring indications for cesarean 2. ACOG guidelines a) One previous cesarean birth and low transverse uterine incision b) An adequate pelvis c) No other uterine scars or previous uterine rupture d) Physician able to do cesarean available throughout active labor e) In-house anesthesia personnel available for emergency cesarean births if warranted 3. Debate and research: rise in cesarean birth and reduction in VBACs 4. Repeat cesarean deliveries associated with higher maternal and neonatal mortality rates 5. TOLAC carries some risks, but they are rare and isolated a) See Table 25–5: Risks Associated with Repeat Cesarean Delivery (1) Blood loss (2) Abnormal placentation (3) Surgical injury to bowel or bladder (4) Adhesions (5) Postsurgical complications (6) Longer hospitalization (7) Increased costs (8) Hysterectomy 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Nursing Management for the Woman Undergoing Trial of Labor After Cesarean 1. Institutional protocols 2. Very low risk a) Blood count, type and screen b) Heparin lock inserted c) Continuous EFM d) Clear fluids e) NPO if higher risk f) Supportive and comfort measures g) Provide information and encouragement

XI.

Focus Your Study

XII.

Activities 1. Individual Have students prepare drug cards, including a dosing guide in milliunits/mL, on the following medications: • Misoprostol (Cytotec) • Dinoprostone (Cervidil) vaginal insert • Dinoprostone (Prepidil) • Oxytocin (Pitocin) 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a nursing care plan for the patient who will be undergoing one of the following procedures: • Amniotomy • External cephalic version • Forceps-assisted birth 3. Large Group Watch the following videos and facilitate a class discussion on forceps- and vacuum-assisted births. • Forceps-assisted birth (50 seconds): http://www.medicalvideos.us/videos/328/ • Forceps- and vacuum-assisted births (4 minutes 11 seconds): http://www.youtube.com/watch?v=YGYfia8oI34

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 26 Physiologic Responses of the Newborn to Birth Fetal Respiratory System......................................................................................

Cardiopulmonary Adaptation...............................................................................

Hematopoietic Adaptations..................................................................................

Thermoregulation……………………………………….…………………………………………………..

Hepatic Adaptations.............................................................................................

Gastrointestinal Adaptations................................................................................

Urinary Adaptations..............................................................................................

Immunologic Adaptations....................................................................................

Neurologic Adaptation.........................................................................................

Focus Your Study..................................................................................................

Activities................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Fetal Respiratory System

A. Fetal Lung Development 1. Continuous state of development during fetal life 2. 20 to 24 weeks → alveolar ducts begin to appear 3. Surfactant critical for alveolar expansion and stability a) 28 to 32 weeks gestation → type II cells increases → production starts b) Peaks at 35 weeks → lungs structurally developed c) Production and maintenance of normal volume of fetal lung fluid essential for normal lung growth d) See Figure 26–1: Process of absorption of fetal lung fluid during breathing at birth, p. 639

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Fetal Circulation 1. In utero, placenta is organ of gas exchange 2. From placenta, highly oxygenated blood (65–70%) flows through umbilical vein 3. Small amount perfuses liver, majority volume flowing through inferior vena cava to right atrium 4. Blood directed to right atrium across the foramen ovale (FO) 5. 60% of right ventricle output bypasses the lung and flows through ductus arteriosus (DA) 6. In fetal circulation, right and left ventricles function together, in parallel, rather than sequentially 7. See Key Facts to Remember: Fetal and Newborn Circulation, p. 640

II.

Cardiopulmonary Adaptation

A. Marked changes at birth 1. During late gestation, lung fluid secretion decreases 2. Onset of labor stimulates catecholamines and other hormones, causing fetal pulmonary epithelial cells to begin reabsorption of fluid from alveolar spaces 3. With birth, changes in sensory environment from warm to cold is stimulus for initiation of breathing 4. Neonate’s first breaths of air empties the airways of fluid, establishes volume and function of newborn’s lungs, causes fetal circulation to convert to neonatal circulation 5. See Figure 26–2: Initiation of respiration in a newborn, p. 640 6. When umbilical cord clamped, placenta is excluded from circulation, cessation of blood flow through umbilical vein facilitates collapse of ductus venosus (DV), systematic vascular resistance increases 7. Fetal pulmonary to systemic pressure relationships are reversed 8. Closure of fetal shunts →systemic pressure b>pulmonary pressure→foramen ovale closes→establishes serial arterial-venous circulation indicative of neonatal circulation 9. See Figure 26–3: Transitional circulation: Conversion from fetal to neonatal circulation, p. 641 10. Four major cardiopulmonary changes a) See Figure 26–4: Major changes that occur in the newborn’s circulatory system, p. 642 b) Increased systemic vascular pressure and decreased pulmonary vascular pressure c) Closure of foramen ovale d) Closure of the ductus arteriosus 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Closure of ductus venosus f) See Figure 26–5: Fetal-newborn circulation, p. 642

B. Maintaining Respiratory Function 1. Ability of the lung to maintain oxygenation and ventilation influenced by lung compliance and airway resistance 2. Lung compliance influenced by elastic recoil of lung tissue and anatomic differences in the newborn 3. Airway resistance depends on the radius length and number of airways

C. Characteristics of Newborn Respiration 1. Normal newborn respiration rate is 30 to 60 breaths per minute 2. Initial respirations largely diaphragmatic, shallow, and irregular in depth and rhythm 3. Periodic breathing: vigorous respiration followed by a pause for up to 20 seconds alternating with breathing 4. Apnea: cessation of breathing lasting more than 20 seconds a) May or may not be associated with changes in skin color or heart rate < 100 beats per minute 5. Newborns are obligatory nose breathers because nasal route is primary means of air entry 6. Immediately after birth and for next 2 hours, respiratory rates 60 to 70 breaths per minute 7. Acrocyanosis normal for first 24 hours 8. Primary care provider should be notified if: a) Respiration drop below 30 or exceed 60 per minute when baby is at rest b) Retractions c) Central cyanosis d) Nasal flaring e) Expiratory grunting f) Increase use of intercostal muscles 9. Pulse oximetry a) Should be > 95% in term newborns b) Takes about 10 minutes on average for pulse ox saturation to be > 90% c) See agency protocols

D. Characteristics of Cardiac Function 1. Heart rate a) Average resting heart rate in first week of life → 110 to 160 beats/min b) May drop to low of 70 to 90 beats/min during deep sleep

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Take via apical pulse with auscultation for one full minute, preferably when newborn is asleep 2. Blood pressure a) Highest immediately after birth → lowest about 3 hours of age b) 4 to 6 days of life → rises, plateaus c) Peripheral perfusion pressure sensitive indicator of ability to compensate d) Average mean blood pressure is 50 to 55 mmHg in full-term, resting newborns over 3 kg during first 12 hours of life e) Preterm newborn → average varies with weight, degree of illness f) See Figure 26–7: Response to blood pressure changes in newborn blood volume, p. 643 3. Cardiac murmurs a) Turbulent blood flow b) 90% of murmurs in newborns transient, not associated with anomalies c) Transition period d) Clicks at lower left sternal border → first few hours of life e) Early discharge → murmurs related to VSD and PDA not picked up until first well-baby checkup at 4 to 6 weeks of age. 4. Cardiac workload a) Before birth → right ventricle does 2/3 of cardiac work → increased size and thickness b) After birth → left ventricle must assume work → progressively increases in size and thickness

III.

Hematopoietic Adaptations

A. Mean hemoglobin level in cord blood at term is 17 g/dL B. Hemoglobin and hematocrit values rise in the first several hours after birth → movement of plasma from the intravascular to the extravascular space C. 3 to 5 days after birth, nucleated red blood cells (RBCs) are normally no longer found 1. May be present if hemolysis or hypoxic stress

D. Oxygen Transport 1. Transportation of oxygen to peripheral tissues depends on type of hemoglobin in red blood cells 2. 70% to 90% of hemoglobin in fetus and newborn is fetal hemoglobin (HbF) 3. Greatest difference between HbF and HbA (adult hemoglobin) relates to transport of oxygen a) Absolute oxygen-carrying capacity of fetal blood is greater than adult blood, which allows fetus to tolerate hypoxic intrauterine environment 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Hypoxia causes increased amounts of erythropoietin to be secreted, resulting in active erythropoiesis 5. Fetal hemoglobin concentration in blood decreases after birth a) 3 to 5% per week, only 5 to 8% of total hemoglobin at 6 months of age 6. Initial decline in hemoglobin creates phenomenon known as physiologic anemia of the newborn a) Lowest level of hemoglobin at 3 months (physiologic nadir) 7. Once erythropoiesis resumes, iron stores used to produce new RBCs 8. By 3 to 5 days after birth, nucleated red blood cells normally no longer found in blood of term or preterm infants 9. Number of maternally administered pharmacologic agents implicated in hematologic abnormalities of fetus or newborn 10. Obtain accurate maternal history including medications 11. Newborn blood volume amount varies based on a) Amount of placental transfusion during delivery b) Gestational age c) Prenatal and/or postnatal hemorrhage d) Site of blood sample

E. Delayed Cord Clamping 1. If the umbilical cord is left unclamped for a short period of time after birth, blood from the placenta passes to the newborn (placental transfusion) 2. Increases neonates blood volume, improve blood flow to organs 3. Previous standard was immediate clamping at birth, WHO recommends delayed as standard of care 4. Placental blood rapidly transferred to newborn → 80mL of blood transferred in 1 min, 100mL at 3 minutes→ may facilitate transition 5. Positive effects a) Significantly higher levels of hemoglobin, higher ferritin levels until 6 months of age, fewer suffered from iron deficiency anemia, less need for blood transfusions, decreased rate of intraventricular hemorrhage 6. Negative a) Increased need for phototherapy for jaundice

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

F. Coagulation 1. Platelet count of newborn comparable to adult values 2. Newborn may have transient diminished platelet function 3. Transient neonatal thrombocytopenia may occur in infants born to mothers with severe hypertension or HELLP syndrome 4. See Table 26–1: Normal Term Newborn Cord Blood and Cord Blood Gas Values, p. 645

IV.

Thermoregulation A. Newborns are homeothermic → physiologic response to changes in ambient temperature in and attempt to maintain a normal core temperature B. Thermoregulation is balance of heat loss, heat gain, and heat production 1. Neutral thermal environment (NTE) → temperature range in which heat production is at the minimum needed for normal body temperature

C. Establishment of thermal stability 1. Heat transfer from newborn organs to skin surface is increased 2. Nonshivering thermogenesis for heat production via metabolism of brown adipose tissue 3. Blood vessels closer to skin 4. Flexed posture decreases surface area exposed to environment 5. Preterm infants have increased heat loss via evaporation due to increased total body water and thin skin

D. Heat Loss 1. Large body surface in relation to mass, less insulating subcutaneous fat a) Loses about four times as much heat as adult b) The greater the difference between core and skin temps, heat transfer increases rapidly (1) Increase in oxygen consumption (2) Increased metabolism of brown fat (3) Depletion of glycogen stores and acidosis c) Heat loss mechanisms (1) Convection → warm body surface to cooler air currents (2) Radiation → body heat transferred to cooler surfaces, objects not in direct contact with body (3) Evaporation → loss of heat incurred when water converted to vapor (4) Conduction → loss of heat to cooler surface by direct skin contact d) See Figure 26–8: Methods of heat loss. A. Convection. B. Radiation. C. Evaporation. D. Conduction, p. 646 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Heat Production (Thermogenesis) 1. Nonshivering thermogenesis (NST) a) Skin receptors perceive drop in environmental temperature → transmit sensations to stimulate sympathetic nervous system (1) Uses brown adipose tissue (BAT) to provide heat (2) BAT = brown fat (a) Found at midscapular area, around the neck, axillae, with deeper placement around the trachea, esophagus, abdominal aorta, kidneys, adrenal glands b) Shivering rarely seen in newborns (1) SGA, intrauterine growth restricted (IUGR), premature → inadequate brown fat stores c) Increase metabolism result of hypothermia (1) Increase oxygen and glucose consumption → show signs of respiratory distress (2) Exposed to cold → preterm newborn unable to increase ventilation (3) Effect of drugs

Hepatic Adaptations A. Neonate less than 20% of hepatocytes than in adult liver B. Iron Storage 1. As RBCs destroyed after birth → iron content stored in liver 2. Term newborn 270 mg of iron at birth, 140 to170 mg of this amount is in the hemoglobin 3. Iron intake of mother adequate → iron stored to last until 5 months of age

C. Glucose Homeostasis 1. Glucose not used for immediate energy needs converted to glycogen 2. Stored in liver, heart, skeletal muscles as glycogen 3. Fetal glucose levels approximately 80% of mother’s glucose level 4. Glycogen storage for postnatal energy needs begins early in gestation; most glycogen stores accumulate in third trimester 5. After umbilical cord clamping, neonate’s blood glucose level fall a) Reaching a nadir at about 1 to 2 hours of ages

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. First hours after birth, neonatal brain metabolizes newborn’s abundant stores of lactate 7. By secreting glucagon and suppressing insulin release, newborn mobilizes glucose to meet energy needs 8. If healthy term infant not fed soon after birth, blood glucose levels rise at 3 to 4 hours of age 9. Hepatic glycogen rapidly depleted if feeding is not established early

D. Conjugation of Bilirubin 1. Bilirubin is primarily the metabolic end product of erythrocyte 2. Bilirubin: metabolic end product of erythrocyte (RBC) breakdown 3. Conjugation → conversion of yellow lipid-soluble pigment into water soluble pigment a) Unconjugated bilirubin → fat soluble, not excretable, potential toxin 4. Total serum bilirubin → sum of conjugated (direct) and unconjugated (indirect) bilirubin a) At birth → less than 3 mg/dl 5. After birth → newborn’s liver must begin to conjugate bilirubin 6. Unconjugated bilirubin formed → transferred to liver for uptake or change to direct bilirubin → through bile ducts → intestines → not reabsorbed → yellow brown stool 7. Can be changed back to unconjugated → in intestine enzyme deconjugate bilirubin → reabsorbed through intestinal wall → back to liver 8. See Figure 26–9: Conjugation of bilirubin in newborns, p. 649 a) Babies with delayed bacterial colonization of gut 9. Infants who establish gut motility, active stooling → early and frequent feedings 10. Less hepatic activity → increases susceptibility to jaundice 11. Hyperbilirubinemia is elevated total serum bilirubin level

E. Physiologic Jaundice 1. Nonpathologic unconjugated hyperbilirubinemia 2. 60% term newborns; 80% preterm neonates intestinal tract 3. Normal biologic response 4. Because of shorter lifespan of fetal RBCs, newborns have two to three times greater production or breakdown of bilirubin 5. Signs of physiologic jaundice appear after the first 24 hours postnatally (yellowing of skin) a) Differentiates physiologic jaundice from pathologic jaundice b) Physiologic jaundice (nonpathologic unconjugated hyperbilirubinemia) 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) 60% of term newborns (2) 80% of preterm newborns (3) Visible when the serum bilirubin concentration is greater than 4 to 6 mg/dL 6. Unmonitored and untreated severe hyperbilirubinemia may progress to excessive levels that are associated with bilirubin neurotoxicity 7. Jaundice detected by blanching skin with digital pressure on forehead, midsternum, or knee to reveal underlying color of the skin a) Develops in cephalocaudal progression b) Maintain newborn’s skin temperature at 36.5°C (97.8°F) or above c) Monitor stool for amount and characteristics d) Encourage early feedings 8. Absence of jaundice is not indication of absence of hyperbilirubinemia 9. Clinical risk factors a) Exclusive and insufficient breast milk feedings b) Family history of neonatal jaundice c) Bruising d) Assisted delivery with vacuum or forceps e) Cephalhematoma f) Asian ethnicity g) Maternal age > 25 years h) Male gender i) Gestational age

F. Breastfeeding Jaundice 1. Breastfeeding jaundice → in first days of life a) Inadequate fluid intake b) Dehydration c) Self-limiting d) Prevention & treatment (1) Encouraging frequent (every 2 to 3 hours) breastfeeding (2) Avoiding supplementation in nondehydrated newborns (3) Accessing maternal lactation counseling

G. Breast Milk Jaundice 1. Exact mechanism unknown, 1:200 term newborns 2. Onset 3 to 5 days, peaks at 2 weeks of life 3. Bilirubin metabolism causes exaggerated physiologic jaundice 4. Breast milk jaundice related to milk composition promotes increased bilirubin reabsorption a) Appear well 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) May need temporary cessation of breastfeeding 5. See Key Facts to Remember: Factors in Physiologic, Breast Milk, and Breastfeeding Jaundice, p. 650

VI.

Gastrointestinal Adaptations

A. Digestion and Absorption 1. Adequate intestinal, pancreatic enzymes to digest most simple carbohydrates, fat, proteins a) Lactose primary carbohydrate in breastfeeding newborn b) Only enzyme lacking is pancreatic amylase 2. Proteins require more digestion 3. Absorbs and digests fats less efficiently 4. Fetal gastrointestinal tract is sterile a) Microbes begin → newborn’s oral mucosa is exposed to the environment 5. Infants born by vaginal delivery become colonized by microbes present in the birth canal and mother’s gastrointestinal tract 6. Infants born by cesarean section initially colonized by skin flora 7. Air enters stomach immediately after birth a) Small intestine is air filled within 2 to 12 hours, large bowel within 24 hours 8. Salivary glands immature at birth 9. Newborn’s stomach has capacity of 50 to 60 mL

B. Cardiac sphincter immature → regurgitation may be noted 1. Monitor continuous vomiting or regurgitation 2. Bilious vomiting abnormal → evaluated 3. Digestion and absorption → growth and development a) Requires 120 kcal/kg/day b) May be weight loss of 5% to 10% → shift of intracellular to extracellular space

C. Elimination 1. Meconium within 24 to 48 hours a) Formed in utero b) Thick, tarry, black to dark green

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Transitional stools 3. Breastfed → pale yellow, more liquid, more frequent 4. Formula → pale, consistency of peanut butter 5. Frequency varies a) One every 2 to 3 days to 10 daily b) Not constipation if bowel movement remains soft c) See Key Facts to Remember: Physiologic Adaptations to Extrauterine Life, p. 652

VII.

Urinary Adaptations

A. Kidney Development and Function 1. Kidneys have full complement of functioning nephrons by 34 to 36 weeks’ gestation a) Glomerular filtration doubles in first few days of life b) Ability to concentrate urine fully attained by 3 months of age c) Feeding practices can affect osmolarity

B. Characteristics of Newborn Urinary Function 1. Normal newborn → 90% void within 24 hours after birth, 99% by 48 hours a) Assess for fluid intake, bladder distention, restlessness, symptoms of pain if no void by 48 hours b) Initial bladder volume → 6 to 44 mL of urine 2. First 2 days → 2 to 6 times daily → 15 mL/kg/day a) Subsequently 5 to 25 times/24 hours → volume 25 mL/kg/day 3. Frequently cloudy, high specific gravity a) Urine straw colored, almost odorless

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. See Table 26–2: Newborn Urinalysis Values, p. 652

VIII.

Immunologic Adaptations

A. Neonatal defense against infections dependent upon maternal immunity 1. Maternal–fetal infection transmission major cause of morbidity and mortality in newborns

B. Defense, homeostasis, surveillance C. Nonspecific immune mechanisms 1. Phagocytosis 2. Inflammatory response 3. Complement 4. Coagulation 5. Function without prior exposure, identified early in gestation, reach functional development at 32 to 33 weeks’ gestation

D. Humoral Immunity 1. Specific antibody-mediated response that functions effectively if there has been recent exposure a) Maturation of specific immune responses begins in utero, 7 to 12 weeks’ gestation 2. Active immunity: woman forms antibodies in response to illness or immunization 3. Passive acquired immunity: antibodies transferred to fetus in utero 4. Immunoglobulin G (IgG) major immunoglobulin of serum and interstitial fluid and provides immunity against bacterial and viral pathogens a) Other immunoglobulins: IgM, IgA, IgE

E. Cellular Immunity 1. Mediated by T lymphocytes 2. Three types of active T cells a) Cytotoxic b) Helper c) Suppressor

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. T lymphocytes modify behavior of phagocytic cells and increase their antimicrobial activity

IX.

Neurologic Adaptation A. Neuronal organization 1. Basis of brain function and its complex circuitry 2. Peaks at 20 weeks’ gestation and continues into adult life

B. Myelination 1. Enhances intracellular communication 2. Begins second trimester and continues into adult life

C. Intrauterine Environmental Influence on Newborn Behavior 1. Intrinsic factors → nutrition and drug exposure 2. External factors → mother’s physical environment 3. Responses to different stresses vary a) Quietly, overreact, combination 4. Intense auditory stimuli in utero → manifested in behavior of newborn

D. Characteristics of Newborn Neurologic Function 1. Perinatal factors a) Labor and delivery, drugs given to mother, overall infant health, gestational age 2. Environment a) A quiet, dim, warm, calming environment versus noisy, bright or cold 3. Usually partially flexed extremities, legs near abdomen 4. Organization and intensity of newborn motor activity influence by several factors a) Sleep–wake states b) Presence of environmental stimuli c) Conditions causing chemical imbalance, such as hypoglycemia d) Hydration status e) State of health f) Recovery from stress of labor and birth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Muscle tone should be symmetric 6. Reflexes, including Moro, grasping, rooting, sucking reflexes, characteristics of neurologic integrity 7. Self-quieting ability: ability of newborn to use their own resources to quiet and comfort themselves 8. Habituation: newborn’s ability to process and respond to complex stimulation

E. Periods of Reactivity 1. First period → birth to about 30 minutes after birth a) Indicate readiness for feeding → sucking, rooting, and swallowing (1) Initiate breastfeeding b) Respirations rapid, heart rate rapid, bowel sounds usually absent 2. Period of inactivity to sleep phase a) Heart rate, respirations decrease b) Sleep phase may last a few minutes to 2 to 4 hours c) Difficult to arouse, no interest in sucking 3. Second period of reactivity a) Awake and alert b) 4 to 6 hours c) Physiologic responses vary (1) Alert for apneic periods d) Close observation e) Gastrointestinal tract more active (1) Secretions can cause gagging, choking, and regurgitating f) Maintain clear airway g) May suck, root, swallow

F. Behavioral States of the Newborn 1. Sleep states a) Deep or quiet sleep (1) Closed eyed, no eye movements (2) Regular, even breathing b) Active of light sleep (rapid eye movement [REM] sleep) (1) Irregular respirations, eyes closed with REM (2) Irregular sucking motions 2. REM active sleep, quiet sleep → intervals of 50 to 60 minutes a) 45% to 50% of total sleep is active b) 35% to 45% is quiet sleep c) 10% transitional d) Any disturbance of the sleep–wake cycle → irregular spikes of growth hormone 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Over time → become diurnal 3. Alert states a) First 30 to 60 minutes after birth b) Periods of alertness short first 2 days after birth c) Subcategories of alert state (1) Drowsy or semidozing (2) Quiet alert (3) Active alert (4) Crying

G. Sensory/Perceptual Capacities of the Newborn 1. Visual capacity a) Orientation → ability to be alert to, to follow, fixate on complex visual stimuli b) Prefers human face; eyes; bright, shiny objects 2. Auditory capacity a) Definite, organized behavior repertoire b) Stimulus used → selected to match the state of the newborn c) Prefers sound of human voice d) Evaluate newborn hearing prior to discharge 3. Olfactory capacity a) Develops rapidly b) Can differentiate mother by smell within first week of life 4. Taste and sucking a) Distinguish between sweet and sour at 3 days of age b) Newborn sucks in bursts with frequent regular pauses (1) Sucking pattern variations between bottle and breastfeeding c) Rooting reflex → awake and hungry d) Feeding → sucking pattern e) Nonnutritive sucking as self-quieting activity 5. Tactile capacity a) Very sensitive to being touched, cuddled, held b) Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex → soothe baby c) Touch may be most important for newborn

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Focus Your Study

XI.

Activities 1. Individual Have students develop a teaching plan for the mother of a term infant that is small for gestational age. Instruct to students to base their information on normal newborn indicators and to cite their resources in APA format. 2. Small Group Divide the class into small groups of three to five students. Have each group develop a sensory assessment plan for the normal newborn for the assigned sense: • Taste • Smell • Hearing • Sight • Touch 3. Large Group As a class, watch the following videos and facilitate class discussions on the subject matter presented: 1. Normal newborn circulation (2 minutes 50 seconds): http://www.dailymotion.com/video/xavrnu_normal-newborn-circulation_creation 2. Newborn normal behavior (1 minute 38 seconds): http://www.youtube.com/watch?v=AlRnKt6q1T8

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 27 Nursing Assessment of the Newborn Timing of Newborn Assessments........................................................................

Estimation of Gestational Age.............................................................................

Physical Assessment............................................................................................

Focus Your Study.................................................................................................

Activities...............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Timing of Newborn Assessments

A. First 24 hours → mortality and morbidity statistically high B. Delivery room disposition: first assessment → birthing area immediately after birth 1. Need for resuscitation 2. Stable → placed with parents

C. Nursery or couplet care admission examination: second assessment → routine assessment to nursery 1. No later than 2 hours after birth 2. Progress of adaptation to extrauterine life 3. Determination of gestational age 4. Ongoing assessment for newborn at risk

D. Before discharge examination 1. Complete physical examination 2. Detect any emerging or potential problems 3. Behavioral assessment

E. See Key Facts to Remember: Timing and Types of Newborn Assessments, p. 659

II.

Estimation of Gestational Age

A. Establish in first 4 hours after birth B. Gestational age tools 1. External physical characteristics a) Sole creases b) Amount of breast tissue c) Amount of lanugo d) Cartilaginous development of the ear e) Testicular descent and scrotal rugae in the male f) Labial development in the female. 2. Neurologic development a) Nervous system unstable during first 24 hours of life b) Second assessment in 24 hours c) Between 26 and 34 weeks significant neurologic changes

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Ballard tool a) Each finding given a point value b) Physical characteristic and neurologic characteristics 4. New Ballard Score → assessment of newborns between 20 and 28 weeks’ gestation, less than 1500 g a) Do assessment in first 12 hours of life, especially if <26 weeks’ gestation 5. Maternal conditions may affect certain components a) Diabetes b) Preeclampsia c) Maternal analgesia and anesthesia

C. Assessment of Physical Maturity Characteristics 1. Resting posture a) See Figure 27–1: Resting posture, p. 661 2. Skin 3. Lanugo a) See Figure 27–2: Lanugo, p. 662 4. Sole (plantar) creases a) See Figure 27–3: Sole creases, p. 662 5. Areola and breast bud tissue a) See Figure 27–4: Breast tissue., p. 663 b) As gestation progresses, breast tissue mass and areola enlarge 6. Ear form and cartilage a) See Figure 27–5: Ear form and cartilage, p. 663 7. Male genitals a) See Figure 27–6: Male genitals, p. 664 8. Female genitals a) See Figure 27–7: Female genitals, p. 664 9. Vernix a) Note in birthing area prior to drying infant

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

10. Hair 11. Skull firmness 12. Nails

D. Assessment of Neuromuscular Maturity Characteristics 1. Central nervous system matures at constant rate a) Caudocephalic progression, lower to upper extremities 2. Characteristics evaluated a) Square window sign (1) See Figure 27–8: Square window sign, p. 665 b) Recoil (1) Test of flexion development (2) First tested in legs (a) Newborn is placed on back on flat surface (b) Legs are placed in flexion then extended parallel to each other on flat surface (c) Response is recoil of legs (i) Preterm infants have less muscle tone → less recoil (3) Arm recoil tested by flexion at the elbow and extension of arms at newborn’s side (4) Bilateral to rule out brachial palsy (5) See Figure 27–9: Arm recoil, p. 665 c) Popliteal angle d) Scarf sign (1) See Figure 27–10: Scarf sign, p. 665 e) Heel-to-ear extension (1) See Figure 27–11: Heel-to-ear. No resistance. Leg fully extended. Score 0, p. 666 f) Ankle dorsiflexion (1) See Figure 27–12: Ankle dorsiflexion …, p. 666 g) Head lag (1) Pulling baby to sitting position (2) Noting degree of head lag h) Ventral suspension (1) Holding newborn prone on examiner’s hand (2) Note position of head, back, degree of flexion in arms and legs i) Major reflexes j) Supplementary method k) View cornea with ophthalmoscope 3. Gestational age determination and birthweight considered together a) Below 10th percentile → small for gestational age (SGA) b) Appropriate for gestational age (AGA) c) Above 90th percentile → large for gestational age (LGA)

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) See Figure 27–13: Select reference percentiles for birth weight at each gestational age from 22 to 44 completed weeks …, p. 668 e) Use information in conjunction with physical examination

III.

Physical Assessment

A. Complete with parents → systematic, head-to-toe manner B. General Appearance 1. Head large for body 2. Prominent abdomen, sloping shoulders, narrow hips, rounded chest 3. Tend to stay in flexed position

C. Weights and Measurements 1. Average full-term Caucasian newborn 3405 g (7 lb 8 oz) a) African, Asian, and Hispanic heritage are usually smaller 2. 70% to 75% of newborns’ body weight water 3. Length of normal newborn difficult to measure a) See Figure 27–14: Measuring the length of the newborn, p. 669 4. Head circumference a) Approximately 2 cm greater than circumference of chest b) See Figure 27–15: A. Measuring the head circumference of the newborn, p. 670 5. Chest circumference a) See Figure 27–15: B. Measuring the chest circumference of the newborn, p. 670 b) See Key Facts to Remember: Newborn Measurements, p. 669 6. Temperature a) Critical b) Heat conservation measures → or core temp falls 0.1°C (0.2°F) per minute (1) Skin temperature 0.3°C (0.5°F) per minute (2) Stabilizes at 8 to 12 hours c) Assess temperature on admission to nursery (1) Every 30 minutes until stable for 2 hours (2) Then once every 8 hours (3) Exposed to group B hemolytic streptococcus → more frequently d) Axillary, skin probe, rectal (1) Continuous skin probe (2) See Figure 27–16: Axillary temperature measurement, p. 670 (3) See Figure 27–17: Temperature monitoring for the newborn …, p. 670 e) Temperature instability may indicate: (1) Infection 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Subnormal or deviation of more than 1°C (2°F) from one reading to the next (2) Reaction to too many blankets (3) Too hot a room (a) May increase respiratory and heart rates (4) Dehydration

D. Skin Characteristics 1. Pink tinge to skin in all babies a) Pigmentation deepens over time b) Cyanotic at rest, pink when crying, may have choanal atresia c) Crying increases cyanosis → heart or lung problems suspected 2. Acrocyanosis a) See Figure 27–18: Acrocyanosis, p. 671 b) Bluish coloration of hands and feet c) First 24 hours 3. Mottling a) Related to chilling, prolonged apnea, sepsis, or hypothyroidism 4. Harlequin sign a) See Figure 27–19: Harlequin sign, p. 671 b) Deep color on one side of body, other side pale 5. Jaundice a) Yellowish discoloration of skin and mucous membranes b) First detectable on face c) Advances from head to toe d) May be related to hematomas, immature liver function, poor feeding, blood incompatibility, oxytocin, augmentation or induction, severe hemolysis process e) See Clinical Skill 27–1: Assessing Jaundice in the Newborn, p. 672 6. Erythema toxicum a) Eruption of lesions on area surrounding a hair follicle b) Appear suddenly, usually trunk and diaper area c) See Figure 27–20: Erythema toxicum, p. 672 7. Milia a) Exposed sebaceous glands b) See Figure 27–21: Facial milia over bridge of nose, p. 673 8. Skin turgor a) Abdomen, forearm, thigh 9. Vernix caseosa a) White, cheeselike substance

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

10. Forceps marks a) Reddened areas over cheeks and jaws b) Reassure parents 11. Sucking blisters a) See Figure 27–22: Sucking blister in middle of upper lip, p. 673

E. Birthmarks 1. Telangiectatic nevi → stork bites a) Eyelids, nose, lower occipital bone, nape of neck b) See Figure 27–23: Stork bites …, p. 673 2. Congenital dermal melanocytosis (Mongolian blue spots) a) Bluish-black or gray-blue, dorsal area, buttocks b) See Figure 27–24: Mongolian spots, p. 673 3. Nevus flammeus (port wine stain) a) Capillary angioma directly below epidermis b) Nonelevated, sharply demarcated, red to purple c) Commonly on face d) Neurologic problems → suggestive of Sturge-Weber syndrome e) See Figure 27–25: Port wine stain over temple area, p. 674 4. Nevus vasculosus (strawberry mark) a) Capillary hemangioma b) Enlarged capillaries in dermal, subdermal layers c) Raised, clearly delineated, dark red, rough-surfaced d) Grow until about 6 months of age e) Shrink, resolve spontaneously f) Information, reassurance g) See Figure 27–26: Nevus vasculosus, also called strawberry mark, on leg, p. 674 5. Note bruises, abrasions, birthmarks on admission

F. Head 1. General appearance a) One-fourth of body size; soft, pliable skull bones b) Normal occipital-frontal circumference 32 to 37 cm for term newborns c) Asymmetry → molding with vaginal birth d) Extreme differences (1) Microcephaly (2) Hydrocephalus (3) Craniosynostosis (4) Plagiocephaly e) Fontanelles

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Anterior → openings at junction of cranial bones (a) Diamond-shaped (b) 3 to 4 long  2 to 3 cm wide (c) Closes within 18 months (2) Posterior → parietal, occipital bone (a) Triangular, smaller (b) 0.5  1 cm (c) Closes at 2 to 3 months (3) Indicator of newborn’s condition 2. Cephalhematoma a) Collection of blood between surface of a cranial bone, periosteal membrane b) See Figure 27–28: A. Cephalhematoma is a collection of blood between the surface of the cranial bone and periosteal membrane …, p. 675 c) Feels loose, slightly edematous 3. Caput succedaneum a) Localized, easily identifiable soft area of scalp b) Long labor, vacuum extraction c) See Figure 27–29: Caput succedaneum is a collection of fluid (serum) under the scalp, p. 676

G. Hair 1. Term newborn → smooth, ethnic texture variations

H. Face 1. Designed to help with suckling 2. Symmetry a) Eyes, nose, ears b) Facial movement c) See Assessment Guide: Newborn Physical Assessment, pp. 685–696

I. Eyes 1. Color a) Scleral color white to bluish white 2. Check for size, equality of pupil size, reaction of pupils to light, blink reflex, edema, inflammation of eyelids 3. Erythromycin, tetracycline used prophylactically 4. Silver nitrate → may cause chemical conjunctivitis 5. Infectious conjunctivitis a) Greenish yellow 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Subconjunctival hemorrhage 7. Transient strabismus a) See Figure 27–30: Transient strabismus in the newborn may be due to poor neuromuscular control, p. 677 8. Observe for opacities, absence of red retinal reflex 9. Cry commonly tearless 10. Peripheral vision, can fixate on near objects

J. Nose 1. Small, narrow 2. Nose breathers for first few months 3. Choanal atresia 4. Has ability to smell

K. Mouth 1. Lips → pink, touch should produce sucking motions 2. Stimulate to cry → depress tongue a) Examine entire mouth for cleft palate b) See Figure 27–31: The nurse inserts the index finger or pinky into the newborn’s mouth and feels for any openings along the hard and soft palates, p. 677 3. Precocious teeth 4. Epstein’s pearls 5. Thrush → candida albicans → treated with nystatin 6. Tongue-tied → ridge of frenulum tissue

L. Ears 1. Soft, pliable, should recoil 2. Top of ear should be parallel to outer, inner canthus of eye 3. Low-set ears → characteristic of many syndromes a) See Figure 27–32: The position of the external ear may be assessed by drawing an imaginary line across the inner and outer canthus of the eye to the insertion of the ear …, p. 678

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Preauricular skin tag 5. Hearing acute as mucus absorbed, eustachian tube aerated, tympanic membrane visible 6. Evaluate response to loud, moderately loud noises 7. AAP has endorsed universal newborn screening in birthing units as standard care

M. Neck 1. Short, creased with skin folds 2. Cannot support full weight of head 3. Palpate for masses, lymph nodes 4. Range of motion 5. Clavicles evaluated for evidence of fractures

N. Chest 1. Thorax cylindric, symmetric at birth, ribs flexible 2. Engorged breasts common → hormones a) See Figure 27–33: Breast hypertrophy, p. 678 b) Whitish secretions

O. Cry 1. Strong, lusty, medium pitch 2. High-pitched, shrill cry abnormal 3. Important method of communication

P. Respiration 1. Normal 30 to 60 respirations per minute, predominantly diaphragmatic 2. Note a) Hyper- or hypoexpansion b) Airway noises 3. Episodic breathing (apnea) may occur with no color, heart rate change

Q. Heart 1. Normal 110 to 160 beats/min a) Up to 180 beats/min b) Note rate, rhythm (1) Pulse rate variable, influenced by physical activity, crying, state of wakefulness, body temperature 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Auscultation over entire heart region a) Placement of heart determined (1) Shift of heart tones → pneumothorax, dextrocardia, diaphragmatic hernia (2) Presence of murmur b) Apical pulse rates by auscultation for a full minute, preferably while asleep 3. Peripheral pulses a) Brachial b) Femoral c) Pedal (1) See Figure 27–34: A. Bilaterally palpate the femoral arteries for rate …. B. Compare the femoral pulses to the brachial pulses …, p. 679 4. Measurement of blood pressure a) See Figure 27–35: Blood pressure measurement using the Dinemapp and Doppler devices. The cuff can be applied to either the newborn’s upper arm or the thigh, p. 680 b) Immobilize extremity c) Crying, movement, inappropriate size → give inaccurate measurements d) If cardiac anomaly suspected → all extremities 5. See Key Facts to Remember: Normal Vital Signs, p. 680 a) Pulse 110 to 160 beats/min (1) During deep sleep as low as 70 beats/min; if crying, up to 180 beats/min (2) Apical pulse counted for 1 full minute b) Respirations 30 to 60 respirations/minute (1) Predominantly diaphragmatic but synchronous with abdominal movements (2) Respirations are counted for 1 full minute c) Blood pressure 70 to 50/45 to 30 mm Hg at birth (1) 90/50 mm Hg at day 10 d) Temperature → normal range: 36.5°C to 37.5°(97.7°F to 99.4°F) (1) Axillary: 36.5°C to 37.2°C (97.7°F to 99°F) (2) Skin: 36°C to 36.5°C (96.8°F to 97.7°F) (3) Rectal: 36.6°C to 37.2°C (97.8°F to 99°F)

R. Abdomen 1. Cylindrical, protrudes slightly, moves with respiration a) Scaphoid abdomen 2. No cyanosis, few blood vessels apparent a) No distention or bulging 3. Auscultate for bowel sounds → by 1 hour after birth a) Auscultate before palpating 4. Palpation systematic a) Liver large in proportion 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

S. Umbilical cord 1. Initially white, gelatinous, two arteries, one vein a) Dry, shriveled, blackened by second, third day 2. Cord bleeding abnormally 3. Foul-smelling drainage abnormal 4. Patent urachus 5. Umbilical cord hernia a) See Figure 27–36: Umbilical hernia, p. 681

T. Genitals 1. Female newborns a) Note labia and clitoris b) Discharge c) Pseudomenstruation 2. Male newborns a) Urinary orifice correctly positioned (1) Hypospadias (2) Epispadias b) Phimosis c) Scrotum inspected for size, symmetry (1) Presence of both testes (2) Cryptorchidism (3) Hydrocele

U. Anus 1. Verify patent anus that has no fissure a) Imperforate anus, rectal atresia 2. Note passage of meconium

V. Extremities 1. Note gross deformities 2. Arms and hands a) Polydactyly b) Syndactyly c) Palmar crease d) Brachial palsy (1) Partial or complete paralysis of portions of the arm (2) From trauma to the brachial plexus during a difficult birth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Erb-Duchenne paralysis (Erb palsy) → arm lies limply at side (a) Lower arm (b) Whole arm (4) Prognosis related to degree of nerve damage 3. Legs and feet a) Equal, symmetric skin folds b) Barlow and Ortolani maneuvers for hip dislocation/instability (1) See Figure 27–37: A. The asymmetry of gluteal and thigh fat folds …, B. Barlow (dislocation) maneuver …, C. Dislocation is palpable …, D. Ortolani maneuver …, p. 682 c) Feet examined for evidence of talipes (1) See Figure 27–38: A. Unilateral talipes equinovarus (clubfoot) ..., p. 683

W. Back 1. Examine in prone position 2. Should be straight, flat 3. Examine for dermal sinus 4. Pilonidal dimple

X. Assessment of neurologic status 1. Important behaviors to assess are: a) State of alertness b) Resting posture c) Cry d) Quality of muscle tone e) Motor activity 2. Position a) Partially flexed extremities, legs abducted to abdomen b) Purposeless, uncoordinated bilateral movements c) Eye movements d) Fixate on faces e) Evaluate muscle tone (1) Slightly hypertonic (2) Symmetric (3) Differentiate tremors from convulsions (4) Neonatal seizures may be: (a) Chewing, swallowing, deviations, rigidity, flaccidity (5) Specific deep tendon reflexes (6) Immature central nervous system

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Tonic neck reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 4. Palmar grasping reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 5. Moro reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 6. Rooting reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 7. Sucking reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 8. Protective reflexes a) Blink b) Gag c) Yawn d) Cough e) Sneeze f) Draw back from pain 9. Trunk incurvation (Galant reflex) 10. Stepping reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 11. Steps to assess central nervous system (CNS) integration a) Unpowdered gloved finger into mouth to elicit sucking reflex b) As soon as newborn sucking vigorously (1) Assess hearing, vision responses by noting sucking changes (2) Should be brief cessation of sucking

Y. Newborn Behavioral Assessment Scale 1. See Assessment Guide: Newborn Physical Assessment, pp. 685–696

Z. The Brazelton Neonatal Behavioral Assessment Scale 1. Third day after birth in quiet, dimly lit room 2. Determine state of consciousness 3. Observe sleep–wake cycle a) Transitions

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Newborn’s style and ability to adapt indicate need for parental interventions? 5. Parental interventions necessary to lessen outside stimuli? 6. Can baby control amount of sensory input to be dealt with? 7. Behaviors and sleep–wake states a) Habituation b) Orientation to inanimate and animate visual and auditory assessment stimuli c) Motor activity d) Variations e) Self-quieting activity f) Cuddliness or social behaviors

IV.

Focus Your Study

Activities 1. Individual Have students prepare a newborn maturity rating and classification for a newborn in the nursery. Instruct students to use the Ballard assessment tool. 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the new parent on the assigned physical assessment area: • Temperature • Birthmarks • Hair • Mouth • Heart • Extremities • Neurologic status • Skin • Head • Face • Chest and respirations • Abdomen and umbilical cord • Reflexes 3. Large Group As a class, view the following three short videos and facilitate a class discussion on the physical examination of the normal newborn: 1. Behavior (1 minute 38 seconds) http://www.youtube.com/watch?v=AlRnKt6q1T8 2. Tone: Scarf Sign (37 seconds) http://www.youtube.com/watch?v=Lx_4DglwmIE&NR=1 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Tone: Arm Recoil (29 seconds) http://www.youtube.com/watch?v=97I03A8eg_Y&NR=1

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 28 The Normal Newborn: Needs and Care Admission and the First 4 Hours of Life..................................................................

The Newborn Following Transition.........................................................................

Preparation for Discharge.......................................................................................

Focus Your Study.....................................................................................................

Activities...................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Admission and the First 4 Hours of Life

A. Nursing Management for the Newborn During Admission and the First 4 Hours of Life 1. Nursing Assessment and Diagnosis a) Review prenatal record for possible risk factors (1) Infectious disease screening results, drug or alcohol use by the mother, gestational diabetes, other data related to needs of the newborn or their transition b) Review birth record (1) Prolonged rupture of membranes, instrument or vacuum delivery, use of narcotic analgesia, presence of meconium c) Preliminary physical examination (1) Notify physician/nurse practitioner of deviations from normal d) Diagnoses include (1) Airway Clearance, Ineffective (2) Body Temperature: Imbalanced, Risk for (3) Pain, Acute

B. Planning and Implementation 1. Initiation of admission procedures a) Evaluates newborn’s need to remain under evaluation (1) Maternal and birth history (2) Airway clearance (3) Skin color (4) Vital signs (5) Measurements (head circumference, body length, body weight) (6) Neurologic status (7) Ability to feed (8) Evidence of complications and/or illness (9) Other evaluations as needed or directed b) Initial assessment indicates newborn not at risk → routine admission procedures (1) In presence of parents (2) No later than 2 hours after birth c) Check, confirm newborn’s identification with mother’s identification 2. Essential data to be recorded a) Condition of newborn b) Labor and birth record c) Antepartum history d) Parent–newborn interaction information e) Weigh newborn in grams and pounds (1) See Figure 28–1: Weighing a newborn. The scale is balanced before each weighing, with a protective pad in place, p. 700 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Length, circumference of head, circumference of chest (3) Rapidly assess color, tone, alertness, general state f) Vital signs g) Hematocrit, blood glucose evaluations on at-risk newborns (1) See Procedure 31–1: Performing a Heel Stick on a Newborn in Chapter 31 3. Maintenance of a clear airway and stable vital signs a) Free-flow oxygen available b) Position on back c) Bulb syringe or DeLee wall suction (1) See Clinical Skill 21–1: Performing Nasal Pharyngeal Suctioning in Chapter 21 d) Initial vital signs (1) Initial temp taken by axillary method (2) Brief periods of apnea, lasting only 5 to 10 seconds with no color or heart rate changes, are considered normal. The normal pulse range is 110 to 160 beats per minute (beats/min), and the normal respiratory range is 30 to 60 respirations per minute e) Monitor core temperature at intervals (1) Every 30 minutes until stable for 2 hours 4. Maintenance of a neutral thermal environment a) Essential to minimize need for increased oxygen (1) Hypothermia → lead to metabolic acidosis, hypoxia, shock b) Assessment and interventions under radiant warmer c) Cap d) Bathe while under warmer with parents e) Recheck temperature after bath f) Protect from drafts g) See Clinical Skill 28–1: Thermoregulation of the Newborn, p. 701 h) See Key Facts to Remember: Maintaining a Stable Temperature in the Newborn, p. 702 5. Prevention of vitamin K deficiency bleeding a) Prophylactic injection of vitamin K1 given b) Intramuscularly in vastus lateralis muscle (1) See Figure 28–2: Injection sites, p. 703 (2) See Figure 28–3: Procedure for vitamin K injection ..., p. 703 6. Prevention of eye infection a) Legally required prophylactic eve treatment for Neisseria gonorrhoeae (1) Topical agents (2) 0.5% erythromycin ophthalmic ointment (3) 1% tetracycline (4) Also effective for chlamydia b) See Figure 28–4: Ophthalmic ointment …, p. 704 c) Massage eyelid gently to distribute ointment d) Can cause chemical conjunctivitis 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Early assessment of neonatal distress a) Constantly alert b) Teach parents to recognize hallmarks of distress (1) How to maintain temperature (2) See Table 28–1: Signs of Neonatal Distress, p. 704 (3) Increased respiratory rate or difficult respirations (4) Sternal, substernal, intercostal retractions (5) Nasal flaring (6) Excessive mucus (7) Cyanosis (8) Pallor (9) Mottling (10) Plethora (11) Jaundice of the skin within 24 hours of birth or because of hemolytic process (12) Abdominal distention or mass (13) Vomiting of bile-stained material (14) Absence of meconium elimination within 48 hours of birth (15) Absence of urine elimination within 24 hours of birth (16) Temperature instability (17) Jitteriness, irritability, or abnormal movements (18) Difficult to waken, lethargy, or hypotonicity (19) Weight change greater than anticipated c) Early onset GBS disease (1) At-risk mothers receive intrapartum antimicrobial prophylaxis (IAP) 8. Initiation of first feeding a) Timing varies b) Breastfeed → encourage to put to breast during first period of reactivity c) Formula fed → by 5 hours of age (1) During second period of reactivity 9. Facilitation of parent–newborn attachment a) Eye-to-eye contact extremely important (1) When the newborn is in the first period of reactivity (2) Optimal range for visual acuity (7 to 8 inches) b) Emergent parent–baby bond c) Interactive bath

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Evaluation 1. Newborn baby’s adaptation to extrauterine life supported and complete 2. Baby’s physiologic and psychologic integrity supported 3. Positive interactions between parent and infant supported

II.

The Newborn Following Transition

A. Nursing Management for the Newborn Following Transition 1. Nursing Assessment and Diagnosis a) Breathing Pattern, Ineffective b) Nutrition, Imbalanced: Less Than Body Requirements c) Urinary Elimination, Impaired d) Infection, Risk for e) Knowledge, Readiness for Enhanced f) Family Processes, Readiness for Enhanced

B. Planning and Implementation 1. Maintenance of cardiopulmonary function a) Assess vital signs every 6 to 8 hours or more b) Place on back for sleeping c) Bulb syringe within reach d) Indicators of risk (1) Pallor, cyanosis, ruddy color, apnea, or other signs of instability 2. Maintenance of a neutral thermal environment a) Maintain within normal range (1) Dried completely → dressed, head covering b) Temperature that falls below optimal levels → use calories to maintain body heat (1) Increased respiratory rate → increased insensible fluid loss 3. Promotion of adequate hydration and nutrition a) Record caloric and fluid intake b) Early and frequent feedings c) Record voiding and stooling patterns d) First voiding within 24 hours, stool within 48 hours e) Weigh at same time each day (1) Birth weight should be regained by 2 weeks f) Excessive handling can increase metabolic rate, calorie use, fatigue (1) Cues of fatigue (2) Decrease in muscle tension and activity in extremities and neck (3) Loss of eye contact g) Assess woman’s comfort, latching-on techniques

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Promotion of skin integrity a) Skin care important for health and appearance, infection control b) Umbilical cord assessed for signs of bleeding or infection (1) Clamp removed within 24 to 48 hours of birth (2) Keep clean and dry (3) See Figure 28–5: The umbilical cord base is carefully cleaned and Figure 28–6: The umbilical cord looks dark and dries up prior to falling off, p. 706 c) Fold diaper down to prevent coverage of cord stump d) Observe for signs, symptoms of infection (1) Instruct parents in care 5. Promotion of safety a) Threat of infant abduction requires hospitals to have active programs for prevention b) Security (1) Checking identification bands in place (2) Electronically tagged band (3) Allowing only people with proper birthing unit identification to remove their baby from room (4) Reporting the presence of any suspicious people on the birthing unit c) Safety (1) Never leaving newborn alone in room (2) Never lifting newborn if a parent feels weak, faint, or unsteady on his or her feet (3) Always keeping an eye and hand on the newborn when he or she is out of crib (4) Protecting from infection, even though newborns possess some immunity 6. Prevention of complications a) Newborns at continued risk for complications (1) Hemorrhage (2) Late-onset cardiac symptoms (3) Jaundice (4) Infection (5) Cyanosis b) Infection best prevented with 2- to 3-minute scrub of all personnel c) Parents instructed d) Jaundice in most newborns benign (1) Monitor to identify 7. Circumcision a) Surgical procedure (1) Prepuce separated from glans penis, excised (2) Religious, ethical, cultural beliefs and practices (3) Informed consent b) Current recommendations (1) AAP and ACOG do not recommend routine circumcision but acknowledge that medical indications for circumcision still exist 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Medical indications exist (2) Recommend analgesia (3) Not performed if newborn premature, compromised (a) Bleeding problem, born with genitourinary defect c) Care of uncircumcised newborn (1) Parents education on hygiene, foreskin and glans (2) Separation of foreskin and glans normally complete at 3 to 5 years (3) Smegma d) Care of the circumcised newborn (1) Allay parents’ anxiety by sharing information (2) Allow to express concerns (3) Potential risks and outcomes (4) Information about good hygiene practices (5) If desired performed after newborn well stabilized (6) Nurse ascertains that physician has explained procedure, parents have any questions (7) Verify circumcision permit signed (8) Preoperative procedures (a) Identification band (b) Gather equipment (c) Remove diaper, place newborn on padded circumcision board (d) Variety of devices used → all produce minimal bleeding (e) Assess newborn’s response (f) Anesthesia (i) Topical analgesia (g) Comfort procedures (h) Assess for signs of hemorrhage, infection (i) Every 30 minutes for at least 2 hours (ii) Observe for first void (9) Teach family members how to assess for bleeding, stress to parents to report any signs or symptoms of infection (a) Newborn circumcision care (i) Clean with warm water with each diaper change (ii) Apply petroleum ointment for next few diaper changes (iii) If bleeding does occur, apply light pressure with a sterile gauze pad (iv) Glans normally has granulation tissue during healing (v) Continued application of petroleum ointment can help protect granulation tissue (vi) If Plastibell: should fall off in 8 days, no ointments or creams while bell is on (vii) Ensure diaper not loose enough to cause rubbing with movement (b) See Figure 28–7: Circumcision using the Yellen or Gomco clamp, p. 708 (c) See Figure 28–8: Circumcision using the Plastibell …, p. 708 (d) See Figure 28–9: Following circumcision, petroleum ointment may be applied to the site for the next few diaper changes, p. 709

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

8. Enhancement of parent–newborn attachment a) Promoted by encouraging all family members to be involved with new member of family (1) See Teaching Highlights: What Parents Need to Know About Enhancing Attachment, p. 709 b) Infant massage c) Discuss waking activities (1) Talking (2) Holding (3) Gently bending baby back and forth while grasping under the knees d) Quieting activities (1) Swaddling (2) Using slow, calming movements (3) Talking softly, singing or humming e) Cultural competence

C. Evaluation 1. Baby’s physiologic and psychologic integrity supported 2. Newborn feeding pattern satisfactorily established 3. Parents express understanding of the bonding process and display attachment behaviors

III.

Preparation for Discharge

A. Crucial transition for family B. Nursing Management for the Newborn in Preparation for Discharge C. Nursing Assessment and Diagnosis 1. Assess whether parents have realistic expectations of newborn’s behaviors 2. Assess depth of knowledge in caring for newborn 3. Diagnoses include a) Parenting, Readiness for Enhanced b) Family Processes, Readiness for Enhanced

D. Planning and Implementation 1. Parent teaching a) Every contact presents opportunity for sharing information b) Observe how parents interact with infant c) Provide mother–baby care and home-care instruction d) One-to-one teaching shown to be most effective

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. General instructions for newborn care a) Picking up baby → hand under neck and shoulders, other hand under buttocks or between legs b) Safety topics (1) Back to sleep, bulb syringe c) Alone only in crib d) Demonstrating bath, cord care, temperature assessment e) When to call healthcare provider f) Nurse demonstrates, reviews taking of temperature 3. Nasal and oral suctioning a) Obligatory nose breathers for first months of life b) Demonstrate use of bulb syringe (1) Bulb syringe compressed and tip placed in nostril (2) Take care not to occlude passageway (3) Expand bulb slowly by releasing compression (4) Remove from nostril (5) Drainage compressed out of bulb (a) See Figure 28–11: Nasal and oral suctioning …, p. 712 (6) Suctioning mouth (a) Bulb compressed (b) Tip placed about 1 inch to one side of the newborn’s mouth and compression released (c) Draws up excess secretions (d) Repeat on other side of mouth (e) Avoid roof of mouth, back of throat (f) Wash in warm, soapy water daily and as needed c) Transient edema of nasal mucosa (1) Use of normal saline to loosen secretions 4. Sleep and activity a) Healthy term infants should be placed on backs to sleep (1) Reduces incidence of sudden infant death syndrome (SIDS) (2) Nurses demonstrate in hospital b) Recognize variations of each newborn, assist parents 5. Car safety considerations a) Car seat adapted to fit newborns (1) Half of children killed or injured in automobile accidents could have been protected by the use of a federally approved car seat (2) See Figure 28–12: Infant car restraint for use from birth to about 12 months of age, p. 713

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Ensure parents are knowledgeable, encourage seats are checked by local specially trained groups 7. Newborn screening and immunization program a) Newborn screening tests (1) Blood spot screening (2) Hearing screening (3) Hyperbilirubinemia screening (4) Critical congenital heart disease screening (5) Specific disorder tested for each state b) Hearing screenings (1) Hearing loss in 1–3:1000 babies in normal newborn population (2) Accomplished before discharge (3) Follow-up if newborn fails to pass initial screen (4) See Figure 28–13: Newborn hearing screen, p. 713 c) Immunization programs (1) Hepatitis B d) Checklist for caregiving methods 8. Community-based nursing care a) Discuss ways to meet newborn’s needs, ensure safety, appreciate unique characteristics and behaviors (1) Checklist may be helpful b) Signs of illness c) How to reach care provider or after-hours clinic d) Importance of follow-up after discharge (1) Should be scheduled within 48 hours of discharge (2) See Key Facts to Remember: What Parents Need to Know About Newborn Care, p. 716 e) Routine well-care baby visits scheduled

E. Evaluation 1. Parents demonstrate safe techniques for caring for newborn 2. Parents verbalize developmentally appropriate behavioral expectations of newborn and knowledge of community-based newborn follow-up care

IV.

Focus Your Study

Activities 1. Individual Have students prepare drug cards on the following medications: • Erythromycin ophthalmic ointment • Vitamin K1 phytonadione

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

•

Hepatitis B vaccine

2. Small Group Divide the class into small groups of three to five students. Have each group research the cultural beliefs of a population in their area. Assign each group a particular group to research and have groups give 10-minute presentations to the class. The groups should include handouts with their presentations and their references should be cited in APA format. 3. Large Group Invite a local resource (law enforcement or another community resource) to come to class to demonstrate the proper installation and use of a car seat.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 29 Newborn Nutrition Nutritional Needs and Breast Milk/Formula Composition..............................

Breastfeeding...................................................................................................

Breastfeeding Technique…………………………………………………………………………….

Timing of Newborn Feedings...........................................................................

Formula Feeding...............................................................................................

Community-Based Nursing Care......................................................................

Nutritional Assessment....................................................................................

Focus Your Study..............................................................................................

Activities...........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Nutritional Needs and Breast Milk/Formula Composition

A. Diet 1. Hydration, calories, protein, carbohydrates, fat, minerals, vitamins 2. Exclusive breast milk is sufficient from birth up to 6 months of age. 3. Breastfeeding with solid foods for the next 6 months is recommended. 4. > 1 year, breastfeeding may be continued for as long as mutually desired by mother and baby

B. Dietary Reference Intakes 1. DRI encompasses four aspects a) Estimated average requirement (EAR) b) Recommended daily allowance (RDA) c) Adequate intake (AI) d) Tolerable upper intake level (UL) 2. Framework → links nutrition and health across lifespan

C. Growth 1. All infants lose weight after birth a) Not a concern unless 7 to 10% of birth weight loss b) In 7 to 14 days should regain their weight c) Weight loss does not result in dehydration 2. Different growth rates due to different composition of human milk, formula a) See Table 29–1: Comparison of Nutrients in Milk, pp. 720–721 b) Breastfeeding “gold standard” for neonatal nutrition c) Formula-fed infant tends to regain birth weight earlier d) Breastfed only same or slightly higher weight gain for 3 to 4 months e) After 3 to 4 months → formula- and combination-fed have greater gain 3. Infants generally double birth weight by 5 months a) Triple birth weight by 1 year b) Quadruple birth weight by 2 years c) Tracking by growth chart d) See Key Facts to Remember: Newborn Caloric and Fluid Needs, p. 721

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) More susceptible to dehydration (1) Insufficient fluid intake (2) Increased fluid loss from diarrhea, vomiting 2. Signs of dehydration a) Fontanelle in addition to other signs (1) See Box 29–1: Signs of Dehydration in the Newborn, p. 722

E. Energy 1. Basal metabolic rate (BMR) a) Energy needed for thermoregulation, cardiorespiratory function, cellular activity, growth b) 100 to 115 kcal/kg/day at 1 month c) 85 to 95 kcal/kg/day from 6 to 12 months

F. Fats 1. Approximately 50% of calories from fat 2. Milk composition a) 98% of human milk fat in form of triglycerides b) Fatty acids key component to brain development c) Needed for myelination of spinal cord d) Fat content variable (1) 30 to 50 gm/L of human milk (2) Influences e) Phospholipids, cholesterol higher in colostrum 3. Fats in milk-based formulas modified to parallel fat profile of human milk

G. Carbohydrates 1. Other main source of energy a) 40% of calories in diet 2. Milk composition a) Breast milk → primary carbohydrate is lactose b) Also contains trace amounts of other carbohydrates

H. Proteins 1. Building blocks for muscle and organ structure 2. Key to almost every metabolic processes 3. Milk composition a) Casein and whey proteins b) Whey predominant protein in human milk (1) Easily digested → more frequent feedings

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Casein predominant in cow milk → 20:80 whey/casein ratio (1) Less easily digested, forms curds d) Cow’s milk–based formulas modified to get closer to mature human milk (1) Human milk 60:40 whey/casein ratio (2) Formulas 48:52 whey/casein ratio 4. Human milk whey protein a) Alpha-lactalbumin b) Serum albumin c) Lactoferrin d) Immunoglobulins e) Lysozyme f) Nonnutritional elements

I. Vitamins, Minerals, and Trace Elements 1. Vitamins a) Adequate vitamin intake important to support growth and metabolism (1) Fat-soluble → A, D, E, K → possibility of toxicity b) Milk composition (1) Influenced by mother’s vitamin intake, general nutritional status, genetic differences → varies as lactation progresses (a) Prenatal vitamins continued (2) Human milk low in vitamin D (a) All infants and children receive 400 international units daily (3) Vitamin K present in breast milk, but in small quantity (a) Standard care to give vitamin K prophylaxis (4) Vitamin B complex and C are water soluble (a) Exclusively breastfed should receive vitamin B12 supplementation (b) Formula is fortified with adequate amounts (5) Vitamin A (a) Healthy skin, hair, nails, gums, glands, bones, teeth, helps prevent infections (6) Vitamin E (a) Antioxidant and free radical scavenger (b) Naturally present in breast milk 2. Minerals a) Diverse regulatory functions throughout body (1) Calcium → clotting (2) Phosphorus → adenosine triphosphate (ATP), deoxyribonucleic acid (DNA), ribonucleic acid (RNA), phospholipids (3) Sodium → fluid balance (4) Calcium, sodium, potassium → nerve and muscle function (5) Chlorine → acid–base balance (6) Cobalt → with vitamin B12 to form blood cells 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(7) Copper and iron → blood production (8) Iodine → thyroid hormone synthesis (9) Magnesium, manganese, zinc → enzymatic processes b) Milk composition (1) Human milk and formulas contain major, trace minerals → satisfy needs (2) Mineral content of milk does not appear to be influenced by maternal diet (3) Iron in human milk more completely absorbed—infant absorbs 50% to 80% of iron compared with less than 12% of iron in formula (4) Nurse educates parents → iron added to formula is in ionic form and does not cause constipation 3. Trace elements a) Nucleotides → building blocks for DNA, RNA b) Carnitine → transport fatty acids to mitochondria for oxidation c) Taurine → growth, central nervous system, auditory function development

J. Feeding Intolerances 1. Evaluate true lactose intolerance versus cow’s milk protein allergy 2. Develops after 2 to 5 years and not a condition affecting infants 3. Eliminate bovine protein from mother’s diet, mother can continue breastfeeding

K. Specialty Formulas 1. American Academy of Pediatrics and ACOG recommend breastfeeding all infants a) Rare exceptions 2. First choice → cow’s milk-based formula 3. Milk-based lactose-free formulas 4. Soy-based formulas a) For infants with primary lactose deficiency b) For infants with galactosemia c) Term infant of formula-feeding vegan parents d) For infants who develop secondary transient lactose deficiency following acute diarrhea e) Sometimes switched for colicky symptoms → will not always solve the cause 5. Hydrolyzed (hypoallergenic) formulas a) For infants who have formula intolerance not related to cow’s milk-based formulas → protein broken down into smaller components b) Nestle Good Start HMO c) Documented cow’s milk-based allergies, metabolic disorder, malabsorption syndrome → hypoallergenic formulas (1) Nutramigen, Alimentum

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

L. Choice of Feeding 1. Meet essential needs of newborn is priority 2. Mothers usually decide by 6 months of pregnancy on feeding method a) Decision influenced by others 3. Educate to help make informed choice 4. Healthy People 2020 a) 82% will initiate breastfeeding b) At least 61% will continue until infant 6 months old c) At least 34% continue until infant 12 months old d) Goal for exclusive breastfeeding at 3 months is 46%, 6 months is 26%

II.

Breastfeeding

Breast Milk Production 1. Breast divided into 15 to 20 lobes a) Separated by fat, connective tissue b) Interspersed with blood vessels, lymphatic vessels, nerves c) Lobules → alveoli → where milk synthesized d) Range ]4-18 milk ducts exiting the nipple e) See Figure 29–1: Anatomy of the breast, p.724 f) Oxytocin

Physiologic and Endocrine Control of Lactogenesis 1. Increased levels of estrogen → stimulate breast duct proliferation, development a) Elevated progesterone levels promote development of lobules, alveoli b) Prolactin levels rise c) Lactation suppressed during pregnancy → elevate progesterone levels secreted by placenta (1) Placenta delivered → progesterone falls, inhibition removed → milk production triggered → lactogenesis II 2. Prolactin released by anterior pituitary → response to breast stimulation from suckling, breast pump a) Stimulates milk-secreting cells b) Stimulates milk production → breastfeed/pump more frequently c) Established during first 2 weeks postpartum 3. Start of feeding → foremilk a) Watery, high in lactose, protein, low in fat (1 to 2%) b) Stretching of nipple, compression of areola → triggers release of oxytocin → myoepithelial cells around alveoli contract → eject milk

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Oxytocin → milk-ejection reflex or let-down reflex → hindmilk (rich in fat) a) Initial let-down → about 2 minutes after feeding starts b) Hindmilk → rich in fat and high in calories 5. By 6 months → prolactin levels 5 to 10 ng/mL → milk production continues a) Feedback inhibitor of lactation (FIL) (1) Negative feedback loop → the more milk left in breast, longer it remains → more milk production decreased (2) Autocrine control 6. Delay or impair lactogenesis a) Maternal factors b) Lifestyle factors

Stages of Human Milk 1. Colostrum a) Initial milk → begins to be secreted mid-pregnancy (1) Immediately available at delivery (2) Small volume → newborn nurses frequently → helps stimulate milk production (3) Thick, creamy, yellowish b) Concentrated amounts protein, fat-soluble vitamins, minerals, antioxidants, lactoferrin, IgA c) Promotes establishment of Lactobacillus bifidus flora d) Laxative effect → pass meconium → decrease hyperbilirubinemia 2. Transitional milk a) “Coming in” b) 48 to 96 hours postpartum, most on day 3 c) Yellow, more copious than colostrum, more fat, lactose, water-soluble vitamins, calories d) See Figure 29–2: Transitional human milk, p. 726 3. Mature milk a) White to slightly blue-tinged b) By 2 weeks postpartum and continues for remainder of breastmilk production c) 13% solids d) 87% water e) Gradual change in composition to accommodate needs of newborn

Advantages of Human Milk 1. American Academy of Pediatricians (AAP) recommends as exclusive feeding for first 6 months 2. Nutritional advantages a) Species specific

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Lactose primary carbohydrate → galactose → brain, central nervous system (CNS) development (1) Energy source, enhances absorption of calcium, magnesium, zinc c) Mineral content constant d) Iron more readily and fully absorbed than that of formula (1) Lactoferrin e) Reduced risk of specific diseases f) Mother benefits (1) Decreased risk for postpartum bleeding → rapid uterine involution (2) Protective function possible against premenopausal breast cancer, ovarian cancer (3) Decrease in type 2 diabetes, rheumatoid arthritis, and hypertension 3. Immunologic advantages a) Varying degrees of protection from respiratory tract and GI infections (1) Urinary tract infections, otitis media, bacterial meningitis, bacterium, allergies b) Secretory IgA → role in decreasing permeability of small intestine c) Breastfeeding does not adversely affect immunization (1) Should be vaccinated as scheduled 4. Psychosocial benefits of breastfeeding a) Self-esteem (1) Providing perfect food for baby, protection with antibodies b) Enhanced bonding (1) Close contact → tactile stimulation 5. See Table 29–2: Comparison of Breastfeeding and Formula-Feeding, p. 727

Potential Challenges to Breastfeeding 1. Challenges a) Pain with breastfeeding b) Concern over adequacy of milk volumes c) Leaking milk d) Embarrassment e) Stress f) Unequal feeding responsibilities/fathers left out g) Diet restriction h) Limited hormonal birth control options i) Vaginal dryness associated with breastfeeding 2. Medications a) Most drugs penetrate into human milk b) Almost all medications appear in only small amounts in human milk c) Very few drugs are contraindicated for breastfeeding women d) Healthcare provider should consider the following: (1) Mother’s need for medication 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Drug’s potential effect on milk production (3) Amount of drug excreted into the milk (4) Extent of baby’s oral absorption of the drug (5) Drug’s potential adverse effects to the infant (6) Baby’s age and health e) Adjustments to be made (1) Avoid long-acting forms of drugs (2) Consider absorption rates, peak blood levels in scheduling administration of drugs (3) Use preparations that can be given at longer intervals (4) Select drug with least tendency to pass into breast milk (5) Use single-symptom drugs versus multi-symptom drugs

Potential Contraindications to Breastfeeding 1. HIV positive or as AIDS → counseled against breastfeeding 2. Mother has active, untreated tuberculosis, varicella, human T-cell leukemia virus type 1 (HTLV1)-positive, or another illness on case by case basis 3. Mother has active herpes on breast 4. Mother uses illicit drugs or is an alcoholic 5. Maternal smoking poses health risks to mother, potential second-hand exposure to baby 6. Specific medications, radioactive isotopes, antimetabolites, chemotherapy drugs a) Mother with diagnosis of breast cancer should not breastfeed to start treatment immediately 7. Infant has galactosemia

Cultural Considerations in Newborn/Infant Feeding 1. Ask questions in a sensitive and respectful way 2. Correct misconceptions a) “Spoiling their milk” b) Do not throw out “dirty” colostrum 3. Best to have a female, non–family member translator 4. Galactagogues used to increase milk production, reestablish supply, assist in initiating lactation when adoptive mother wished to nurse 5. Some of these herbs not recommended if nursing mother also pregnant a) Most notice increase in milk supply → 1 to 3 days b) Also needs to increase frequency c) Hydrate d) Eat well

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Herbal galactagogues → tea, capsule, tincture 7. Fenugreek 8. Others a) Alfalfa, dandelion, fennel, horsetail, red raspberry, caraway, anise

Breastfeeding Technique 1. Breastfeeding position and latching on a) Not instinctive → learned 2. Positioning a) Multiple positions (1) Cross-cradle (a) See Figure 29–5: Cross-cradle position, p. 733 (2) Cradle (a) See Figure 29–6: Cradle position, p. 733 (3) Football-hold (a) See Figure 29–7: Football hold position, p. 734 (4) Side-lying (a) See Figure 29–8: Side-lying position, p. 734 3. Latching on a) Position for an optimal attachment b) Infant needs to attach lips far back on areola, not on actual nipple (1) Sore nipples c) Elicit rooting reflex → infant opens mouth wide → draw baby toward her (1) See Figure 29–9: C-hold hand position, p. 735 (2) See Figure 29–10: Scissor-hold hand position, p. 735 (3) See Figure 29–11: Nose to nipple, p. 736 (4) See Figure 29–12: Initial attempt to elicit the rooting reflex, p. 736 (5) See Figure 29–13: Continued attempt to elicit the rooting reflex, p. 736 (6) See Figure 29–14: Baby is latched on, p. 737 4. Breastfeeding assessment a) Monitor progress with systematic assessment of several feeding episodes (1) Anticipatory guidance (2) Maternal response to infant cues (3) Latch-on technique (4) Positioning (5) Signs of active feeding (6) Let-down response (7) Nipple condition (8) Maternal comfort during feeding (9) Infant’s weight from previous measurement (10) Infants report of intake and output 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(11) LATCH Scoring Tool 5. Breastfeeding efficiency a) No visual assurance of amount of breast milk consumed b) Other signs of effective, active breastfeeding (1) Rhythmic suckling pattern (2) Suckling with jaw compressions (3) Feeding 10 to 20 minutes on first breast, few minutes or not at all on second (4) Observe for swallowing (5) Infant will pull away, fall asleep when satiated (6) Extremely relaxed (7) Characteristic output (8) Pre- and postfeeding weights c) See Figure 29–15: Breastfeeding intake and output expectations, p. 739 d) Minimum output (1) Day 1 (a) Infant should produce at least one wet diaper and one meconium stool by 24 hours of age (b) Note pinkish-red “brick dust” appearance on the diaper (c) Uric acid crystals produced by kidneys (i) Associated with concentrated urine (ii) Red flag raised if presence continued beyond day 2 or 3 of life (2) Day 2 → Infant should produce at least two wet diapers and two early transitional stools in a 24-hour period by 48 hours of age (3) Day 3 → Infant should produce at least three wet diapers and three transitional stools in a 24-hour period by 72 hours of age (a) When a mother’s milk supply is abundant on day 2, some babies will have transitioned to yellow milk stools as early as day 3 (4) Day 4 → Infant should produce at least four wet diapers and three to four yellowgreen transitional stools or yellow milk stools in a 24-hour period by 96 hours of age (5) Day 5 → Infant should produce at least five wet diapers and three to four yellow milk stools per day; stools typically explosive with curdy or seedy appearance (a) Hereafter, breastfeeding infants will consistently produce at least six wellsaturated wet diapers per day (b) These infants will typically continue to produce at least three to four yellow milk stools daily, but may have up to 10 stools per day until they are about a month old (c) Infants 4 weeks or older may suddenly decrease their stool frequency, even skipping days 6. Bottle-Feeding Human Milk a) Hand expression (1) Teach all mothers the skill (a) Be sure breasts are clean (b) Hands are washed before preparing to pump 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Take a few minutes to massage the breasts and relax (d) Sit up straight or lean slightly forward (e) Position thumb at 12 o’clock position on top edge or areola, forefinger, middle finger pads at 6 o’clock position on bottom edge of areola (f) Mother will stretch areola back toward her chest wall without lifting her fingers off her breast (g) Now mother rolls thumb and fingers simultaneously forward (h) Repeat sequence multiple times to completely drain breasts (i) Move fingers to other positions on same breast when milk flow slows (2) Should not be painful (3) See Figure 29–16: Hand expression, p. 740 b) Breast pumps (1) Not all breast pumps of same quality (2) Should be able to cycle from low to high suction 45 to 60 cycles per minute (a) See Figure 29–18: Manual breast pump, p. 742 (b) See Figure 29–19: Individual double electric breast pump, p. 742 (c) See Figure 29–20: Hospital-grade multi-user breast pump, p. 742 (3) Breast flange fit and comfort important c) Storing human breast milk and formula (1) See Table 29–3: Pumping Instructions and Breast Milk Storage Guidelines, pp. 740– 74139 (a) Once a day, rinse breasts with water (b) Wash hands well with soap and water before pumping (c) Take a few minutes to massage breasts and relax (d) Sit up strait or lean slightly forward (e) For hand-expressing, use Marmet technique (i) Thumb at 12 o’clock position at top of areola and forefinger and middle finger at 6 o’clock (ii) Stretch areola back towards chest (iii) Roll thumb and fingers simultaneously forward (iv) Repeat sequence (f) For single sided pumping (i) Pump each breast for 10-20 minutes (ii) Pump expressed milk into glass or plastic bottles (iii) Feed freshly expressed milk whenever possible. (iv) Store expressed human milk (v) Never thaw in microwave or in a pan on the stove (a) For quick thaw, place container in a bowl in the sink and run warm water over it for no longer than 15 minutes (b) For slow thaw overnight, take frozen container from freezer day or several hours before and defrost in refrigerator (vi) Check temperature of milk before feeding to baby (2) Feeding (a) Human milk or formula 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(i) Opened/reconstituted (ii) Being fed (iii) Finish feed within 1 hour (b) Fresh human milk (i) Room temperature (ii) 72°F to 79°F (iii) 4 hours (c) Fresh human milk (i) Room temperature (ii) 66°F to 72°F (iii) 6 to 10 hours (d) Fresh human milk (i) Cooler w/ frozen ice packs (ii) 59°F (iii) 24 hours (e) Formula (i) Opened/reconstituted (ii) Room temperature (iii) 2 hours (f) Thawed human milk (i) Refrigerator (ii) 24 hours (g) Formula (i) Opened/reconstituted (ii) Refrigerator (iii) 24 to 48 hours (see label) (h) Fresh human milk (i) Refrigerator (ii) 8 days (i) Formula powder (i) Opened can (ii) Room temperature (iii) 1 month (j) Fresh human milk (i) Freezer (ii) 3 to 4 months (k) Formula/powder in sealed container (i) Avoid excessive heat (ii) Printed expiration date (l) Thawed human milk (i) Freezer (ii) Do not refreeze (m) Formula (i) Freezer 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(ii) Do not freeze d) Supplementary formula-feeding (1) Only when medically indicated (2) May cause infant to develop incorrect sucking pattern (3) Nipple confusion/nipple preference (a) Latching different, tongue movement different (4) Valid medical indication (a) Mother’s own milk (b) Pasteurized donor milk (c) Formula (5) See Table 29–6: Factors Requiring Consideration of Supplementation, p. 743 (6) Risk factors for inadequate intake (a) Maternal/infant separation (b) Maternal barriers to breastfeeding (e.g., medications, fatigue, pain, cultural) (c) Congenital malformation or illness interfering with ability to breastfeed (d) Delayed lactogenesis after day 3 or 4 (e) Primary lactation failure (usually due to breast pathology or prior breast surgery) (f) Low birth weight or infant with illness/disorder requiring nutrient requirements that may exceed that available through breastfeeding (7) Signs of potential inadequate intake: (a) Weight loss >7% from birth weight (b) Delayed bowel movements or continued meconium stools beyond day 2 (c) Hypoglycemia not responding to frequent breastfeeding attempts (d) Hyperbilirubinemia due to breastfeeding jaundice

III.

Timing of Newborn Feedings

A. Ideally determined by physiologic, behavioral cues B. Initial Feeding 1. Infant should be placed on mother’s chest a) Skin-to-skin contact helps maintain body temperature, self-regulation, increases maternal oxytocin levels, helps mother to notice subtle feeding cues, promotes bonding b) First 2 hours of life → alert and ready to breastfeed 2. Plans to bottle-feed → still skin to skin a) Formula-feeding not typically initiated in birthing room 3. Assessment of newborn’s physiologic status primary, ongoing concern a) Watch for complications when eating b) Wet burps normal, with some degree of reflux c) Holding baby upright on parent’s chest for 15 to 20 minutes after feeding

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Establishing a Feeding Pattern 1. “On-demand” feeding program facilitates own rhythm, helps mother establish lactation a) Rooming in → 24-hour access b) Following initial alert period, newborn typically sleeps for several hours c) Cluster feeding 5 to 10 episodes over 2 to 3 hours d) Uninterested in nursing → prolonged pushing, medications in labor 2. Waking sleepy baby a) Late-preterm tend to be very sleepy, less stamina, greater difficulty with suck/latch/swallow b) Remove blanket, clothing → infant in diaper, T-shirt c) Blanket over baby after latching d) Encourage mother to use tactile stimulation while newborn attached to breast 3. Feeding pattern may change when milk comes in a) Every 1½ to 3 hours around the clock b) May struggle with latch-on with engorged breasts c) Express milk to soften breast 4. Rates of digestion differ between breast milk and formula a) Formula-fed newborns sleep longer b) Awaken to feed every 3 to 4 hours 5. Normal feeding pattern erratic 6. Satiety behaviors a) Longer pauses toward end of feeding b) Noticeable total body relaxation c) Infant may release his mother’s nipple, bottle nipple, fall asleep d) Breastfed newborn awakens → feed no matter how long it has been (1) Pacifier inappropriate at this time, wait to 3 to 4 weeks 7. Growth spurts require increased feeding volume

IV.

Formula Feeding A. Formula-Feeding Guidelines and Technique 1. Commercial formulas a) Powder (1) Least expensive (2) Use within 24 to 48 hours once prepared (3) Standard → one level unpacked scoop to 60 mL water (4) Not sterile b) Formula concentrate (1) More expensive than powder (2) Dilute with equal part of water 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Ready-to-feed formula (1) Easiest (2) Most expensive 2. Underscore importance of proper preparation a) Follow directions on package precisely b) Recommended sanitary and safety precautions include: (1) Check the expiration date on the formula container (2) Ensure good hand washing before preparing formula; never dip into the can without clean hands (3) Clean bottles, nipples, rings, disks, and bottle caps (4) Wash in a dishwasher when available (small items and heat-sensitive items on top rack secured in a basket), or boil briefly (1 to 2 minutes) in a pot of water, or (5) Clean using a microwave sterilization kit, or (6) Clean using very warm soapy water and a nipple and bottle brush (7) Inspect and replace bottle nipples as soon as they show wear (8) Wash the top of the formula container before piercing the lid, and shake the liquid formulas well before pouring out desired amount (9) Shake prepared milk that has been sitting in the refrigerator before feeding (10) Use hot water (158°F or higher) to make powdered formula (11) Use only the scoop supplied in the can of formula when formula preparation instructions call for a “scoop” of powdered formula; a scoop should not be “packed” and should be leveled off (12) Do not add anything else to the bottle, except under direction of baby’s healthcare provider (13) Warm up formula in a bottle by placing the bottle in a bowl of warm tap water for no longer than 15 minutes; do not fill the bowl with water higher than the rim of the bottle (14) Allow freshly prepared (unused) formula to sit out at room temperature for no longer than 2 hours; use an insulated pack to transport formula; milk left over in the bottle after a feeding should be discarded (15) In warm weather, transport reconstituted or formula concentrate from an open can in an insulated pack with frozen gel packs (16) Travel with water and formula separated (17) Hold the infant during feedings (18) Do not allow the infant to bottle feed in a supine position → increases the risk of otitis media, dental caries (19) Never prop a bottle—this is a choking hazard (20) Allow infants to take what they want and to stop when they want 3. Guidance about water for reconstitution a) If boiling → boil for 1 to 2 minutes after reaching rolling boil b) Allow the water to cool before using it to reconstitute the formula c) Distilled, filtered water → fluoride concerns d) See Table 29–7: Water Sources, p. 746 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Bottles and nipples a) Based on preference b) Feeding technique is emphasis c) Burp frequently d) Vented bottle, tilting bottle at 45-degree angle e) Slow-flow nipple to start → graduate to medium-flow to high-flow f) Observe bottle for bubbles (standard bottle), liner retracts g) Infants who persistently leak from side of mouth may be getting fluid too quickly (1) See Figure 29–22: Burping baby sitting up on lap, p. 747 (2) See Figure 29–23: Burping baby over the shoulder, p. 747 (3) See Figure 29–24: Bottle-feeding, p. 747 h) Concern regarding chemicals in plastic baby bottles (1) Bisphenol A (BPA) (2) Read labels (3) Limit heating bottles (4) Throw out old bottles with scratches

B. Involving Fathers and Partners 1. Speak to both parents when entering room 2. If breastfeeding a) Ask to wait to give bottles until breastfeeding is established b) Help mother position, help reposition latch c) Massage breasts to help stimulate sleepy baby d) Burp baby e) Skin-to-skin contact (1) See Figure 29–25: Father and newborn skin to skin, p. 748

Community-Based Nursing Care A. Promotion of Successful Newborn/Infant Feeding 1. Baby-Friendly Hospital Initiative a) Promoting hospitals, birthing centers that offer optimal lactation services 2. Community resources a) La Leche League International (LLLI) b) Peer counseling 3. WIC a) Supplemental Nutrition Program for Women, Infants, and Children (WIC) b) Provides low-income women and children with nutritious foods

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Nutritional Assessment

A. Includes 1. Nutritional intake and output 2. Infant’s measurements (length, head circumference, weight) 3. Physical examination a) Head-to-toe physical

B. Nursing Management for a Newborn with Significant Weight Loss 1. Nursing Assessment and Diagnosis 2. Breastfeeding, Ineffective, related to a) Mother’s lack of knowledge about breastfeeding b) Mother’s not responding to infant’s feeding cues c) Mother’s inability to facilitate effective breastfeeding 3. Breastfeeding, Ineffective, related to a) Insufficient knowledge regarding newborn’s reflexes and breastfeeding techniques b) Lack of support by father of baby or other support persons c) Lack of maternal self-confidence d) Maternal self-confidence e) Maternal fatigue f) Possible maternal ambivalence g) Poor infant sucking reflex h) Difficulty waking the sleepy baby 4. Nutrition, Imbalanced: Less Than Body Requirements, related to a) Mother’s increased caloric and nutrient needs status post-cesarean section b) Newborn’s inability to correctly latch on and transfer milk

C. Nursing Plan and Implementation 1. Review the mother’s history 2. Maternal assessment 3. Newborn assessment 4. Newborn feeding history 5. Pre- and postbreastfeeding weight check a) Calculate milk transfer during breastfeeding 6. Observation of breastfeeding technique 7. Review feeding requirement/caloric requirement based on infant’s birth weight a) Fluid requirement: 140 to 160 mL/kg/day 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) 496 to 567 mL/day b) Infant should feed 8 to 12 times per day (1) 496/10 = 49.6 mL/feeding (2) Day 3 feeds less c) Caloric requirement 100 to 115 kcal/kg/day (1) Up to full caloric requirement about day 6 8. Assess teaching needs and provide verbal and written instructions a) Review benefits of breastfeeding b) Review breastfeeding technique c) Watch infant for early feeding cues d) Provide breast pump instructions and review collection and storage e) May start pumping to increase breast stimulation f) Review process of breastfeeding and practice proper breastfeeding technique g) Review infant intake and output, weight gain expectations h) Provide information on maternal nutrition and fluid requirements 9. Arrange for follow-up lactation consultation visit in 2 days to reassess 10. Evaluation a) Newborn will rouse to feed at least every 3 hours and will stay awake until end of feeding b) Newborn will correctly latch onto breasts, effectively breastfeed 8 to 12 times per day c) Newborn will gain at least 10 g/kg/day and be back to birth weight no later than day 14 of life d) Newborn will have four wet diapers, three to four bowel movements on day 4; five wet diapers, three to four bowel movements on day 5; and six to eight wet diapers, three to four bowel movements every day thereafter during the first month of life e) Newborn’s stools will transition from black to yellow by day 5 and will change in consistency from thick and sticky to loose and explosive with small curds or seedy appearance f) Newborn will not have any uric acid crystals in her diaper after day 3 or 4 g) Newborn will be satiated after feeding, as evidenced by relaxed muscle tone and sleepiness 11. Expected outcomes for the mother include: a) Mother will verbalize/demonstrate an understanding of breastfeeding technique, including positioning and latch on, signs of adequate feeding, self-care b) Mother will breastfeed pain-free c) Mother will express satisfaction with the breastfeeding experience d) Mother will consume a nutritionally balanced diet with appropriate caloric and fluid intake to support breastfeeding

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students prepare a teaching plan for the partner who will assist the new mother with breastfeeding. Have students focus their plans on one of the following: • Adolescent father • Primipara • Multipara who is breastfeeding for the first time • Multipara with first cesarean birth 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the woman who will be bottle feeding. Instruct the groups to include comparisons of specific bottles, nipple types, etc. The groups can then prepare a resource list for new mothers. 3. Large Group Invite speaker from the La Leche League or another lactation consultant to speak with students. Ask the speaker to bring a variety of breast pumps and assistive devices to demonstrate to students.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 30 The Newborn at Risk: Conditions Present at Birth Identification of At-Risk Newborns.....................................................................

Care of the Small-for-Gestational-Age/Intrauterine Growth Restriction Newborn………………………………………………………………………………………………

Care of the Large-for-Gestational-Age Newborn...............................................

Care of the Newborn of a Mother with Diabetes...............................................

Care of the Postterm Newborn...........................................................................

Care of the Preterm (Premature) Newborn........................................................

Care of the Newborn with Congenital Anomalies..............................................

Care of the Newborn with Congenital Heart Defect………………………………………

Care of the Newborn of a Substance-Abusing Mother......................................

Care of the Newborn Exposed to HIV/AIDS........................................................

Care of the Newborn with an Inborn Error of Metabolism................................

Focus Your Study.................................................................................................

Activities..............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Identification of At-Risk Newborns

A. At-risk newborn often involves one or more predictable risk factors 1. Low socioeconomic level of the mother 2. Limited access to health care or no prenatal care 3. Exposure to environmental dangers, such as toxic chemicals and illicit drugs 4. Preexisting maternal conditions 5. Maternal factors such as age or parity 6. Medical conditions related to pregnancy and their associated complications 7. Pregnancy complications

B. Birth of at-risk newborns can often be anticipated 1. Even if identified → labor cannot be predicted 2. Apgar score is a helpful tool

C. Newborn classification and neonatal mortality risk chart 1. Preterm: less than or equal to 36 weeks, 6 days 2. Late preterm: 34 weeks, 0 days through 36 weeks, 6 days 3. Early term: 37 weeks, 0 days through 38 weeks, 6 days 4. Full term: 39 weeks, 0 days through 40 weeks, 6 days 5. Late term: 41 weeks, 0 days through 41 weeks, 6 days 6. Postterm: 42 weeks, 0 days and beyond 7. Large-for-gestational-age (LGA) → above 90th percentile 8. Appropriate-for-gestational-age (AGA) → between 10th and 90th percentile 9. Small-for-gestational-age (SGA) → below 10th percentile 10. Chart should correlate with characteristics of the patient populations 11. Neonatal mortality risk → chance of death within neonatal period 12. Neonatal morbidity → can also be anticipated based on birth weight and gestational age

D. Identifying nursing care needs 1. Decreasing physiologically stressful situations

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Constantly observing for subtle signs of change in clinical status 3. Interpreting laboratory data and coordinating interventions 4. Conserving the infant’s energy for healing and growth 5. Providing for developmental stimulation and maintenance of sleep cycles 6. Assisting the family in developing attachment behaviors 7. Involving the family in planning and providing care

II.

Care of the Small-for-Gestational-Age/Intrauterine Growth Restriction Newborn

A. Terminology 1. SGA → less than 10th percentile for birth weight 2. Intrauterine growth restriction (IUGR) → advanced gestation and decreased growth potential for the fetus

B. Factors Contributing to IUGR 1. Maternal factors a) Primiparity, grand multiparity, multiple gestation pregnancy, lack of prenatal care, age extremes, low socioeconomic status b) Nutritional supply in third trimester 2. Maternal disease 3. Environmental factors a) High altitude, exposure to x-rays, excessive exercise, work-related exposure to toxins, hyperthermia, use of teratogenic drugs 4. Placental factors 5. Fetal factors

C. Patterns of IUGR 1. Growth failure early → organs small, weight subnormal 2. Growth failure late → organs normal, size diminished 3. Symmetric (proportional) IUGR → long-term maternal conditions, fetal genetic abnormalities a) Noted by ultrasound in first half of second trimester 4. Asymmetric (disproportional) IUGR → acute compromise of uteroplacental blood flow a) May not be evident before third trimester b) Decrease in growth rate of abdominal circumference 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Particularly at risk for perinatal asphyxia, pulmonary hemorrhage, hypocalcemia, hypoglycemia in newborn period 5. Physiologic maturity develops according to gestational age

D. Common Complications of the SGA or IUGR Newborn 1. Fetal hypoxia a) Little reserve to withstand demands of labor and birth 2. Aspiration syndrome a) Fetus gasps during birth → amniotic fluid into lower airways, meconium 3. Hypothermia a) Diminished subcutaneous fat, depletion of brown fat in utero 4. Hypoglycemia a) Increased metabolic rate in response to heat loss, poor hepatic glycogen stores 5. Polycythemia a) Number of red blood cells increased

E. Factors contributing to poor outcome include: 1. Congenital malformations a) 5% of SGA infants 2. Intrauterine infections a) Rubella, cytomegalovirus (CMV) 3. Continued growth difficulties 4. Cognitive difficulties a) Subsequent learning disabilities

F. Clinical therapy 1. Early recognition, medical management of potential problems

G. Nursing Management or the SGA/IUGR Newborn 1. Nursing Assessment and Diagnosis a) Gestation age b) Identify signs of potential complications c) Symmetric IUGR → in proportion, below normal size (1) Generally vigorous d) Asymmetric IUGR → long, thin, emaciated, loose skin folds, dry, desquamating skin (1) Head appears large because chest, abdominal girth decreased (2) See Figure 30–1: Thirty-one week-gestational age, SGA 2-day-old baby girl, p. 756

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nursing diagnoses include: a) Gas Exchange, Impaired b) Injury, Risk for c) Tissue Perfusion: Peripheral, Ineffective d) Parenting, Risk for Impaired (1) See Nursing Care Plan: For the Small-for-Gestational-Age Newborn, pp. 758–761 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Hypoglycemia (2) Other conditions b) Community-based nursing care (1) Long-term needs (2) Promote positive atmosphere to enhance growth and outcomes 4. Evaluation a) SGA/IUGR newborn free from respiratory compromise b) SGA/IUGR newborn maintains stable temperature c) SGA/IUGR infant free from hypoglycemic episodes and maintains glucose homeostasis d) SGA/IUGR newborn gains weight and takes breast or formula feedings without physiologic distress or fatigue e) Parents verbalize concerns surrounding baby’s health problems and understand rationale behind management of their newborn

III.

Care of the Large-for-Gestational-Age Newborn

A. LGA at or above 90th percentile 1. Best-known condition → maternal diabetes a) 3% to 10% all pregnancies complicated by diabetes b) 60% gestational diabetes; 33% insulin-dependent diabetes c) Directly proportional to high, unstable glucose concentrations d) Multiparous women → two to three times number of LGA infants as primigravidas e) Male infants typically larger than female infants f) Babies with erythroblastosis fetalis, Beckwith-Wiedemann syndrome, transpositions of great vessels usually large 2. Characteristically proportional a) Diabetic mother may have higher body weight b) Tend to be more difficult to arouse c) Problems maintaining quiet, alert state

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Common Complications of the LGA Newborn 1. Birth trauma due to cephalopelvic disproportion (CPD) and macrosomia 2. Hypoglycemia, polycythemia, hyperviscosity

C. Nursing Management for the Large-for-Gestational-Age Newborn 1. Perinatal history in conjunction with ultrasonic measurement of biparietal diameter a) Gestational age testing b) Monitoring vital signs c) Screening d) Address parental concerns 2. Similar to care of infant of diabetic mother

IV.

Care of the Newborn of a Mother with Diabetes A. IDMs → at risk 1. Close observation first few hours of the first few days of life 2. Macrosomic, ruddy in color, excess adipose tissue 3. Decreased total body water 4. Excessive weight due to increased weight of visceral organs, cardiomegaly, increased body fat 5. Caused by exposure to high levels of maternal glucose a) May be obese as children b) See Figure 30–2: Macrosomic newborn of an undiagnosed diabetic mother born at 35 weeks’ gestation weighing 3775 g …, p. 762

B. Common Complications of the Infant of a Diabetic Mother 1. Low glucose concentrations (hypoglycemia) a) Blood sugar less than 40 mg/dl b) IDM continues to produce high levels of insulin c) Deplete infant’s blood glucose within hours after birth d) Signs and symptoms of hypoglycemia 2. Hypocalcemia a) Tremors b) Secondary hypoparathyroidism c) Treatment rarely necessary 3. Hyperbilirubinemia a) 48 to 72 hours after birth

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Birth trauma a) Trauma may occur during labor and vaginal birth 5. Polycythemia a) Fetal hyperglycemia, hyperinsulinism → increased oxygen consumption 6. Respiratory distress syndrome (RDS) a) More frequently in newborns of diabetic mothers who are not well controlled b) Lungs less mature than expected c) RDS not as problematic for infants born to diabetic mothers who have decreased placental perfusion 7. Congenital birth defects

C. Nursing Management for the Infant of a Mother with Diabetes 1. Nursing Assessment and Diagnosis a) IDM will appear older than gestation age scoring b) Assess for signs of respiratory distress, hyperbilirubinemia, birth trauma, congenital anomalies 2. Nursing diagnoses include: a) Nutrition, Imbalanced: Less Than Body Requirements b) Gas Exchange, Impaired c) Tissue Perfusion. Peripheral, Ineffective d) Tissue Integrity, Impaired e) Family Processes, Interrupted 3. Nursing Plan and Implementation a) Ongoing monitoring of: (1) Hypoglycemia (2) Polycythemia (3) Hyperbilirubinemia (4) Birth injuries (5) Congenital malformations b) Parental teaching 4. Evaluation a) Newborn’s respiratory distress and metabolic problems are minimized b) Parents understand the etiology of the baby’s health problems and preventive steps they can initiate to decrease the impact of maternal diabetes on subsequent pregnancies c) Parents verbalize their concerns surrounding their baby’s health problems and understand the rationale behind management of their newborn

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Postterm Newborn A. Any newborn born after 42 weeks’ gestation 1. 6% of all pregnancies 2. Most normal size and health 3. Some keep growing, > 4000g 4. Potential intrapartum problems → CPD, shoulder dystocia

B. Common Complications of the Newborn with Postmaturity Syndrome 1. Truly postmaturity → high risk for morbidity, mortality rate 2 to 3 times that of term infants a) Majority of deaths occur during labor 2. Characteristics of postmaturity syndrome newborn a) Hypoglycemia b) Meconium aspiration in response to in-utero hypoxia c) Oligohydramnios d) Polycythemia e) Congenital anomalies f) Seizures g) Cold stress 3. Long-term effects unclear 4. Combination of placental aging and subsequent insufficiency

C. Clinical therapy 1. Differentiate fetus with postmaturity syndrome from large, well nourished, active fetus 2. Antenatal testing 3. Monitor hypoglycemia 4. SGA → peripheral and central hematocrits 5. Fluid resuscitation, partial exchange transfusion 6. Oxygen for respiratory distress

D. Nursing Management for the Newborn with Postmaturity Syndrome 1. Nursing Assessment and Diagnosis a) Newborn with postmaturity syndrome appears alert b) Dry, cracking, parchment-like skin c) No vernix, lanugo d) Fingernails long 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Meconium staining → yellow to green (green is recent) f) See Figure 30–4: The skin of the postterm infant exhibits deep cracking and peeling of skin, p. 765 2. Nursing diagnoses include: a) Hypothermia b) Nutrition, Imbalanced: Less Than Body Requirements c) Gas Exchange, Impaired d) Tissue Perfusion: Peripheral, Ineffective 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Monitor cardiopulmonary status (2) Provide warmth (3) Frequently monitor blood glucose, initiate early feeding (4) Obtain central hematocrit 4. Evaluation a) Postterm newborn establishes effective respiratory function b) The postmature baby is free of metabolic alterations (hypoglycemia) and maintains a stable temperature

VI.

Care of the Preterm (Premature) Newborn

A. Infant born prior to the start of the 37th week 1. 1 in 10 neonates born in United States 2. Rise in multiple birth rates 3. Variable immaturity of all systems

B. Alteration in Respiratory and Cardiac Physiology 1. Preterm infant unable to produce adequate amounts of surfactant 2. Muscular coat of pulmonary blood vessels is incompletely developed a) Left to right shunting through ductus arteriosus → increases blood flow back into lungs 3. Ductus may remain open → increases blood volume to lungs

C. Alteration in Thermoregulation 1. Five physiology and anatomic factors increase heat loss in preterm newborn a) Higher ratio of body surface to body weight b) Very little subcutaneous fat c) Thinner, more permeable skin d) Gestational age→ amount of flexion of extremities e) Decreased ability to vasoconstrict superficial blood vessels and conserve heat 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. More preterm baby is less able to maintain heat balance 3. Provide neutral thermal environment (NTE)

D. Alteration in Gastrointestinal Physiology 1. Gastrointestinal (GI) immaturity a) Danger of aspiration due to poorly developed gag reflex, incompetent esophageal cardiac sphincter, inadequate suck/swallow/breathe reflex b) Difficulty in meeting high caloric and fluid needs for growth (1) Small gastric capacity c) Limited ability to convert certain essential amino acids to nonessential amino acids d) Inability to handle increased osmolarity of formula protein due to kidney immaturity e) Difficulty absorbing saturated fats due to decreased bile salts and pancreatic lipase f) Difficulty with lactose digestion initially (1) Processes may not be fully functional during the first few days of preterm infant’s life g) Deficiency of calcium, phosphorus → deposited in last trimester (1) Rickets, bone demineralization h) Increased basal metabolic rate, increased oxygen requirements i) Feeding intolerance, necrotizing enterocolitis (1) Diminished blood flow, tissue perfusion to bowel

E. Alteration in Hepatic and Hematologic Physiology 1. Decreased glycogen stores → frequently experiences stress a) High risk for hypoglycemia 2. Iron stored in liver → lower iron stores a) Many require transfusions of packed cells b) Oral iron supplementation c) Erythropoietin 3. Conjugation of bilirubin in liver impaired → bilirubin levels increase more rapidly 4. Normal cord hemoglobin in infant 34 weeks’ gestation → 16.8 g/dl, 80 to 100 mL/kg total blood volume a) Blood loss significant

F. Alteration in Renal Physiology 1. Glomerular filtration rate (GFR) lower → low renal blood flow a) Related to lower gestational age

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Preterm infant’s kidneys limited in ability to concentrate urine, excrete excess amounts of fluid → blunted response to antidiuretic hormone (ADH) 3. Preterm kidneys begin excreting glucose at lower serum glucose level than term infant 4. Kidney’s buffering capacity reduced 5. Immaturity of renal system affects ability to excrete drugs

G. Alteration in Immunologic Physiology 1. Preterm infant increased susceptibility to infections acquired in utero 2. In utero, fetus receives passive immunity from maternal IgG immunoglobulins a) Last trimester → preterm infant has few antibodies 3. IgA → found in breast milk 4. Skin surface easily excoriated → with invasive procedures → risk for nosocomial infections a) Hand-washing technique vital

H. Alteration in Neurologic Physiology 1. Most rapid brain growth and development occurs in third trimester of pregnancy a) Closer to term a baby is born, the better the neurologic prognosis 2. Intraventricular hemorrhage (IVH) a) Hydrocephalus may develop as consequence of IVH

I. Alteration in Reactivity Periods and Behavioral States 1. Preterm periods of reactivity delayed a) Hypotonic, unreactive for several days after birth b) Disorganized in sleep-wake cycles c) Neurological responses weaker

J. Management of Nutrition and Fluid Requirements 1. Early feedings extremely valuable for premature newborn 2. Nutritional requirements a) Uncompromised, healthy preterm infant → 95 to 130 kcal/kg/day b) Fortified breast milk, preterm formula (1) Human donor milk option (2) Feeding protocol based on infant’s weight, estimated stomach capacity c) More protein d) Supplemental multivitamins (1) Vitamins A, D, E, iron, trace minerals (2) Vitamin E e) Considered adequate with consistent weight gain of 20 to 30 g/day 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Methods of feeding a) Bottle feeding (1) Coordinated, rhythmic suck-swallow-breathing pattern → bottle (2) Readiness to feed → engagement and hunger cues (a) Ability to suck (b) Bringing hands to the mouth (c) Being alert (d) Exhibiting fussiness (e) Sucking on fingers or pacifier (f) Exhibiting rooting behavior (g) Showing relaxed facial expression and good tone (3) Observe for tachypnea, decrease in oxygen saturation levels, bradycardia, lethargy, uncoordinated suck and shallow b) Breastfeeding (1) As soon as infant demonstrates (a) Coordinated suck and swallow reflex (b) Showing consistent weight gain (c) Control body temperature outside incubator (2) Allows mother to contribute actively to infant’s well-being (3) Skin-to-skin holding of low-birth-weight (LBW) infants → mothers can significantly increase milk volume (4) Football hold (a) Feeding time may be up to 45 minutes (b) Burp in between breasts (c) Coordinate flexible feeding schedule (5) Pumping (a) Double-pumping system c) Gavage feeding (1) Tube feeding (a) Lack of, or poorly coordinated, suck-swallow-breathing pattern, respiratory compromise, ventilator dependent (b) < 34 weeks’ gestation (2) Intermittent bolus or continuous drip, nasogastric or orogastric (3) Minimal enteral nutrition (MEN) → small-volume feedings of formula, human milk (a) Prime intestinal tract (b) No increased in incidence of necrotizing enterocolitis (c) Fewer days on total parental nutrition (TPN) (d) Increased weight gain and muscle maturation (e) Increased gut peristalsis (f) Increased gut hormone levels (g) Shorter time required to reach full-volume enteral feedings (h) Lower risk of osteopenia (i) Possible decrease in hospital stay (4) See Clinical Skill 30–1: Performing Gavage Feeding, p. 772 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Fluid requirements (1) Based on weight, postnatal age (2) Recommendations for preterm infant weighing 1500 g (a) 60 to 80 mL/kg/day → day 1 (b) 80 to 100 mL/kg/day → day 2 (c) 100 to 160 mLkg/day → day 3 (d) Increased up to 190 mL/kg/day if (i) Very small (ii) Phototherapy (iii) Radiant warmer (3) Daily weights (a) Weights every 6 to 8 hours sometimes if < 1000g (b) Weight loss expected first 5 to 6 days, 15 to 20% of birth weight

K. Common Complications of Preterm Newborns and Their Clinical Management 1. Apnea of prematurity a) Refers to cessation of breathing for 20 seconds or longer b) Etiology multifactorial (1) Neuronal immaturity (2) Obstructive apnea c) Onset often insidious d) Document all episodes of apnea (1) Activity, length, treatment e) Assess quickly f) Interventions (1) Gentle stimulation (2) Respiratory support (3) Pharmacologic intervention (a) Caffeine citrate (4) Conservative management of gastroesophageal reflux 2. Patent ductus arteriosus (PDA) a) Functional closure of ductus arteriosus related to birth weight b) Pulmonary vascular resistance (PVR) falls and systemic vascular resistance (SVR) rises, a left-to-right shunt via the PDA results c) Blood flows from aorta into pulmonary artery, increasing pulmonary blood flow d) Leads to left ventricular volume overload, pulmonary edema, congestive failure e) Oxygenation is compromised, and ventilator requirements will increase, leading to possible difficulty in weaning from ventilator and long-term pulmonary sequelae 3. Early identification with prompt intervention → minimize long-term complications a) Adequate respiratory support b) Restricting fluids c) Diuretics 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Digoxin e) Prostaglandin synthetase inhibitors can cause ductal closure (1) Indomethacin → short course or long course (2) Ibuprofen lysine → short course f) Surgical ligation 4. Respiratory distress syndrome (RDS) a) Results from inadequate surfactant production 5. Intraventricular hemorrhage a) Most common type if intracranial hemorrhage in small preterm infant b) Most common site → periventricular subependymal germinal matrix (1) Before 34 weeks’ gestation & <1500g → tiny vessels fragile (2) Highly susceptible to hypoxic events, respiratory distress, birth trauma, birth asphyxia (3) Germinal matrix vessel ruptures

L. Long-Term Needs and Outcomes 1. Follow-up care important 2. LBW preterm infants face higher mortality rates a) Sudden infant death syndrome (SIDS) b) Respiratory infections c) Neurologic defects 3. Higher morbidity if < 1500g 4. Retinopathy of prematurity (ROP) a) Susceptible to injury of delicate capillaries of retina (1) Ischemia → results in hemorrhage, scarring, retinal detachment, impaired vision, eventual complete blindness b) Multifactorial in origin (1) Hyperoxemia (2) Other factors c) Judicious use of supplemental oxygen therapy d) Treatment (1) Laser photocoagulation, cryotherapy e) Parental support and education for parents of visually impaired infant 5. Bronchopulmonary dysplasia (BPD) a) Long-term lung disease from damage to alveolar epithelium secondary to positive pressure respiratory therapy 6. Speech defects a) Delayed development

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Neurologic defects a) Most common include (1) Cerebral palsy, hydrocephalus, seizure disorders, lower IQ scores, learning disabilities 8. Auditory defects a) 1 to 4% incidence of moderate to profound hearing loss (1) Formal audiologic examination before discharge, 3 to 6 months b) Evoked otoacoustic emissions test (EOAE) c) Automated auditory brain response (AABR) (1) See Figure 30–12: Preterm newborns should have a formal hearing test prior to discharge, p. 776 9. Speech defects a) Delayed development (1) Receptive and expressive ability

M. Nursing Management for the Preterm Newborn 1. Nursing assessment a) Assess physical characteristics, gestational age (1) Color (2) Skin (3) Lanugo (4) Head size (5) Skull (6) Ears (7) Nails (8) Genitals (9) Posture (10) Cry (11) Reflexes (12) Activity b) Gestational age assessment tools 2. Nursing diagnoses a) Gas Exchange, Impaired b) Breathing Pattern, Ineffective c) Tissue Perfusion: Cardiac, Risk for Decreased d) Tissue Perfusion: Peripheral, Ineffective e) Nutrition, Imbalanced: Less Than Body Requirements f) Thermoregulation, Ineffective g) Fluid Volume, Deficient h) Family Processes, Dysfunctional

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing Plan and Implementation a) Maintenance of respiratory function (1) Increased danger of respiratory obstruction (a) Positioning (b) Supine → slightly elevate infant’s head (c) Prone → splints chest wall, decreases amount of respiratory effort (i) Facilitates chest expansion (2) Monitor for signs of respiratory distress (a) Cyanosis → serious sign when generalized (b) Tachypnea → sustained respiratory rate greater than 60/minute after first 4 hours of life (c) Retractions (d) Expiratory grunting (e) Nasal flaring (f) Apneic episodes (g) Presence of crackles or rhonchi on auscultation (h) Diminished air entry (3) Administer oxygen per physician/nurse practitioner order if respiratory distress occurs (4) If hypoxemia not treated (a) May result in PDA, metabolic acidosis (b) Periodic arterial blood gas sampling (5) Consider respiratory function before initiation of feedings b) Maintenance of neutral thermal environment (1) Minimizes oxygen consumption (a) Allow skin-to-skin contact (b) Warm and humidify oxygen (c) Place baby in double-walled incubator (d) Avoid placing baby on cold surfaces (e) Use warmed ambient humidity (f) Keep the skin dry, place cap on the baby’s head (g) Keep radiant warmers, incubators, cribs away from windows, cold external walls (h) Open incubator portholes, doors only when necessary (i) Use a skin probe to monitor baby’s skin temperature (j) Warm formula, stored breast milk before feeding (k) Use reflector patch over skin temperature probe (2) When stable → clothed with double-thickness cap, cotton shirt, diaper, swaddled c) Maintenance of fluid and electrolyte status (1) Hydration based on weight, gestational age, chronologic age, volume of sensible, insensible water loss (2) Assess and record signs of dehydration (3) Assess and record signs of overhydration (a) Excessive weight gain (b) Intake and output 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Infant weighed once daily at same time of day Weigh diapers, 1 ml = 1 g d) Provision of adequate nutrition and prevention of fatigue during feeding (1) Feeding method depends on preterm newborn’s feeding abilities and health status (a) Nipple and gavage methods initially supplemented with IV therapy (b) MEN via gavage (c) Measure abdominal girth, auscultate abdomen (d) Check for residual formula (e) Preterm infants who are ill, fatigue easily → fed by gavage (2) Readiness to feed (a) Gradual nipple-feeding program (3) Monitor weight (4) Nurse involves parents in feeding e) Prevention of infection (1) Minimize preterm newborn’s exposure to pathogenic organisms (a) Strict hand washing, use of separate equipment for each infant (b) Standard precautions, short-trimmed nails (no artificial nails) (c) 2- to 3-minute scrub (d) Nurse may be first to identify subtle clinical signs (i) Apnea, bradycardia (e) Other potential interventions (i) Limiting visitors, requiring visitors to wash their hands, maintaining strict aseptic practices when changing IV tubing and solutions, change incubators and radiant warmers weekly, prevent skin break down f) Promotion of parent–newborn attachment (1) Preterm newborns may be separated from parents for prolonged periods (2) Take measures to promote positive parental feelings toward newborn (3) Early involvement in care and decisions regarding baby provides parents with realistic expectations for baby (a) Daily participation, early, frequent visits (4) Skin-to-skin (kangaroo) care (a) See Figure 30–14: Kangaroo (skin-to-skin) care facilitates a closeness and attachment between mother and her premature newborn, p. 780 (b) Improved oxygenation (c) Enhanced temperature regulation (d) Decline in episodes of apnea and bradycardia (e) Increased periods of quiet sleep (f) Stabilization of vital signs (g) Positive interaction between parent and infant; enhances attachment and bonding (h) Increased growth parameters (i) Early discharge (5) Plan nursing care around times when infant is alert (6) Some parents will progress easily; others will not 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

g) Promotion of developmentally supportive care (1) Prolonged separation and the NICU environment necessitate individualized baby sensory stimulation programs (2) Preterm newborns are not developmentally able to deal with more than one sensory input at a time (3) Prove developmentally and supportive, family-centered care → improved outcomes (4) Noise levels reduced (5) Dimmer switches (6) Blankets over incubators (7) Plan nursing care to decrease number of times disturbed (8) Developmental techniques (a) Containment measures (b) Gentle touch, no sudden postural changes (c) Promote soothing activities (d) Simulate kinesthetic advantages (e) Nonnutritive sucking 4. Preparation for home care a) Parents often anxious when transferred out of NICU, discharged home (1) Instructions include breastfeeding, formula-feeding techniques, formula preparation, medication administration (2) Information on bathing, diapering, hygiene, normal elimination patterns (3) Referrals may be necessary for severe abnormalities, feeding problems, complications (4) Normal growth and development expectations b) Preterm, LBW infants at greater risk of increased morbidity from vaccine-preventable diseases (1) Full doses of: (a) Diphtheria (b) Tetanus (c) Acellular pertussis (d) Haemophilus influenzae type b (Hib) (e) Hepatitis B (f) Inactivated poliovirus (g) Rotavirus (h) Pneumococcal conjugate vaccine (PCV) (i) Influenza at 6 months of age 5. Evaluation a) Preterm newborn is free of respiratory distress and establishes effective respiratory function b) Preterm newborn gains weight and shows no signs of fatigue or aspiration during feedings c) Preterm newborn demonstrates a serial head circumference growth rate of 1 cm per week 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Parents are able to verbalize feelings, show positive attachment behavior such as frequent visits and growing confidence in participatory care activities

VII.

Care of the Newborn with Congenital Anomalies

A. Newborn and family at risk 1. Life threatening or visible and cause emotional distress 2. If one found, look for others 3. See Table 30–4: Congenital Anomalies: Identification and Care in Newborn Period, p. 783– 787

VIII.

Care of the Newborn with Congenital Heart Defect

A. Congenital heart defect (CHD) most common congenital defect B. Overview of Congenital Heart Defects 1. Only 25% identified on prenatal ultrasound 2. Early treatment → identified in first days of life with pulse oximetry a) Post ductal on foot b) Accurate probe placement (1) Light probe emitter directly opposite the light emitter (2) Avoiding placing probes on an extremity with the automatic blood pressure cuff (3) Cleaning and drying skin prior to placement of the probe (4) Covering the probe with an opaque covering 3. Multifactorial cause with no specific trigger a) Environmental or genetic 4. Common defects seen in first 6 days of life a) Left ventricular outflow obstructions (1) Mitral stenosis, aortic stenosis, atresia b) Hypoplastic left heart c) Coarctation of the aorta d) Patent ductus arteriosus (PDA) e) Transposition of the great vessels f) Tetralogy of Fallot g) Large ventricular septal defect h) Atrial septal defects

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Heart murmur d) Congestive heart failure (CHF) e) See Table 30–6: Cardiac Defects of the Early Newborn Period, pp. 789–791 2. Initial repair in newborn becoming more common a) Stabilize → decisions about ongoing needs 3. Careful and complete explanations 4. Emotional support of parents 5. Allow parents to verbalize concern

IX.

Care of the Newborn of a Substance-Abusing Mother A. Infant of a substance-abusing mother (ISAM) → exposed to licit or illicit drugs B. See Table 30–7: Common Drugs of Abuse, p. 792 C. The Newborn with Fetal Alcohol Spectrum Disorders 1. Fetal alcohol syndrome (FAS) a) Leading cause of preventable nongenetic intellectual disability b) FASD now includes all categories of prenatal alcohol exposure (1) Clinical manifestations of FAS (2) Social & family environment (3) Maternal alcohol history (a) Ethanol crosses placenta (b) Characteristics (i) Abnormal structural development and CNS dysfunction (ii) Growth deficiencies (iii) Distinctive facial abnormalities (iv) Associated anomalies

D. Long-term complications for the infant with FAS 1. Delay in oral feeding development a) Persistent vomiting until 6 to 7 months of age b) Difficulty adjusting to solid foods 2. CNS dysfunctions most common and serious a) Increased placidity, hypotonicity, decreased ability to block out repetitive stimuli 3. Impulsivity, cognitive impairment, speech and language abnormalities 4. Thin, underweight children 5. Learning disabilities indicative of CNS involvement a) Severe intellectual disabilities or normal intelligence

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Nursing Management for the Newborn with Fetal Alcohol Spectrum Disorders 1. Nursing assessment a) Abnormal structural development, CNS dysfunction b) Growth deficiencies c) Patience with feeding (1) Breastfeeding not contraindicated, but excessive alcohol intake can lead to infant intoxication d) Symptoms in first week of life (1) Sleeplessness, excessive arousal states, inconsolable crying, abnormal reflexes (2) Hyperactivity (3) Seizures (4) Reinforce positive parenting, parents can get easily frustrated

F. Opiate Dependency 1. Drugs of abuse of opiates include heroin, morphine, codeine, prescription narcotics a) Obstetric complications for the fetus and substance-abusing mother include: (1) Intrauterine asphyxia (2) Intrauterine infection (3) Intrauterine growth restriction (IGR) (4) Low Apgar scores 2. Common complications of the drug-exposed newborn a) Respiratory distress b) Jaundice c) Congenital anomalies and growth restriction d) Behavioral abnormalities e) Withdrawal 3. Long-term effects a) Behavior lability, unable to express strong feelings (1) Poor social interaction skills, cannot habituate, easily overstimulated, difficulty sleeping b) Higher incidence of GI and respiratory illness 4. Clinical therapy a) Complete prenatal care b) Methadone or buprenorphine maintenance c) Newborn treatment (1) Management of complications (2) Serologic tests (3) Urine drug screen (4) Meconium analysis (5) Social service referral (6) Pharmacologic management for withdrawal 21 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(7) Nutritional support

G. Nursing Management for the Substance-Exposed Newborn 1. Nursing Assessment and Diagnosis a) Discovering mother’s last drug intake b) Assessing for congenital malformations, complications related to intrauterine withdrawal c) Identifying signs and symptoms of newborn withdrawal/neonatal abstinence syndrome (1) See Table 30–9: Clinical Manifestations of Newborn Withdrawal, p. 794 (2) Central nervous system signs (3) Cutaneous signs (4) Gastrointestinal signs (5) Autonomic signs d) Neonatal abstinence syndrome (NAS) (1) Systematic scoring for assessing severity (2) Helps guide need for pharmacologic treatment (3) See Table 30–9: Scoring of Neonatal Abstinence Syndrome Signs and Symptoms, p. 795 2. Nursing diagnoses include: a) Infant Behavior: Disorganized b) Breathing Pattern, Ineffective c) Skin Integrity, Impaired d) Parenting, Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Reducing withdrawal symptoms (2) Promote adequate respiration, temperature, nutrition (3) General nursing care measures include: (a) Performing neonatal abstinence scoring per hospital protocol (b) Monitoring temperature for hypothermia (c) Carefully monitoring pulse and respirations every 15 minutes and pulse oximetry until stable (d) Providing small, frequent feedings, especially in the presence of vomiting, regurgitation, and diarrhea (e) Breastfeeding recommended for women who are not using additional drugs or who are in methadone treatment (f) Positioning on the right side-lying or semi-Fowler’s to avoid possible aspirations of vomitus or secretions (g) Monitor weight-gain pattern daily to assess for the need for increased calorie content of formula (h) Administering medications as ordered, such as oral morphine elixir, methadone, and deodorized of tincture of opium. 22 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(i) Monitoring frequency of diarrhea and vomiting and weighing infant every 8 hours during withdrawal (j) Swaddling with hands near mouth to minimize injury and achieve more organized behavioral state (k) Gentle, vertical rocking can be successful in calming an infant who is out of control (l) Protecting face and extremities from excoriation by using mittens and soft sheets or sheepskin (m) Applying protective skin emollient to the groin area with each diaper change (n) Placing newborn in quiet, dimly lighted area of nursery b) Community-based nursing care (1) Parents need to prepare for what to expect (a) NAS infants may be jittery, irritable from 6 days to 8 weeks (b) Higher risk for SIDS with heroin, cocaine, or opiate use (c) Apnea monitoring (d) Demonstrate feeding techniques, comforting measures, how to recognize cues, appropriate parenting responses (e) Available resources (f) Follow-up and ongoing evaluation 4. Evaluation a) Newborn tolerates feedings, gains weight, decreased number of stools b) Parents learn innovative ways to comfort newborn c) Parents able to cope with frustrations, begin to use outside resources

H. Newborns of Mothers Who Are Tobacco Dependent 1. Risks of tobacco to the fetus and newborn a) Preconceptual cigarette smoking decreases fertility b) During pregnancy → associated with spontaneous abortion, placenta previa, abruptio placentae 2. Carbon monoxide binds hemoglobin → decreases oxygen-carrying capacity of blood a) Chronic hypoxia b) Polycythemia/hyperviscosity c) Intrauterine growth restriction (IUGR) d) Prematureinfants e) Neuroteratogen 3. Greatest risks a) IUGR and/or prematurity b) Intrauterine distress c) Neonatal neurobehavioral abnormalities d) Hypertonia or hypotonia, tremors, increased Moro reflex e) Signs of nicotine toxicity (tachycardia, irritability, poor feeding) f) SIDS 23 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Clinical therapy a) Prenatal history → inquiry into tobacco use, exposure b) Cotinine found in fetal blood fluids → correlation between cigarettes smoked and cotinine concentration c) Newborns may be screened with the NICU Network Neurobehavioral Scale (NNNS) to assess their neurologic, behavioral, and stress/abstinence neurobehavioral function d) Hearing impairment risk increased e) Long-term respiratory problems such as asthma, cognitive and receptive language delays that may persist into school age, should be evaluated

Care of the Newborn Exposed to HIV/AIDS A. Preventative strategies have reduced risk of maternal–child transmission 1. 1% to 2% 2. Transmission occurs through placenta, breast milk–contaminated blood 3. Vertical transmission in mothers not receiving antiretroviral therapy → 25% to 40% 4. Universal testing (with notification) of pregnant women

B. Early identification of babies with/at risk essential 1. bDNA polymerase assay and HIV RNA assay a) Positive result with 48 hours suggests utero transmission b) Repeat 14 to 21 days c) Repeat at 1 to 2 months d) Repeat 4 to 6 months

C. Full-term newborns 1. 4 week ZDV/AZT started prophylactically as soon after birth as possible → 6 weeks 2. Confirmed positive HIV → combination antiretroviral therapy 3. Breastfeeding avoided with HIV-positive mother in developed countries

D. Nursing Management for the Newborn Exposed to HIV/AIDS 1. Nursing Assessment and Diagnosis a) Many newborns exposed to HIV/AIDS premature, SGA, both (1) May show signs, symptoms within days of birth (a) Enlarged spleen and liver, swollen glands, recurrent respiratory infections, rhinorrhea, interstitial pneumonia (rarely seen in adults), recurrent GI (diarrhea and weight loss) and urinary system infections, persistent or recurrent oral candidiasis infections, loss of achieved developmental milestones (2) High risk of acquiring Pneumocystis jirovecii pneumonia

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nursing diagnoses a) Nutrition, Imbalanced: Less Than Body Requirements b) Skin Integrity, Impaired c) Infection, Risk for d) Mobility: Physical, Impaired e) Development: Delayed, Risk for f) Parenting, Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Normal care given to newborns (2) Plus use standard precautions for bloodborne pathogens (3) See Table 30–10: Issues for Caregivers of Newborns at Risk for HIV/AIDS, p. 800 b) Community-based nursing care (1) Hand hygiene (a) Parent teaching (2) Nutrition essential (3) Baby has own skin care items (a) Wash separate linens soiled with blood or body fluids (4) Diaper changing area separate from food prep and serving areas (5) Parent teaching signs of infection, disease transmission c) Regular clinical, immunologic, virologic monitoring 4. Evaluation a) Parents are able to bond with their infant and have realistic expectations about the baby b) Potential opportunistic infections are identified early and treated promptly c) Parents verbalize their concerns surrounding their baby’s existing and potential health problems and accept outside assistance as needed

XI.

Care of the Newborn with an Inborn Error of Metabolism

A. Inborn errors of metabolism (IEM) are hereditary disorders transmitted by mutant genes 1. Enzyme defect → blocks a metabolic pathway → accumulation of toxic metabolites 2. Newborn screening a) Phenylketonuria, congenital hypothyroidism, sickle cell disease, congenital adrenal hypoplasia, s-beta thalassemia, and galactosemia required in all states b) Mandatory newborn screening for other inborn errors of metabolism varies among states and often includes maple syrup urine disease (MSUD), homocystinuria, and cystic fibrosis (CF).

B. Selected Inborn Errors of Metabolism 1. Phenylketonuria (PKU) most common of amino acid disorders a) Phenylalanine essential amino acid → converted into tyrosine 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) PKU → lacks converting ability → accumulate in blood and brain tissue → progressive intellectual disability c) Guthrie blood test for PKU (1) See Figure 30–18: Guthrie card for newborn testing, p. 801 (2) Done at least 24 hours after initiation of feedings 2. Congenital hypothyroidism (CH) a) Elevated thyroid-stimulating hormone (TSH), low T4 → premature infant

C. Clinical therapy 1. Screening and early clinical intervention a) Early discharge can make a challenge b) False positives

D. Nursing Management for the Newborn with an Inborn Error of Metabolism 1. Nursing Plan and Implementation a) Newborn with phenylketonuria (1) Normal appearing newborn → blond hair, blue eyes, fair complexion (2) Fails to thrive → vomiting, eczematous rashes (3) By 6 months → intellectual disability, other CNS involvement b) PKU infant treated with special diet limits ingestion of phenylalanine (1) Food lists (2) Special formula (3) If treatment is begun before 1 month of age, CNS damage can be minimized c) Newborn with congenital hypothyroidism (1) Recognizable features at birth (a) Large tongue (b) Umbilical hernia (c) Cool and mottled skin (d) Low hairline (e) Hypotonia (f) Large fontanelles (g) Prolonged newborn jaundice, poor feeding, constipation, low-pitched cry, poor weight gain, inactivity, early sleeping through the night, delayed motor development (h) < 30 weeks’ gestation→ lower T4 and TSH values than term babies (2) Managed (a) Adjustment of thyroid medication to accommodate growth and development (b) Laboratory monitoring

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Evaluation 1. Risk of inborn errors of metabolism promptly identified, early intervention initiated 2. Parents verbalize concerns about baby’s nutritional status, health problems, long-term care needs, and potential outcomes 3. Parents are aware of available community health resources and use them as indicated

XII.

Focus Your Study

XIII.

Activities 1. Individual Have each student prepare drug cards on the following medications specific to newborns at risk: • Caffeine citrate • Phenobarbital • Vitamin K • Iron supplementation • Erythropoietin • Diphtheria • Tetanus • Acellular pertussis • Haemophilus influenzae type b (Hib) • Hepatitis B • Inactivated poliovirus • Rotavirus • Pneumococcal conjugate vaccine 2. Small Group Divide the class in to small groups of three to five students. Have the groups prepare a teaching plan for parents of a preterm newborn. Each group will present one of the following areas: • Respiratory distress syndrome (RDS) • Patent ductus arteriosus (PDA) • Hypothermia and cold stress • Necrotizing enterocarditis (NEC) and feeding difficulties • Chronic lung disease • Sensorineural hearing loss • Neurologic sequelae 3. Large Group Present and review the following video (4 minutes 44 seconds) on premature triplets. Have students assess the characteristics presented. Consider presenting the video without audio: http://www.youtube.com/watch?v=Q6jEKv0Kp_w

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 31 The Newborn at Risk: Birth-Related Stressors Care of the Newborn at Risk Due to Asphyxia......................................................

Care of the Newborn with Respiratory Distress...................................................

Care of the Newborn with Meconium Aspiration Syndrome...............................

Care of the Newborn with Complications Due to Respiratory Therapy............. .

Care of the Newborn with Cold Stress..................................................................

Care of the Newborn with Hypoglycemia.............................................................

Care of the Newborn with Jaundice......................................................................

Care of the Newborn with Anemia.......................................................................

Care of the Newborn with Infection.....................................................................

Care of the Family with Birth of an At-Risk Newborn...........................................

Considerations for the Nurse Who Works with At-Risk Newborns……………………

Focus Your Study...................................................................................................

Activities................................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Newborn at Risk Due to Asphyxia

A. Neonatal asphyxia → deprivation of oxygen to the baby’s brain and organs during the birth process B. Incidence increases as gestational age decreases 1. Results from several factors 2. Circulatory → inability to transition to extrauterine circulation 3. Respiratory → failure of lung expansion 4. Biochemical → hypoxemia, metabolic acidosis, hypercapnia → cause a) Pulmonary vasoconstriction, high pulmonary vascular resistance b) Hypoperfusion of the lungs → failure to achieve FRC c) Large right-to-left shunt in heart (1) Right atrial pressure > left atrial pressure → foramen ovale reopens d) Change from aerobic to anaerobic metabolism (1) Buildup of lactate (2) Metabolic acidosis (3) Respiratory acidosis (4) Glycogen stores mobilized 5. Protective mechanisms a) Relatively immature brain b) Resting metabolic rate lower than that observed in the adult c) Ability to mobilize substances within the body for anaerobic metabolism and to use energy more efficiently d) Intact circulatory system able to redistribute lactate and hydrogen ions in tissues still being perfused

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Severe prolonged hypoxia will overcome protective mechanisms

C. Risk factors Predisposing to Asphyxia 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Impairment of maternal oxygenation 3. Alteration of blood flow through placenta or cord 4. Significant intrapartum bleeding 5. Difficult birth, prolonged labor 6. Pregnancy-induced hypertension or preeclampsia 7. Difficult birth, prolonged labor, malposition, PROM 8. Narcotic use in labor 9. History of meconium in amniotic fluid 10. Prematurity 11. Male newborn 12. Intrauterine growth restriction (IUGR) 13. Small for gestational age (SGA) 14. Large for gestational age (LGA) or macrosomia 15. Multiples 16. Structural lung abnormality/oligohydramnios 17. Congenital heart disease 18. Maternal fever 19. Anemia: Isoimmunization, intrapartum hemorrhage, maternal viral illness 20. Not always apparent 21. Antenatal neuroprotection

D. Clinical therapy 1. Fetal biophysical assessment a) Monitoring of fetal pH b) Fetal acidosis via three factors (1) Excess CO2 (2) Lactic, uric or keto acids (3) Both carbonic and noncarbonic acids 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Fetal heart rates (FHRs) d) Fetal oximetry 2. Assess newborn’s need for resuscitation a) Color b) Heart rate c) Respirations d) Cry e) Apgar score (1) Score < 7 at 5 minutes requires additional scores every 5 minutes for 20 minutes 3. Resuscitative efforts a) 10% all newborns to begin breathing → 3% require positive pressure ventilation → < 1% requiring more b) Identification of newborns who do not require resuscitation rapid assessment (1) What is the gestational age? (2) Is amniotic fluid clear of meconium, evidence of infection? (3) How many babies are expected? (4) Are there any other risks? c) Questions following birth (1) Is the baby full term? (2) Is the baby breathing and crying? (3) Does the baby have good muscle tone? d) If all yes → no resuscitation e) If any answer no → resuscitative assistance (1) Initial steps in stabilization (a) Warming, positioning, clearing the airway as necessary, drying, stimulating, and repositioning (2) Oxygen administration while monitoring pulse oximetry (3) Positive pressure ventilation/intubation (4) Chest compressions (5) Administration of epinephrine, volume expansion, or both (6) Neonatal therapeutic hypothermia (7) Newborn blood gas to follow up cord gas values and response to resuscitation efforts

E. Resuscitation Management 1. Suctioning a) Head-down sniffing position → avoid aspiration b) Establish patent airway 2. Level position under preheated radiant heat source, dries baby a) Stable baby → mother’s chest, abdomen b) Extremely preterm newborn → temperature of the delivery room be raised to 23° to 25°C (74° to 77°F), plastic wrap, bag to prevent evaporative heat loss 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Heat loss through evaporation tremendous first few minutes of life 3. Ventilation established a) Simple to complex progression of interventions b) Position and clear airway, simple stimulation c) Positive pressure if respiration not initiated, inadequate (1) Sniffing position (2) Mask positioned securely on face (3) Avoid hyperextension (a) See Figure 31–1: Demonstration of resuscitation of a newborn with flow inflating/anesthesia bag and mask .., p. 808 d) Devices used (1) Self-inflating bag (2) Flow inflating/anesthesia bag (3) T-Piece resuscitator e) Chest movement observed for proper ventilation (1) Air entry, heart rate checked by auscultation (2) Ventilation adequate → chest moves symmetrically f) Endotracheal intubation may be needed (1) See Figure 31–2: Endotracheal intubation is accomplished with the newborn’s head in the “sniffing position …, p. 809 4. Heart rate absent or < 60 beats per minute after 30 seconds of 100% oxygenation given via effective PPV → external cardiac massage a) Positioned on firm surface b) Resuscitator stands at foot or head of infant (1) Both thumbs over lower third of sternum, hands wrapped around newborn to support back (2) Two fingers instead of thumbs (3) Sternum depressed sufficiently to generate palpable pulse (4) Rate of 90 beats per minute (5) Ratio of 3:1 heartbeat/assisted ventilation (a) 90:30 (6) See Figure 31–3: External cardiac massage …, p. 810 5. Available drugs a) Oxygen b) Epinephrine → 0.1 to 0.3 mL/kg of 1:10,000 solution (0.1 mg/mL) (1) IV → umbilical vein (2) Endotracheal → higher dose c) Naloxone hydrochloride → not recommended d) Volume expanders for shock (1) Normal saline → 10 mL/kg via umbilical vein (2) Known fetal hemorrhage → packed red blood cells

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Neonatal therapeutic hypothermia (therapeutic cooling) a) Standard of care in the newborn with asphyxia → decrease injury to the brain during reperfusion (1) Decrease cell death, improve long-term outcomes (2) Cooling blanket (3) Criteria (a) 5-minute Apgar < 5 (b) Cord pH or newborn pH 7.0, base deficit > -15 (c) Abnormal neurologic exam (d) Initiate within 6 hours of delivery

F. Nursing Management for the Newborn Needing Resuscitation 1. Nursing Assessment and Diagnosis a) Identification of newborns who may be in need of resuscitation b) Ongoing monitoring as labor progresses c) Assisting with fetal scalp blood sampling d) Observing for presence of meconium e) Alert interdisciplinary resuscitation team 2. Nursing diagnoses include: a) Breathing Pattern, Ineffective b) Cardiac Output, Decreased c) Coping: Family, Compromised 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Identification of possible high-risk situations (2) Effective resuscitation (a) Check and maintain equipment before emergency (b) Systematic check each shift (3) Dry newborn quickly with warmed towels, blankets, place hat on infant (4) Under radiant warmer (5) Neonatal Resuscitation Program (NRP) certification b) Supporting parents (1) Procedure may be distressing to parents who are present (2) Support person for parents 4. Evaluation a) Newborn requiring resuscitation is promptly identified, intervention started early b) Newborn’s metabolic and physiologic processes stabilized, recovery proceeds without complications c) Parents can verbalize reason for resuscitation, and what was done to resuscitate their newborn d) Parents can verbalize fears about resuscitation process and potential implications for their baby’s future 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

II.

Care of the Newborn with Respiratory Distress

A. Respiratory distress syndrome (RDS) 1. Former name was hyaline membrane disease (HMD)→ primary absence, deficiency, alteration in production of pulmonary surfactant a) “Golden hour” b) Higher in newborns exposed to infection and without antenatal steroids 2. Factors associated with development of RDS a) Prematurity b) Surfactant deficiency disease 3. Development of RDS indicates failures to synthesize adequate surfactant a) Instability of alveoli b) See Figure 31–4: Cycle of events of RDS leading to eventual respiratory failure, p. 813 c) Increasing amounts of energy to reopen collapsed alveoli d) Lung compliance decreases e) Physiologic alterations of RDS produce (1) Hypoxia (2) Respiratory acidosis (3) Metabolic acidosis f) Radiologic picture of RDS → diffuse bilateral reticulogranular density (1) See Figure 31–5: RDS chest x-ray …, p. 814 4. Clinical therapy a) Prenatal (1) Prevent preterm birth (2) Antenatal steroids b) Postnatal (1) Surfactant replacement therapy → delivered via endotracheal tube or continuous positive airway pressure (CPAP) (a) Low birthweight, >30 weeks’ gestation (2) Supportive medical management (a) Establishing PEEP to transition to FRC (b) Ventilatory therapy (c) Blood gas monitoring (d) Pulse oximetry monitoring (e) Correction of acid–base imbalance (f) Environmental temperature regulation (g) Adequate nutrition (h) Protection from infection (3) Mild → increased humidified oxygen (a) CPAP (b) Heated high-flow O2 via nasal cannula (4) Ventilator 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Pressure control mode (b) See Figure 31–6: One-day-old …, p. 814 (5) High-frequency ventilation (HFV) (a) When ventilator not successful 5. Nursing Management for the Newborn with Respiratory Distress Syndrome a) Nursing Assessment and Diagnosis (1) Characteristics of RDS (a) See Table 31–2: Clinical Assessments Associated with Respiratory Distress, p. 815 (b) Skin color (c) Respiratory (i) Increasing cyanosis (ii) Tachypnea (iii) Apnea (d) Chest (i) Grunting respirations (ii) Nasal flaring (iii) Significant retractions (e) Cardiovascular (i) Systolic murmur (ii) PMI 4th or 5th intercostal space (f) Hypothermia (g) Muscle tone (2) Silverman-Anderson index b) Nursing interventions (1) Per institutional protocol (2) Noninvasive oxygen monitoring (3) Ventilatory assistance (4) NICU

B. Transient Tachypnea of the Newborn 1. Progressive respiratory distress that resembles RDS a) Due to maternal diabetes and asthma, male sex of fetus, macrosomia, cesarean-section delivery b) Typically < 40% oxygen relieves hypoxia c) Fails to clear lung mucus and other debris from airways d) Mild respiratory at first → grunting, nasal flaring, retractions, desaturation, mild cyanosis on room air e) Tachypnea at 6 hours, respirations > 60 breaths/minute f) Improve within 12 to 24 hours, up to 48 to 72 hours 2. Clinical therapy a) Initial x-ray may be identical to RDS (1) But will also have generalized overexpansion of the lungs (hyperaeration of alveoli) 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Dense streaking b) Ambient oxygen concentrations of 30 to 50% c) IV fluids during acute phase 3. Hypoxemia is severe and tachypnea continues → persistent pulmonary hypertension of the newborn (PPHN) a) See Nursing Care Plan: For the Newborn with Respiratory Distress Syndrome, pp. 819– 821

C. Persistent Pulmonary Hypertension of the Newborn 1. PPHN → serious disorder, 1–2:1000 live newborns 2. Failure to transition mediators from iNO to O2 → cycle of pulmonary constriction starts → right to left shunting in heart → blood bypasses lungs and fails to get oxygenated 3. Clinical therapy a) Diagnosis → assessment, ECG b) Perinatal asphyxia precursor c) Goal to lower pulmonary vascular resistance (1) Excellent ventilation (2) Elevated oxygenation (3) 20ppm of iNO (4) Volume expanders (5) Drug therapy-analgesics, sedatives, vasopressors, hydrocortisone, afterload reducters 4. Nursing Management for the Newborn with Persistent Pulmonary Hypertension a) Assess for signs in first hours of life b) Fail to respond to therapies c) Critically ill, NICU

III.

Care of the Newborn with Meconium Aspiration Syndrome

A. Body’s physiologic response to asphyxia/hypoxia → increased intestinal peristalsis, relaxation of anal sphincter 1. Meconium indicates asphyxia 2. 10 to 15% live-born, late-preterm, term infants → born through meconium-stained amniotic fluid (MSAF) a) 4 to 5% will develop meconium aspiration syndrome (MAS) 3. Presence of meconium in lungs produces: a) Mechanical obstruction of airways → air allowed in but not exhaled b) Chemical pneumonitis leading to possible development of secondary bacterial pneumonias c) Inactivation of natural surfactant 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Clinical Manifestations of MAS 1. Fetal hypoxia in utero a few days, few minutes before birth 2. Presence of signs of distress at birth a) Pallor, cyanosis, apnea, slow heartbeat, low Apgar (<6) 3. After initial resuscitation → severity of clinical symptoms correlates with extent of aspiration a) Overexpansion of lungs, barrel shape chest b) Diminished air movement c) Displaced liver d) Yellowish/pale green staining of skin, nails, umbilical cord e) MAS chest x-ray → asymmetric, coarse, patchy densities/infiltrates 4. Biochemical alterations a) Metabolic acidosis b) Respiratory acidosis c) Hypoxia d) If meconium pH 7.0–7.2 → chemical pnuemonitis e) Bile acids inactivates natural surfactant f) Hypoxia → cardiopulmonary shunting → PPHN 5. Clinical therapy a) Prevention management b) Vigorous infant with meconium stained amniotic fluid → no special action c) Absent, depressed respirations, heart rate (HR) < 100, poor muscle tone → direct tracheal suctioning by specially trained personnel d) Further resuscitative efforts as indicated e) Transfer to nursery (1) Neutral thermal environment (2) Umbilical arterial line (3) Umbilical venous catheter f) Treatment (1) Oxygen (2) Low positive end-expiratory pressure (PEEP) (3) Providing exogenous surfactant (4) Dopamine, dobutamine (5) High-frequency ventilation, nitric oxide therapy, extracorporeal membrane oxygenation (ECMO) (6) Chest physiotherapy (7) Prophylactic antibiotics (8) Continuous infusion of sodium bicarbonate

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Nursing Management for the Newborn with Meconium Aspiration Syndrome 1. Nursing Assessment and Diagnosis a) Intrapartum → signs of fetal hypoxia, meconium staining b) Birth → signs of distress c) Ongoing assessment → signs of complications 2. Nursing diagnoses include: a) Gas Exchange, Impaired b) Nutrition, Imbalanced: Less Than Body Requirements c) Coping: Family, Compromised 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Early identification (2) Maintaining adequate oxygenation, ventilation (3) Regulating temperature (4) Glucose testing, hypoglycemia (5) Calculating necessary fluids (a) May restrict in first 48 to 72 hours (6) Providing caloric requirements possibly with TPN (7) Monitoring IV antibiotic therapy 4. Evaluation a) Newborn at risk of MAS promptly identified, early intervention initiated b) Newborn is free of respiratory distress and metabolic alterations c) Parents verbalize their concerns about their baby’s health problem and survival and understand the rationale behind management of their newborn

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Care of the Newborn with Complications Due to Respiratory Therapy A. Oxygen, mechanical ventilation can have harmful effects 1. Ventilator-associated lung injury (VALI) 2. Barotrauma, volutrauma

B. Pulmonary Interstitial Emphysema 1. PIE → accumulation of air in lung tissues 2. Air collects outside lung 3. As air collects → blood vessels constricted → blood gas exchange impaired 4. May precede pneumothorax, pneumopericardium, air embolism, pneumomediastinum

C. Pneumothorax 1. Accumulation of air in thoracic cavity a) Between the parietal and visceral pleura b) Precedes collapse of lung 2. In newborn causes several challenges a) Collapse of the lung b) Compression of heart and lungs c) Compromise of venous return to right heart with mediastinal air d) Development of pleural space 3. Symptoms a) Sudden, unexplained deterioration in newborn’s condition b) Decreased breath sounds c) Apnea d) Bradycardia e) Tachypnea f) Nasal flaring g) Grunting h) Palpable liver or spleen i) Cyanosis j) Increased oxygen requirements k) Higher PCO2 l) Decreased pH m) Mottled, asymmetric chest expansion n) Decreased arterial blood pressure o) Mottled asymmetric chest expansion p) Decreased arterial blood pressure q) Shocklike appearance 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

r) Shift of apical cardiac impulses 4. Transillumination of chest for rapid evaluation 5. X-ray a) See Figure 31–9: Chest x-ray of a left-sided pneumothorax .., p. 824 6. Potentially life threatening a) Removal of accumulated air → thoracentesis

D. Bronchopulmonary Dysplasia/Chronic Lung Disease 1. BPD → chronic lung disease of prematurity (CLD) a) Oxygen therapy → causes injury 2. Definition of BPD → dependence on oxygen at or longer to 28 days of age following mechanical ventilation with subsequent x-ray changes and dependence on supplemental oxygen longer than 36 weeks’ corrected gestational age 3. Clinical therapy a) Therapeutic interventions (1) Oxygen levels adjusted to keep saturation at a percentage between the low and mid-90s (2) Diuretics and fluid restrictions (3) Electrolyte supplementation (4) Bronchodilators (5) Long-term steroids (6) Serial echocardiography to monitor cardiac response

E. Nursing Management for the Newborn with Complications Due to Respiratory Therapy 1. Hospital-Based Nursing Care a) Observe for changes in oxygenation b) Blood gases based on chronic blood gas protocol c) Maintain body temperature d) Bronchodilators e) Diuretics f) Steroids g) Electrolyte supplements h) Nutrition i) Monitor for infection (1) Keep visitors with early signs of infection away (2) Help family coping 2. Health promotion education a) Family becomes aware of implications of chronic illness and prolonged hospitalization (1) Involve them in plan of care 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Demonstrate ability to provide all care for their child (1) Feeding (2) Adjusting oxygen, oxygen saturation monitoring, suctioning, airway management, CPT, bathing, giving medications (3) When to call home health nurse, care provider (4) How to assess infant’s respiratory condition

Care of the Newborn with Cold Stress A. Excessive heat loss resulting in use of compensatory mechanisms to maintain core body temperature 1. Major source of heat production in nonshivering thermogenesis (NST) → brown fat metabolism 2. Ability of infant to respond to cold stress impaired a) Hypoxemia b) Intracranial hemorrhage or any central nervous system abnormality c) Hypoglycemia 3. Monitor temperature more closely a) Neutral thermal environment conscientiously maintained b) See Figure 31–11: Cold stress chain of events .., p. 826 4. Consequences of cold stress can be devastating and potentially fatal

B. Nursing Management for the Newborn with Cold Stress 1. Prevention of hypothermia is critical in very-low-birth-weight and ELBW newborns 2. Observe for signs of cold stress a) Increased movements and respirations, decreased skin temperature and peripheral perfusion, development of hypoglycemia, development of metabolic acidosis 3. Decrease in rectal temperature means long-standing cold stress 4. Determine if hypoglycemic 5. Hypothermia → nursing interventions include: a) Maintain neutral thermal environment (NTE) b) Warm the newborn slowly c) Increase air temperature in hourly increments of 1°C until infant’s temperature stable d) Monitor skin temperature every 15 to 30 minutes e) Remove plastic wrap, caps, heat shields while rewarming f) Warm IV fluids before infusion g) Initiate efforts to block heat loss by evaporation radiation, convection, conduction (1) Maintain newborn in NTE h) Assess for presence of anaerobic metabolism 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

i) Initiate interventions for resulting metabolic acidosis

VI.

Care of the Newborn with Hypoglycemia

A. Low blood sugar 1. Plasma glucose concentration < 45 to 47 mg/dl a) Values <20 to 25 mg/dL treated with parenteral glucose D10W → raise >45 mg/dl 2. Most at risk a) Symptomatic newborn b) Newborns of mothers with diabetes c) LGA newborn d) SGA or IUGR newborns e) Neonates with perinatal stress f) Preterm → not in utero for sufficient time to store glycogen and fat g) Infants of White’s classes A through C, type 1 diabetic mothers → increased stores of glycogen and fat h) Infants with recurrent episodes of hypoglycemia have long-term neurologic deficits i) SGA infant used up glycogen, fat stores j) Newborn stressed at birth → asphyxia, cold → uses up available glucose stores

B. Clinical therapy 1. Identification → symptoms may include: a) Lethargy, sleepiness, limpness b) Poor feeding, poor/inadequate sucking reflex, vomiting c) Hypothermia or temperature instability d) Pallor, cyanosis e) Apnea, irregular respirations, respiratory distress, cyanosis, tachypnea f) Hypotonia, possible loss of swallowing reflex g) Tremors, jerkiness, seizure activity, irritability, eye rolling h) High-pitched cry i) Exaggerated Moro reflex j) Temperature instability 2. Aggressive treatment recommended after single low blood glucose level a) Glucose oxidase reagent strip with reflectance meter below 40 mg/dl b) See Clinical Skill 31–1: Performing a Heelstick on a Newborn, pp. 829–830 c) Must confirm with laboratory determination (1) Venous blood glucose concentrations are approximately 15% to 19% lower than arterial blood glucose d) Adequate caloric intake → early feeding → likely to remain above hypoglycemic level e) IV infusions of a dextrose solution begun immediately after birth → prevent hypoglycemia (1) May cause hyperglycemia 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Nursing Management for the Newborn with Hypoglycemia 1. Nursing Assessment and Diagnosis a) Identify and screen infants (1) Glucose strips, urine dipsticks, urine volume 2. Nursing diagnoses include: a) Nutrition, Imbalanced: Less Than Body Requirements b) Breathing Pattern, Ineffective c) Pain, Acute d) Coping: Family, Compromised e) Parenting, Risk for Impaired 3. Nursing Plan and Implementation a) Monitor all at-risk groups within 30 to 60 minutes after birth b) Method of feeding influences glucose and energy requirements (1) Monitoring during transition from IV to oral feedings c) Complementary health approaches (1) Assist infants to cope with, recover from, painful clinical procedures (2) Avoid unnecessary stimuli as possible (3) Containment with swaddling, facilitated tucking (4) Nonnutritive sucking → thought to produce analgesia through stimulation of orotactile and mechanoreceptors (5) Wide range of oral sucrose used for procedural pain relief → calming effect

VII.

Care of the Newborn with Jaundice

A. Most common abnormal physical finding → icterus neonatorum 1. 80% healthy newborns 2. Total bilirubin levels > 6–9 mg/dL 3. Jaundice → yellowish coloration of skin, sclera that develops from deposit of bilirubin in lipid/fat-containing tissues a) Infant must conjugate bilirubin → rate depends on rate of hemolysis, bilirubin load, maturity of liver, presence of albumin-binding sites 4. Pathologic jaundice a) Newborns who exhibit jaundice within first 24 hours of life b) Total serum bilirubin concentration increase > 0.2 mg/dl/hour c) Surpass 95th percentile on nomogram for age in hours d) Persistent visible jaundice after 1 week of age in term infants, 2 weeks in preterm

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Physiologic Jaundice 1. Normal process that occurs during transition from intra- to extrauterine life, appears after 24 hours of life 2. Differs between breast- and bottle-fed newborns

C. Pathophysiology of Hyperbilirubinemia 1. Serum albumin-binding sites usually able to conjugate enough bilirubin a) Conditions that decrease number or quality of binding sites (1) Asphyxia (2) Neonatal drugs (3) Acidosis (4) Hypothermia (5) Hypoglycemia (6) Maternal use of sulfa drugs and salicylates (7) Less albumin 2. Bilirubin not bound crosses blood-brain barrier a) Kernicterus or acute bilirubin encephalopathy b) Can cause permanent neurologic sequelae 3. Screen all newborns

D. Causes of Hyperbilirubinemia 1. Hemolytic disease of the newborn a) Alloimmune hemolytic disease → erythroblastosis fetalis (1) Rh-negative mother pregnant with Rh-positive fetus → maternal antibodies cross placenta b) Hydrops fetalis → maternal antibodies attach to Rh site on fetal red blood cells (RBCs) (1) Severe anemia, multiple organ system failure result (2) Severe generalized massive edema develops 2. ABO incompatibility → may result in jaundice, rarely severe 3. Predisposing maternal conditions 4. Prognosis depends on extent of hemolytic process, underlying cause a) May lead to kernicterus if not aggressively treated (1) Exchange transfusion required (a) Poor tone, lethargy, feeding/sucking issues 5. Clinical therapy a) Prevention b) Laboratory and diagnostic assessments (1) Maternal and neonatal blood types tested (2) Coombs test 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Serum bilirubin levels (4) Hemoglobin (5) Reticulocyte percentage (6) White cell count (7) Positive smear for cellular morphology c) Neonatal hyperbilirubinemia considered pathologic if: (1) Clinically evident jaundice appearing before 24 hours of life or if jaundice seems excessive for the newborn’s age in hours (2) Serum bilirubin concentration rising by more than 0.2 mg/dl per hour (3) Symptoms of primary illness (4) Conjugated bilirubin concentrations greater than 2 mg/dl or more than 20% of the total serum bilirubin concentration (5) Clinical jaundice persisting for more than 8 days in a term newborn and 14 days in premature newborn d) Transcutaneous bilirubin (TcB) measurements are noninvasive method of assessing bilirubin levels and may be used for predischarge risk assessment (1) See Figure 31–14: A newborn being screened with a transcutaneous bilirubinometer, p. 833 e) Coombs test determines whether jaundice is due to Rh or ABO compatibility f) Rh sensitization (1) Rh-positive newborn with positive Coombs test (2) Increased erythropoiesis with many immature circulating RBCs (3) Anemia (4) Elevated levels of bilirubin in cord blood (5) Reduction in albumin binding capacity g) ABO incompatibility (1) Increase in reticulocytes (2) Indirect Coombs strongly positive h) Prevention i) Any cause → management similar (1) Alleviate anemia, remove maternal antibodies and erythrocytes, reduce serum bilirubin levels, minimize consequences of hyperbilirubinemia (2) Phototherapy, exchange transfusion, drug therapy (3) If newborn has hemolysis, unconjugated bilirubin level of 14 mg/dl, weighs less than 2500 g, less than 24 hours old → exchange transfusion may be best (4) Over 24 hours old → phototherapy j) Phototherapy (1) Exposure of newborn to high-intensity light → photoisomerization (a) Alone or with exchange transfusion (b) Changes bilirubin from non-water soluble to water soluble (c) Excreted in urine and bile (2) Used for prevention of hyperbilirubinemia (3) Halogen light source, phototherapy lights, fiber-optic blanket LEDs, or combination (a) Blanket → light on at all times, infant accessible 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Used with standard light source → intensive phototherapy (4) Nurse tracks hours each lamp used (5) See Clinical Skill 31–2: Newborn Receiving Phototherapy, pp. 834–835 k) Exchange transfusion (1) Withdrawal and replacement of newborn’s blood with donor blood (2) Monitor total serum bilirubin (TSB) (3) Type and cross-match (4) Use modified whole blood → red cells and plasma

E. Nursing Management for the Newborn with Jaundice 1. Nursing Assessment and Diagnosis a) Identify prenatal, perinatal factors that predispose b) Often due to multitude of causes including genetic basis c) Note behavior, evidence of bleeding (1) Suspect hemolytic disease if (a) Placenta is enlarged (b) Newborn is edematous, with pleural and pericardial effusion plus ascites. (c) Pallor or jaundice is noted during the first 24 to 36 hours. (d) Hemolytic anemia is diagnosed (e) Spleen and liver are enlarged. d) Visual inspection (1) Blanch skin over bony prominence → yellow before normal color returns (a) Conjunctival sacs in darker skinned baby (b) Progresses cephalocaudal 2. Nursing diagnoses include: a) Fluid Volume: Risk for Deficient b) Injury, Risk for c) Neurovascular Dysfunction: Peripheral, Risk for d) Parenting, Risk for Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Phototherapy success measured every 12 hours, or daily (a) Turn off lights when drawing blood (2) Eye patches over newborn’s closed eyes (a) Assess eyes for conjunctivitis at least one shift (b) Removed for feeding (3) Photometer to measure, maintain desired irradiance levels (4) Parents need explanations repeated, clarified (5) Education if rooming in (a) Keep baby in the room 24 hours a day (b) Take emergency action if necessary (c) Complete instruction checklists 19 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(d) Sign a consent b) Community-based nursing care (1) Early discharge → increase hospital readmission (2) Home therapy only if nomogram indicates optional phototherapy (3) Generates feelings of guilt, fear (4) Reassurance and support (5) Cultural beliefs (a) Interpret illness within cultural framework (6) Education to record temperature, weight, fluid intake and output, stools, feedings, use of equipment (7) Lights versus blanket (8) Ongoing monitoring of bilirubin levels c) See Nursing Care Plan: For the Newborn with Hyperbilirubinemia, pp. 837–839 4. Evaluation a) Newborns at risk for development of hyperbilirubinemia identified, action taken to minimize potential impact of hyperbilirubinemia b) Newborn will not have any corneal irritation or drainage, skin breakdown, or major fluctuations in temperature c) Parents understand rationale for, goal of, and expected outcome of therapy d) Parents verbalize their concerns about their baby’s condition and identify how they can facilitate their baby’s improvement

VIII.

Care of the Newborn with Anemia

A. Normal full-term hemoglobin → 13 to 16 g/dl B. Physiologic anemia of infancy exists as a result of the normal gradual drop in hemoglobin C. Nadir → lowest point 1. Most common causes of anemia → blood loss, hemolysis, impaired RBC production a) Blood loss in utero, fetomaternal, fetofetal, umbilical cord, birth trauma b) Excessive hemolysis c) Physiologic anemia of infancy → normal gradual drop in hemoglobin d) In preterm newborns seen earlier, more severe

D. Clinical therapy 1. Initial lab workup a) Should determine (1) Hemoglobin and hematocrit (2) Reticulocyte count (3) Examination of maternal blood smear (4) Bilirubin levels 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Mild or chronic anemia → iron supplements, iron-fortified formula a) Severe → transfusions b) Anemia of prematurity → treat causative factor, supplemental iron

E. Nursing Management for the Newborn with Anemia 1. Assessment a) Symptoms of anemia (1) Signs of shock (a) Capillary filling time greater than 3 seconds (b) Decreased pulses (c) Tachycardia (d) Low blood pressure. b) Signs of longer term compromise (1) Poor weight gain (2) Pallor (3) New onset of jaundice or recurrent jaundice (4) Tachycardia (5) Tachypnea Apneic episodes. c) Constant cardiac and respiratory monitoring d) Report symptoms e) Limit phlebotomy losses f) Document blood losses, replacement

IX.

Care of the Newborn with Infection A. Sepsis neonatorum → caused by organisms that do not typically cause significant disease in older children 1. Early-onset neonatal sepsis (EONS) 2. Late-onset sepsis (LOS) 3. Nosocomial infections → methicillin-resistant Staphylococcus aureus (MRSA), Candida a) Full-term infants susceptible → immunologic systems immature b) See Figure 31–17: Term newborn with suspected sepsis, p. 841 4. Present as bacteremia/sepsis, urinary tract infection, meningitis, pneumonia 5. Maternal antepartum, intrapartum infections, PROM 6. More common in VLBW, and newborns of African heritage 7. Gram-negative and gram-positive β-hemolytic streptococcus most common a) Pseudomonas common with ventilator support and oxygen therapy equipment 8. Protections starts prenatally a) Screening 21 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Sterile technique c) Antibiotic prophylaxis

B. Health care prevention education: preventing newborn infections 1. During the prenatal period 2. During the intrapartum period 3. During the postpartum period

C. Clinical therapy 1. Cultures as soon after birth as possible, before antibiotic therapy a) Anaerobic, aerobic blood cultures b) Spinal fluid culture c) Urine culture d) Skin or mucus membrane cultures e) Tracheal aspirate cultures f) Placental cultures g) Complete blood count, C-reactive protein (CRP), procalcitonin (PCT) chest x-ray, serology, Gram stains of fluids, white blood cell (WBC) count (1) WBC count may be normal or low (2) Serum IgM → elevated h) Neonatal infection correlates with high mortality→institute therapy while sepsis workup is begun 2. Institute therapy before results return a) Combination of two broad-spectrum antibiotics until culture results obtained b) Appropriate specific antibiotic therapy c) Cephalosporins 3. Supportive physiologic care 4. See Table 31–6: Neonatal Sepsis Antibiotic/Antiviral Therapy, p. 845

D. Nursing Management for the Newborn with Infection 1. Nursing Assessment and Diagnosis a) Subtle behavioral changes b) Temperature instability, commonly hypothermia c) Feeding intolerance d) Hyperbilirubinemia, petechial hemorrhages, hepatosplenomegaly e) Tachycardia initially, followed by spells of apnea, bradycardia 2. Nursing diagnoses include: a) Infection, Risk for b) Fluid Volume: Deficient c) Coping: Family, Compromised 22 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Nursing Plan and Implementation a) Controlling environment, preventing infection b) Strict hand-washing techniques c) Aseptic collection of specimens d) Care of equipment e) Provision of antibiotic therapy (1) Proper dose, based on weight, desired peak and trough levels (2) Appropriate route, method, timing (3) Admixture incompatibilities (4) Side effects and signs of toxicity (5) Term infants → neonatal home infusions f) Provision of supportive care (1) Observes for resolution of symptoms or development of other symptoms (2) Maintain neutral thermal environment (3) Provide respiratory support (4) Provide cardiovascular support (5) Provide adequate calories (6) Provide fluids, electrolytes to maintain homeostasis (7) Observe for hypo-, hyperglycemia, acidosis, hyponatremia, hypocalcemia g) Instruction for parents for daily care 4. Evaluation a) Risks for development of sepsis are identified early and immediate action taken b) Appropriate use of aseptic technique protects newborn from further exposure to illness c) Baby’s symptoms relieved, infection is treated d) Parents verbalize concerns about baby’s illness, understand rationale behind the management of their newborn

Care of the Family with Birth of an At-Risk Newborn A. Parental Responses 1. Acute grief reaction to loss of idealized baby a) Attachment fragile b) Feelings of guilt and failure c) Waiting between suspicion, confirmation of abnormality or dysfunction anxious 2. During waiting period → support, acknowledgement that it is an anxious time a) Discussion of problem, anticipatory management (1) Maintain trust (2) Appreciate reality of situation (3) Begin grieving process (4) Mobilize internal, external support b) Anger common (1) Direct at physician, nurse, hospital, routine

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Posttraumatic stress disorder (PTSD) in mothers spending time in neonatal intensive care unit (NICU) 3. Grief and mourning mark parental reactions to infant with abnormalities a) Grief work b) Parental detachment precedes parental attachment c) A healthy parent–child relationship can occur

B. Developmental Consequences 1. Baby at risk for emotional, intellectual, cognitive development delays 2. Parents must understand reality of disability, hurdles ahead a) Interprofessional team b) Early and continued involvement of parents

C. Nursing Management for the Family of an At-Risk Newborn 1. Nursing Assessment and Diagnosis a) Level of understanding b) Behavioral responses c) Difficulties with communication d) Paternal and maternal education level e) Documentation of information gathered (1) Recording of visits, caretaking, affect toward newborn (2) Telephone calls (3) Serial observations f) If distancing behaviors evolve → interventions g) See Table 31–7: Adaptive and Nonadaptive Parental Responses to a Newborn’s Health Crisis, p. 848 2. Diagnoses may include: a) Grieving, Complicated b) Fear c) Parenting, Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Parents acutely perceptive about other’s responses, reactions to child (2) Nurse must work out personal reactions (a) Therapeutic questions (b) Grief is individual and the child and situation are what is important (3) Support of parents in initial viewing or the newborn (a) Prepare for visit → realistic, positive attitude (b) Observe baby → present strengths and deficiencies (c) NICU booklet prior to entering unit (d) May be overwhelmed with sounds, language, atmosphere 24 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(e) Primary nurse and physician with parents (f) Slow, complete simple explanations (g) Concerns may be voiced, or may not be (i) Anticipate questions (ii) Concerns about physical appearance common (h) Set tone → safe, trusting environment (i) Parents as essential caregivers (i) Trusting relationship → one-to-one basis (j) Nurses invest baby with value in eyes of parents (4) Facilitation of attachment if neonatal transport occurs (a) Essential that mother see, touch infant before transport (b) Explanations and support (i) Photographs (5) Promotion of touching and parental caretaking (a) See Figure 31–20: Mother of this 26-week …, p. 850 (b) Several visits to become comfortable, confident (c) Eye contact, touching may take several visits (d) Facilitate touching → getting to know infant, establishing bond (e) Encourage parents to meet newborn’s need for stimulation (i) See Figure 31–21: This mother of a 31-week …, p. 850 (f) Encourage visiting, involvement in care (g) Refer to infant by name (h) Promote parental success → demonstrate caretaking → positively reinforce behavior (i) Parents may be ambivalent toward nurse → criticism, manipulation (i) Recognize feeling of mothers → enhance bonding (ii) Positive remarks about breast milk, weight gain, etc. (iii) Encourage parents to talk about hopes, fears → involve in parent groups (iv) Detachment easier after attachment → comforted that they did all they could (6) Facilitation of family adjustment (a) Maintaining interpersonal relationships difficult → primary nurse to coordinate continuity (b) Transfer to step-down nursery, regular unit difficult → new healthcare professionals (c) Liaison between parents and wide variety of professionals (d) Encourage to use support system (i) Friends, neighbors, as well as family (e) Impact of crisis on family varies (f) Encourage open communication between spouses → no secrets (i) Important if mother hospitalized apart from infant (ii) Give parents information together (g) Sibling responses (i) Not to be overlooked (ii) Hostility, shame if infant has anomaly → guilt over reaction 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(iii) Family tension (h) Respect and facilitate desires, needs of individuals → elicit feelings (7) Cultural barriers → increase feelings of isolation uncertainty (a) Language barriers (b) Cultural differences (8) Families with children in NICU become friends → support one another (a) Early one-to-one contact b) Community-based nursing care (1) Predischarge planning begins once condition stable (a) Collaborative care team approach (b) Adequate teaching helps transform feelings of inadequacy → self-assurance, attachment (c) Sudden infant death syndrome (SIDS) risk-reduction practices (d) Home care instruction in optimal learning environment over time (e) Interact with staff while transitioning to sole caretakers (2) Basic elements of home care instruction (a) Teach parents routine well-baby care (b) Help parents learn to do special procedures as needed by newborn (i) Written tools as well (c) Make sure all screening tests, immunizations done (d) Refer parents to community health and support organizations (e) Help parents recognize growth and development needs of infant (f) Arrange follow-up care before discharge (g) Evaluate need for durable medical equipment for infant care in the home (h) Arrange for neonatal hospice for parents of medically fragile infant (3) Teaching not always perceived as adequate → stress levels of family 4. Evaluation a) Parents are able to verbalize feelings of grief and loss b) Parents verbalize concerns about their baby’s health problems, care needs, potential outcome c) Parents able to participate in infant’s care and show attachment behaviors

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

XI.

Considerations for the Nurse Who Works with At-Risk Newborns

A. NICU staff nurses never see long-term results B. Emotional environment → lots of living and lots of dying C. NICU nurses need supported D. Ability to cope with stress key to creating emotionally healthy environment 1. Caregivers may be unaware of need to grieve 2. Group meetings 3. Individual support 4. Primary care nursing

XII.

Focus Your Study

XIII.

Activities 1. Individual Have students prepare drug cards for the following medications used for the newborn at risk: • Epinephrine • Oxygen • Dextrose • Naloxone hydrochloride • Surfactant • Dopamine • Dobutamine • Nitric oxide • Albuterol 2. Small Group Divide the class into small groups of three to five students. Have each group interview a separate NICU nurse or other NICU staff member. Instruct the groups to develop a set of questions they want answers to prior to the appointment. Advise the groups to make appointments rather than showing up unexpectedly at the NICU. They can ask questions that include the topics covered in this chapter or other topics with the approval of the instructor. Their questions should include those about the emotional support of families, siblings, and staff. Have the groups write up the results of their interviews for discussion by and distribution to the class. 3. Large Group Review the interview results with the class. Facilitate a discussion about the emotional support needed for family and siblings of at-risk newborns.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 32 Postpartum Adaptation and Nursing Assessment

Postpartum Physical Adaptations.....................................................................

Postpartum Psychologic Adaptations...............................................................

Development of Family Attachment.................................................................

Postpartum Nursing Assessment......................................................................

Discharge Assessment and Follow-Up..............................................................

Focus Your Study...............................................................................................

Activities............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Postpartum Physical Adaptations

A. Reproductive System 1. Involution of the uterus → rapid reduction in size of uterus a) Return to condition similar to non-pregnant state → slightly larger b) Decidua irregular, jagged, varied in thickness → cast off as lochia c) Process complete by 3 weeks except placental site takes up to 6 weeks d) Heals by exfoliation → no scar e) Estrogen, progesterone levels decrease → uterine cells atrophy f) Involution enhanced by: (1) Uncomplicated labor and birth (2) Complete expulsion of amniotic membranes and placenta (3) Breastfeeding (4) Manual removal of placenta during cesarean (5) Early ambulation g) See Table 32–1: Factors That Slow Uterine Involution, p. 857 (1) Prolonged labor (2) Anesthesia (3) Difficult birth (4) Grandmultiparity (5) Full bladder (6) Incomplete expulsion of placenta or membranes (7) Infection (8) Overdistention of uterus h) Changes in fundal position (1) Uterus contracts firmly immediately following expulsion of placenta (2) Fundus midline of abdomen, between symphysis pubis and umbilicus (a) See Figure 32–1: Involution of the uterus …., p. 857 (3) Above umbilicus, boggy → associated with bleeding (4) Full bladder → fundus higher, not midline (deviated to right) (a) See Figure 32–2: The uterus becomes displaced …, p. 858 (b) Void immediately, in-and-out catheterization (5) Top of fundus descends approximately 1 fingerbreadth (1 cm) per day (6) Breastfeeding → may hasten involution (7) Infection, oversized uterus during pregnancy, etc. → slow involution (subinvolution) 2. Lochia a) Discharge of debris remaining in uterus after birth (1) Lochia rubra → dark red → first 2 to 3 days postpartum (2) Lochia serosa → pinkish color → 1 to 2 weeks (3) Lochia alba → creamy or yellowish b) Trend of flow should be toward a lighter color c) Musty, stale odor, not offensive 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Foul smell → suggests infection (2) Total volume approximately 225 mL (3) Amount may increase by exertion, breastfeeding (4) Less lochia with cesarean birth d) Evaluation to determine hemorrhage, assess involution e) Continuous seepage of blood immediately after birth → consistent with lacerations 3. Cervical changes a) Following birth → spongy, flabby, formless, may appear bruised b) Admits two fingers → end of first week to one fingertip c) Shape of os permanently changed by first childbearing d) Cervical os permanently changed → dimple to slit appearance 4. Vaginal changes a) Appears edematous, gaping, may be bruised b) Size decreases, rugae begin to return within 3 weeks c) Nonlactating → appears normal d) Lactating → hypoestrogenic due to ovarian suppression → dyspareunia e) Kegel exercises improve tone, contractibility of vaginal opening 5. Perineal changes a) Early postpartum → edematous with some bruising b) Episiotomy, laceration edges → approximated c) Ecchymosis may delay healing d) Complete healing 4 to 6 months 6. Recurrence of ovulation and menstruation a) Varies (1) Nonbreastfeeding → 7 to 10 weeks (a) First ovulation 70 to 75 days (2) Breastfeeding → 3 or more months (a) Rise in serum progesterone (b) Return of menstruation and ovulation directly related to length of time breastfeeding (c) LAM

B. Abdomen 1. Uterine ligaments stretched, abdominal wall loose and flabby 2. Diastasis recti abdominis → separation of rectus abdominis muscles a) Tone may be regained → responds well to exercise within 2 to 3 months b) See Figure 32–3: Diastasis recti abdominis, a separation of the musculature, commonly occurs after pregnancy, p. 860 3. Striae (stretch marks) → stretching, rupture of elastic fibers in skin a) Differ based on mother’s skin color 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Lactation 1. Breasts develop in preparation for lactation from estrogen and progesterone changes 2. After birth → hormonal changes lead to establishment of milk production

D. Gastrointestinal System 1. Hunger following birth common, thirsty a) Light meal 2. Bowels tend to be sluggish → progesterone, decreased abdominal muscle tone, bowel evacuation associated with labor and birth 3. Episiotomy, lacerations, hemorrhoids → woman may delay elimination a) Actually may increase constipation, pain by waiting b) Cesarean birth → may start with clear liquids until bowel sounds 4. Flatulence → early ambulation

E. Urinary Tract 1. Increased bladder capacity, swelling and bruising of tissues around urethra, decreased sensitivity to fluid pressure, decreased sensation of bladder filling 2. Urinary output increases during early postpartum period → puerperal diuresis a) 2000 to 3000 mL 3. Stasis → increased risk for urinary tract infection 4. Hematuria occasionally occurs → in week 2 or 3 may indicate infection

F. Vital Signs 1. Afebrile except for first 24 hours → 38°C (100.4°F) due to exertion, milk coming in 2. Transient rise in systolic and diastolic blood pressure a) Orthostatic hypotension → first 48 hours b) Monitor late preeclampsia → blood pressure if woman complains of headache 3. Bradycardia common first 6 to 10 days a) Pulse >100 beats/min may indicate hypovolemia, infection, fear, pain

G. Blood Values 1. Return to pre-pregnant state by end of postpartum period a) Coagulation factors may continue b) Nonpathologic leukocytosis → up to 20,000 to 25,000/mm3 → normal by end of first week 2. Hemoglobin, hematocrit difficult to interpret in first 2 days a) Blood loss 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Average blood loss is 200 to 500 mL with vaginal birth, > 1000 mL cesarean birth (2) 2 to 3 percentage point drop in hematocrit equals a blood loss of 500 mL b) Lochia c) Extracellular fluid decreases d) Hemodilution after 3 to 4 days e) Platelets typically fall with placental separation → increase gradually

H. Cardiovascular Changes 1. Increased cardiac output during birth → stabilizes within 1 hour of birth 2. Cardiac output declines by 30% in first 2 weeks → normal by 6 to 12 weeks

I. Neurologic Changes and Conditions 1. Headaches most common → fluid shifts, spinal anesthesia, pregnancy-induced hypertension (PIH), stress, leakage of spinal fluid 2. Migraines tend to resume postpartum 3. Women with epilepsy nine times more likely to have seizure in labor, first 24 hours a) Retitration of antiepileptic drugs (AED) b) More likely to be diagnosed with depression 4. Multiple sclerosis (MS), Guillain-Barré syndrome → more likely to have symptoms

J. Weight Loss 1. Initial loss of 10 to 12 lb → birth of infant, placenta, amniotic fluid 2. Puerperal diuresis → additional 5 lb 3. By 6 to 8 weeks → back to approximate pre-pregnant weight if had 25 to 30 lb gain

K. Postpartum Chill 1. Intense tremors after birth → theories offered 2. If no fever → no clinical concern 3. Warmed blankets, warm drink

L. Postpartum Diaphoresis 1. Elimination of fluid, waste products via skin

M. Afterpains 1. More common in multipara → intermittent uterine contractions a) Lost tone results in alternate contraction and relaxation b) Can cause severe pain 2 to 3 days after birth c) Oxytocic agents, breastfeeding → stimulates uterine contractions 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Ibuprofen, warm water bottle (1) Breastfeeding → mild analgesic 1 hour before feedings

II.

Postpartum Psychologic Adaptation

A. Readjustment and adaptation 1. Changes in body image, reality that she is no longer pregnant

B. Taking-In and Taking-Hold Periods 1. Taking in → passive, somewhat dependent a) Talk about perceptions of labor, birth b) Food and sleep 2. 2 to 3 days → taking hold → ready to resume control of body, mothering, life in general a) Worries about breastfeeding techniques b) May feel demoralized by nurse, older family member holds baby proficiently

C. Becoming a mother 1. Maternal role attainment (MRA) a) Process by which woman learns mothering behavior, becomes comfortable with identity as a mother b) 3 to 10 months after birth 2. Becoming a mother (BAM) → dynamic transformation, evolution of persona 3. Nurses aware of long-term adjustments and stresses childbearing family faces 4. Nursing interventions to foster process of becoming a mother a) Instructing about newborn/infant caregiving b) Building awareness of and responsiveness to newborn/ infant interactive capabilities c) Promoting maternal–newborn attachment d) Preparing the woman for the maternal social role e) Encouraging interactive therapeutic nurse–patient relationships

D. Postpartum Blues 1. Transient period of depression during first few days of puerperium a) Mood swings, anger, weepiness, anorexia, difficulty sleeping, feeling of letdown b) Fatigue, discomfort, overstimulation may play a part 2. Hormonal, environmental, fatigue, overstimulation all factors a) Resolves naturally in 10 to 14 days b) Persistent or if symptoms worsen → evaluate for postpartum depression

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Importance of Social Support 1. Network a) Family interaction can be source of stress b) Increasing contact with parents of small children c) New mother support group 2. Postpartum doula a) Tailored to help new mother feel rested, well nourished, place house in order

III.

Development of Family Attachment

A. Maternal–Newborn Attachment Behavior 1. Personal characteristics important a) Level of trust b) Level of self-esteem c) Capacity for enjoying herself d) Adequacy of knowledge about childbearing and childrearing e) Prevailing mood or usual feeling tone f) Reactions to present pregnancy

B. Initial Attachment Behavior 1. Regular pattern a) Progression of touching activities b) Increases en face position time (1) See Figure 32–4: The mother has direct face-to-face and eye-to-eye contact in the en face position, p. 864 c) Relies heavily on sight, touch, hearing (1) Responds verbally to sounds d) May be experiencing shock, disbelief, denial 2. Acquaintance phase a) Infant gives behavioral cues → responds to mothering b) Newborn also becoming acquainted 3. Mutual regulation phase a) Balance sought between needs of mother, needs of infant b) Primarily enjoying each other → reciprocity 4. Reciprocity a) Interactional cycle, involves mutual cuing behaviors 5. Father–newborn interactions a) Engrossment → sense of absorption, preoccupation, interest in infant demonstrated by fathers

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) See Figure 32–5: The father experiences strong feelings of attraction during engrossment, p. 865 6. Siblings and others a) Infants capable of maintaining number of strong attachments without loss of quality

C. Cultural Influences in the Postpartum Period 1. Western culture emphasizes events of birth, many other cultures place emphasis on postpartum period 2. Expectations influenced by beliefs, values of family and cultural group a) Influences needs regarding food, fluids, rest, hygiene, medications, relief measures, support, counsel 3. Nurses belong to own ethnoculture a) Important to understand approaching care from own perspective 4. Describing practices involves some generalization a) European heritage → full meal, large amount of iced fluids following birth b) Women of Islamic faith may have modesty requirements (1) Coverings (2) No man, other than her husband or a family member, may be alone with her c) Hispanic, African, Asian cultures → may avoid cold after birth d) Beliefs related to hot and cold

IV.

Postpartum Nursing Assessment A. Risk Factors 1. Ongoing assessment and patient education a) See Table 32–2: Postpartum High-Risk Factors, p. 867 (1) Preeclampsia (2) Diabetes (3) Cardiac disease (4) Cesarean birth (5) Overdistention of uterus (6) Abruptio placentae, placenta previa (7) Precipitous labor (8) Prolonged labor (9) Difficult birth (10) Extended period of time in stirrups at birth (11) Retained placenta

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Consider patient’s need for possible premedication before painful assessments c) Provide an explanation of the purposes of regular assessment d) Ensure woman is relaxed before starting e) Document and report results according to hospital/unit policy f) Take appropriate precautions to prevent exposure to body fluids 2. Excellent opportunity for patient teaching a) See Key Facts to Remember: Common Postpartum Concerns, p. 868 (1) Gush of blood that sometimes occurs when she first arises (2) Passing clots (3) Night sweats (4) Afterpains (5) “Large stomach” after birth and failure to lose all weight gained during pregnancy 3. Use opportunities for teaching regarding self-care 4. Vital signs a) Begin assessment with vital signs b) Temperature elevation → only last 24 hours (1) Identify risk factors c) Alterations may indicate complications → assessed at regular intervals d) Inform woman of results 5. Auscultation of lungs a) Should be clear b) Preterm labor or preeclampsia → risk for pulmonary edema 6. Breasts a) Don gloves → assess fit, support of bra (1) Support, maintains shape b) Breastfeeding → straps cloth, easily adjustable (1) Wide back, three rows of hooks (2) Nursing bra (3) Have woman remove bra so breasts can be examined (4) Palpate lightly for softness, slight firmness, firmness (5) Warmth, tenderness (6) Assess for fissures, cracks, soreness, inversion (7) Teach woman how to recognize problems c) Nonbreastfeeding mother (1) Evidence of discomfort → relief measures 7. Abdomen and fundus a) Void prior to examination b) Determine relationship of fundus to umbilicus, firmness c) Midline or displaced

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) See Clinical Skill 32–1: Assessing the Status of the Uterine Fundus After Vaginal or Cesarean Birth, pp. 869–870 d) Teaching woman as assessment completed e) Cesarean birth → abdominal incision exquisitely tender (1) Palpate fundus with extreme care (2) Inspect incision for signs of healing f) Feels firm, not overly tender (1) If boggy → massage gently with finger tips (2) Observe perineal pad for results of massage g) Postpartum uterine atony nursing interventions (1) Reevaluate for full bladder (2) Question woman on bleeding history since birth, last examination (3) Put newborn to breast for feeding to stimulate oxytocin production (4) Assess maternal blood pressure and pulse to identify hypotension (5) Reassess fundus → if still boggy, alert physician/CNM physician immediately → further intervention needed 8. Lochia a) Assessed for character, amount odor, presence of clot b) Don gloves c) Rubra with clots normal days 1 to 3 → after 2 to 3 days serosa d) Should never exceed a moderate amount → partially saturate 4 to 8 pads daily e) See Figure 32–7: Suggested guidelines for assessing lochia volume, p. 870 (1) Weigh pads → 1 g = 1 mL f) Clots, heavy bleeding → atony, retained placental fragments, unknown laceration (1) Assess vital signs (2) Possible medication (3) See Key Facts to Remember: Changes in Lochia That Cause Concern, p. 871 g) If odor is present → infection h) Hygienic measures 9. Perineum a) Inspected with woman in Sims position b) Assess wound if episiotomy, laceration repair c) Evaluate state of healing d) Assess hemorrhoids for size, number, pain or tenderness e) Talk to woman about comfort measures, information about episiotomy, dissolvable sutures f) See Figure 32–8: Intact perineum with hemorrhoids, p. 872 g) See Clinical Skill 32–3: Postpartum Perineal Assessment, pp. 872–873 10. Lower extremities a) Risk for thrombophlebitis, thrombus formation, inflammation of vein b) Hypercoagulability, severe anemia, obesity, traumatic delivery c) Homans sign (1) See Figure 32–9: Homans sign ..., p. 874 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Edema → compare both legs e) Early ambulation, passive range-of-motion exercises f) Patient teaching g) Record results 11. Elimination a) Signs of bladder distention → postpartum diuresis b) Assess frequently c) Techniques to facilitate voiding d) Catheterization e) Assess fluid intake, signs of UTI f) Intestinal elimination status (1) Stool softeners (2) Encourage ambulation, force fluids, fresh fruits, roughage g) Provide information 12. Rest and sleep status a) Physical fatigue concern b) Significant factor in apparent disinterest in newborn → tired c) Evaluate amount of sleep woman getting d) Daily rest period should be encouraged 13. Nutrition a) Nonbreastfeeding → dietary requirements to pre-pregnancy levels → reduce intake by 300 kcal b) Lactating mothers → increased requirements → increase 200 kcal over pregnancy requirements → 500 kcal over non-pregnant requirements c) Iron supplement (1) Inform dietitian → special needs

C. Psychologic Assessment 1. Physical and developmental tasks of postpartum weeks a) Restoring physical condition b) Developing competence in caring for, meeting needs of infant c) Establishing relationship with new child d) Adapting to altered lifestyles and family structure resulting from the addition of a new member e) Little or no experience → may be feeling overwhelmed f) Characteristics (1) Excessive, continued fatigue; marked depression; excessive preoccupation with physical status or discomfort; evidence of low self-esteem; lack of support systems; marital or relationship problems; inability to care for or nurture the newborn; current family crises g) Referrals

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Assessment of Early Attachment 1. Assess progress toward attachment a) Is mother attracted to newborn? b) Is mother inclined to nurture infant? c) Does mother act consistently? d) Is mothering consistently carried out? e) Is mother sensitive to newborn’s needs as they arise? f) Does mother seem pleased with appearance and sex? g) Are there any cultural factors that might modify mother’s response? 2. Is there a problem in attachment? 3. See Assessment Guide: Postpartum—First 24 Hours After Birth, pp. 876–878

Discharge Assessment and Follow-Up A. Include: 1. Physical examination 2. Discharge teaching

B. Home visit, follow-up phone call C. 3 to 4 days after birth 1. Assessment and teaching

VI.

Focus Your Study

VII.

Activities 1. Individual Have students prepare a teaching plan for the woman who is 2 weeks postpartum, detailing normal changes in the physical assessment. Students should cite their references in APA format. 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a list of questions for a follow-up phone call from the postpartum unit. The groups should include appropriate questions regarding physical assessment, attachment, feelings about the baby, and family adjustment. Have the groups include an assessment for postpartum depression. 3. Large Group Have the entire class watch the following video (4 minutes 54 seconds) on postpartum depression and discuss the appropriate assessment questions: http://www.youtube.com/watch?v=MJ6ALUrwSRM

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 33 The Postpartum Family: Needs and Care Nursing Care During the Early Postpartum Period.............................................

Community-Based Nursing Care.........................................................................

Health Promotion Education …………………………………………………………………………

Promotion of Maternal Comfort and Well-Being...............................................

Promotion of Maternal Nutrition, Rest, and Activity.........................................

Promotion of Family Wellness and Shared Parenting........................................

Nursing Care Following Cesarean Birth..............................................................

Nursing Care of the Obese Postpartum Mother................................................

Nursing Care of the Adolescent Postpartum Mother .......................................

Nursing Care of LGBTQ Postpartum Mothers………………………………………………..

Nursing Care of the Postpartum Mother with Special Needs...........................

Nursing Care of the Postpartum Mother with a History of Sexual Abuse…………………………............................................................................

Nursing Care of the Woman Who Relinquishes Her Newborn..…………………….

Discharge Information........................................................................................

Evaluation of the Postpartum Family.................................................................

Focus Your Study................................................................................................

Activities.............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Nursing Care During the Early Postpartum Period

A. Nursing Diagnoses 1. Maternal a) Urinary Elimination, Impaired b) Skin Integrity, Impaired c) Pain, Acute d) Infection, Risk for e) Constipation, Risk for 2. Wellness diagnoses include a) Knowledge, Readiness for Enhanced b) Coping: Readiness for Enhanced c) Breastfeeding, Readiness for Enhanced

B. Nursing Plan and Implementation 1. Individualized to woman, newborn, family 2. Patient teaching a) Self-care b) Effective newborn care 3. Desired patient outcomes include a) Mother and baby remain healthy, safe, and free of injury or complications b) Mother verbalizes comfort c) Mother tells birth story and verbalizes feelings and concerns regarding the event d) Mother reviews educational resources for self- and infant care e) Mother performs appropriate self- and infant care f) Parent(s) and newborn demonstrate positive bonding behaviors g) Parents practice principles of infant safety h) Mother verbalizes understanding of and demonstrates successful breastfeeding and breast care; or mother describes accurate preparation of infant formula, demonstrates safe bottle-feeding techniques, and verbalizes understanding of lactation suppression care i) Mother verbalizes sources of support to assist in newborn care and family responsibilities j) Mother states plan for follow-up health care for self and infant k) Mother identifies signs and symptoms of maternal or newborn complications and reasons to seek care before routine follow-up visits 4. Additional outcome for cesarean birth mother include: a) Mother states in own words the reason for the cesarean birth and verbalizes feelings related to the event b) Mother maintains desired comfort level (pain level less than 4 on 1 to 10 scale) c) Mother maintains mobility (up in chair within 12 hours; ambulates within 24) 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Care designed to achieve outcome for woman and family 6. See Key Facts to Remember: Postpartum Assessment, p. 883

II.

Community-Based Nursing Care

A. Services 1. Education opportunities a) Nutrition counseling b) Breastfeeding assistance c) Maternal exercise d) Newborn/infant care e) Newborn/infant development f) Parenting courses 2. Healthcare programs a) Well-baby clinics b) Immunization clinics c) Lactation centers d) Family planning agencies e) New mother support groups 3. Different locations

B. Home health care 1. See Evidence-Based Practice: Postnatal Support from the Midwife, p. 883

III.

Health Promotion Education

A. Meeting educational needs primary responsibility of postpartum nurse 1. Assess learning needs through observation, sensitivity, questions

B. Timing and Methods of Teaching 1. Provide education efficiently and effectively → shortened postpartum stays 2. Assessment begins at first access to healthcare system 3. Variety of educational options a) Structured group classes b) Individualized instruction c) Printed materials d) Online materials e) Educational television channels f) Approved streaming videos produced by professional organizations

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

4. Streamlined to meet individual needs of patients 5. Nurse to be available for clarification and ongoing communication 6. Continued learning through printed materials accompanied by verbal explanations

C. Content of Teaching 1. Expected physiologic changes 2. Activity level 3. Self-care 4. Maternal nutrition 5. Exercise 6. Sexuality and contraception 7. Emotional responses to childbearing 8. Newborn care 9. Newborn safety 10. Newborn immunizations 11. Signs of maternal and newborn complications 12. Emergency contact information 13. Psychosocial support 14. Specific follow-up for high-risk patients 15. Healthcare team roles and follow-up appointments

D. Maternal learning needs vary 1. Not limited to how-to activities

E. Anticipatory guidance 1. Colic 2. Postpartum health issues 3. Discussion groups 4. Complications and discomforts in first-year postpartum common a) Pain, fatigue, urinary incontinence, sleep deprivation, changes in mental health status 5. Special concerns → adolescent mothers, cesarean delivery, congenital anomalies a) See Table 33–1: Areas to Include in Postpartum Teaching, pp. 885–888 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Include partner or other family member in teaching c) Critical concepts to review: (1) Headache (2) Leg pain (3) Abnormal vaginal bleeding (4) Swelling of face or extremities (5) Chest pain or shortness of breath (6) Thoughts of harming self or baby (7) Oral temperature of 100.4°F or higher (8) Excessive incisional pain or discharge

F. Evaluating Learning 1. Methods vary according to objectives, teaching methods a) Return demonstration, discussion 2. Less concrete learning evaluation more difficult a) Follow-up phone calls, home visits

IV.

Promotion of Maternal Comfort and Well-Being A. Assess patient on regular basis, providing care per protocol 1. Relieving specific discomforts 2. Medications for comfort, anemia, immunizations

B. Monitoring Uterine Status 1. Institutional protocols a) Presence of bogginess b) Positioning out of midline c) Heavy lochial flow d) Presence of clots e) Formation of hematoma 2. Monitor amount, consistency, color, odor of lochia 3. Breastfeeding or medication to promote uterine contractions 4. Teaching for self-care a) Teach woman to assess fundus and massage b) Teach to monitor lochia c) When to call healthcare provider

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Hygienic practices 3. Perineal care a) After each elimination → cleanses, promotes comfort (1) Peri-bottle with warm tap water (2) Towelettes (3) Patting motion with toilet paper b) Front to back c) Teaching for self-care (1) Demonstrate and assist as necessary 4. Local perineal cooling a) Episiotomy or laceration (1) Reduce edema, numb tissue (2) Ask permission and consider cultural norms (3) Cooling packs or cold gel pads (4) Most often used in first 24 hours, continue as long as necessary (5) Apply for 10 to 20 minutes b) Teaching for self-care (1) Purpose, anticipated effects, benefits, possible problems 5. Sitz bath a) Warmth provides comfort, decreases pain, increases circulation to tissues (1) Promotes healing, reduces incidence of infection (2) May be used as needed (PRN) for 20 minutes (3) Clean towel, peripad ready to apply (4) See Figure 33–1: A sitz bath promotes …, p. 891 b) Teaching for self-care (1) Purpose, anticipated effects, benefits, possible problems, safety measures (2) 4 to 6 inches of water (3) Assess for temperature (4) Soak for 15 to 20 minutes 6. Topical agents a) Apply after sitz bath or perineal care (1) Anesthetic sprays, foams, ointments, Tucks pads b) Teaching for self-care (1) Purpose, use, anticipated effects, benefits, possible problems, safety measures (2) Return demonstration 7. See Clinical Skill 33–1: Use of Perineal Hygiene, Perineal Cooling, and Sitz Baths, pp. 892– 893

D. Relief of Hemorrhoidal Discomfort 1. Use of sitz baths, topical anesthetics, cool packs, witch hazel pads (Tucks) a) Short-term use of topical creams, rectal suppositories may be helpful 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Increase fiber, fluid 2. Teaching for self-care a) Side-lying position, tighten buttocks when sitting down b) Diet and fluids c) Walking d) Assure hemorrhoids usually disappear a few weeks after birth

E. Relief of Afterpains 1. Intermittent uterine contractions a) Multiparous women frequently (1) Breastfeeding can initiate (2) Pillow under lower abdomen → intensifies for 5 minutes, then diminishes (3) Ambulation (4) Analgesics b) Mother’s description most reliable method of determining analgesic (1) Mild analgesics pose little risk to newborn c) Teaching for self-care (1) Cause and methods to decrease discomfort (2) Explains medications

F. Relief of Discomfort from Immobility and Muscle Strain 1. Pushing during labor 2. Early ambulation a) Assist first few times woman gets up b) Dizziness a concern 3. Teaching for self-care a) Importance of ambulation, monitoring signs of dizziness, weakness

G. Postpartum Diaphoresis 1. Fresh linens, dry gown 2. Cultural considerations for showering 3. Offer fluids 4. Teaching for self-care a) Information about normal physiologic changes

H. Suppression of Lactation in the Nonbreastfeeding Mothers 1. Engorgement → leakage, discomfort a) Nonpharmacologic means (1) Support bra continuously

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Avoid breast stimulation (3) Applying cold packs (4) Apply cabbage leaves b) Signs peak by 4 days → spontaneously resolve by 10th day c) Analgesics d) Acupuncture, acupressure, ultrasound, Gua Sha scraping therapy are used in some settings 2. Teaching for self-care a) Avoid stimulation of breasts, nipples b) Heat avoided → water over back in shower c) 24-hour support bra d) Analgesics e) Cold compresses

I. Pharmacologic Interventions 1. See Table 33–2: Essential Information for Postpartum Immunizations, p. 896 2. Immunizations a) Pertussis in Tdap (1) Administer to pregnant woman at 27 to 36 weeks 3. Influenza a) Prior to discharge 4. Rubella a) If not rubella immune on lab test b) Use with caution in breastfeeding mothers 5. MMR II 6. Rho immune globulin a) Rh– woman with Rh+ baby (1) Within 72 hours after childbirth (2) Woman needs to understand implications of Rh– status in future pregnancies 7. Analgesics a) Variety of drugs used alone or in combination to provide relief of postpartum pain (1) Acetaminophen (2) Nonsteroidal anti-inflammatory agents (3) Narcotic b) Nurse should assess level of consciousness, vital signs 1 hour after administering

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Becoming a mother (BAM) a) Life-transforming process (1) Commitment, attachment, preparation → pregnancy (2) Acquaintance, learning, physical restoration → first 2 to 6 weeks after birth (3) Moving toward a new normal → 2 weeks to 4 months (4) Achievement of the maternal identity → around 4 months 3. Taking-in period → dependent, inwardly focused a) Promote skin-to-skin contact (SSC) early postpartum 4. Taking hold → self-care needs met → will shift to care of newborn, parenting a) Positive feedback b) Tell birth story c) Adjust to reality of child 5. Postpartum mood disturbances a) Often discharged before onset (1) Postpartum baby blues for up to 2 weeks following delivery (2) Immediate postpartum period predictor of postpartum depression (3) Individually assess b) Teaching for self-care (1) Advise mother of physical, psychologic, hormonal factors influencing response to childbirth (2) Discuss normal adaptations (3) Symptoms relatively mild and self-limiting, usually resolving within 10 days (a) If severe or last > 14 days, contact healthcare provider (4) Advise families about symptoms of postpartum depression

Promotion of Maternal Nutrition, Rest, and Activity A. Promotion of Nutrition 1. Hungry and thirsty immediately following delivery a) Eat and drink as desired 2. Breastfeeding → 500 kcal/day additional calories from prepregnant intake 3. Nonbreastfeeding → normal nonpregnant caloric requirements 4. Prenatal vitamins and iron supplementation until postpartum checkup

B. Relief of Fatigue 1. Following birth → exhaustion or euphoric with energy a) Evaluate individual needs 2. Fatigue common a) Expected resolve over first few postpartum weeks b) Sleep deprivation contributes to problem 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Mother sleeps → adult in room or newborn to nursery d) Severe → complicate recovery process, parental self-efficacy, parenting behaviors 3. Teaching for self-care a) Nearly all new mothers (1) Cesarean birth → newborn and own recovery b) Counsel to sleep when baby sleeps c) Ask for help d) Call provider if signs of anemia, infection, thyroid dysfunction, unrelenting fatigue

C. Resumption of Activity 1. Gradually increase ambulation and activity a) Naps, avoid heavy lifting, avoid excessive stair climbing b) Week 2 → light housekeeping c) All activities when lochial flow stopped, around 4 to 5 weeks 2. Teaching for self-care a) Suggestions to limit number of activities b) Increase in lochia → increase rest periods, decrease extra activities

D. Postpartum Exercise 1. Simple exercises in birthing unit 2. Promotes well-being and less fatigue 3. Teaching for self-care a) Kegel exercises immediately after birth b) Short walks c) Abdominal exercises d) Regular exercise after 6-week postpartum examination

VI.

Promotion of Family Wellness and Shared Parenting

A. Satisfactory maternity experience → positive for whole family 1. Family-centered care a) Mother–baby care, couplet care b) Skin-to-skin (SSC) care positive effects on infants c) Crib near mother’s bed (1) Self-contained unit (2) On-demand feeding d) Flexible to permit baby to nursery e) Involved fathers → may not have role model, support, resources (1) Anticipatory guidance

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Reactions of Siblings 1. Sibling visitation meets needs of siblings, mother a) Visiting hours more flexible b) See Figure 33–3: This young girl visits her mother …,p. 901 c) Sibling prepared → arrival requires adjustments d) Have father carry baby inside → mother’s arms free to immediately hug, hold older children e) Working with parents to care for newborn (1) Constant supervision f) Regression common g) Reassurance that older sibling still special, truly loved, valued h) Patent–child time, one-on-one i) Genital differences → simple explanation

C. Resumption of Sexual Activity 1. Risks minimal after 2 weeks a) Abstain from intercourse until perineum healed, lochial flow stopped b) Vaginal dryness → water-based lubrication c) Breastfeeding couples should be forewarned → milk may spurt from nipples 2. Other factors may inhibit satisfactory sexual experience a) Baby’s crying b) Body image c) Sleep deprivation d) Libidinal changes 3. Fatigue 4. Most couples resume sexual activity within 3 months 5. Health promotion education a) Discuss normal sexual changes that frequently occur b) Facilitate open dialog

D. Contraception 1. Family planning information before discharge a) Consistency of use outweighs absolute reliability b) Method appropriate for couple 2. Health promotion education a) Discuss available contraceptive methods b) Written information c) Stress that pregnancy can occur before first menstrual period

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Parent–Newborn Attachment 1. Interventions designed to promote feelings of well-being, comfort, satisfaction a) Determine the childbearing/childrearing goals of the infant’s parents (1) Incorporate them when planning nursing care for the family b) Postpone eye prophylaxis for 1 hour after birth to facilitate eye contact c) Provide private time in first hour after birth for the new family, encourage SSC d) Arrange setting so nurse–patient relationship can be developed and maintained e) Encourage the mother to tell her birth story f) Encourage the parents to involve the siblings g) Use anticipatory guidance from conception through the postpartum period h) Include parents in any nursing intervention, planning, and evaluation i) Initiate and support measures to alleviate fatigue in the parents j) Help parents identify, understand, accept both positive and negative feelings related to the birth, the newborn, and the overall parenting experience k) Support and assist parents in determining the personality and unique needs of their infant 2. Allow parent to care for baby as soon as possible a) Observe beginnings of parent–newborn attachments b) Remember cultural values, beliefs, practices 3. Health promotion education a) Advise parents that they may experience feelings of uncertainty b) Provide reassurance c) Normal infant behavior and activity d) Explain that new attachments, new relationships have discovery

VII.

Nursing Care Following Cesarean Birth

A. 32% women delivered by cesarean birth in United States in 2014 1. Similar postpartum needs with surgical needs

B. Promotion of Maternal Physical Well-Being After Cesarean Birth 1. Promotion of comfort, safety, prevention of postoperative complications a) Routine postpartum assessments (1) Inspection of dressing, incision (2) Lung sounds (3) Gastrointestinal status (4) Genitourinary status b) Immobility → increases chances of pulmonary infection (1) Incentive spirometry, cough and deep breathe every 2 to 4 hours (2) Increases risk of abdominal distention, deep vein thrombosis, pulmonary embolism (a) Dangle legs on side of bed, early ambulation

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Assess pain level, provide relief as needed a) Administer analgesic medications b) Promote comfort through positioning, back rubs, oral care, reduction of noxious stimuli c) Encourage presence of father or partner, newborn d) Encourage use of breathing, relaxation, distraction e) Instruct woman to splint incision with pillow f) Encourage adequate rest periods g) Encourage early ambulation h) Allow woman to begin judiciously consuming food and fluids as desired when awake and alert 3. Neuraxial analgesia a) Administered first 24 hours following birth 4. Patient-controlled analgesia (PCA) a) PCA → woman given bolus at beginning of therapy, presses button to self-administer small doses as needed (1) Preset with time lockout (2) Feel less anxious 5. Oral analgesics 6. General anesthesia → abdominal distention may occur a) Leg exercises, abdominal tightening, avoiding carbonated beverages, avoid straws b) Mylicon 7. Positioning for activities a) Feeding, holding b) Pillow in lap c) Football hold d) Demonstrate body mechanics for getting out of bed 8. Special needs following discharge a) Sleep, rest b) Incisional care c) Assistance with household chores d) Infant care e) Self-care f) Pain relief 9. Teaching for self-care a) Assist in identifying interventions to relieve pain b) Encourage to take medication regularly c) Avoid prolonged activity d) Frequent rest e) Help identify resources for assisting mother

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

C. Promotion of Parent–Newborn Interaction After Cesarean Birth 1. Factors may hinder successful interactions a) Physical condition of mother and newborn, reactions of mother b) Condition of infant c) Skin-to-skin contact (SSC) as soon as possible → father or mother d) Signs of grief response to loss of fantasized vaginal birth experience e) Positive support to couple (1) Allow to tell story (2) Allow them to make choices (3) Presence of father positively influences woman’s perceptions of birth event f) Perception of and reactions to birth (1) Mothering role perceived as extension of childbearing role (2) Might lead to feelings of failure, frustration g) Teaching for self-care (1) Advise mother she can hold, cuddle, lift, feed infant (2) Assist with positioning (3) Advise to care for infant → delegate other household duties

VIII.

Nursing Care of the Obese Postpartum Mother

A. Increasing in United States 1. Special needs a) Risk for postpartum hemorrhage, increased risk of postpartum mortality (1) Vigilant assessment of the fundus b) Assess for airway obstruction, hypoxia c) Encourage early ambulation d) Sequential compression devices (SCDs) e) Mother to demonstrate incision care f) Mother needs to recognize signs of infection, dehiscence g) Safety needs with transfer, position changes, ambulation h) Emotional needs (1) Sometimes experience prejudice, psychologic distress, and humiliation (2) Bed size, transport equipment, etc. 2. Teaching for self-care a) Advise to ambulate as early as possible b) Teach symptoms of infection, what to report c) Children at risk for obesity, impaired glucose tolerance, cardiometabolic complication

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IX.

Nursing Care of the Adolescent Postpartum Mother A. Transition to motherhood stressful for adults → teen mothers with fewer resources 1. Newborns more likely to be low birth weight, preterm, die in infancy

B. Same basic physical care needs 1. May not have working knowledge of their own anatomy and physiology 2. Demonstrate self-care 3. Detailed teaching on contraception

C. Nurse–patient relationship 1. Sensitivity, nonjudgmental 2. Still trying to meet educational goals 3. Relying on others

D. Opportunities for teaching 1. Serve as role model 2. Ensure adolescent mother has knowledge and skills to care for newborn 3. Newborn physical exam at bedside a) Gives adolescent permission to explore baby b) Group classes with other adolescent mothers 4. Information about options in community a) Adolescent clinics b) Support groups and programs c) Group classes

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Nursing Care of LGBTQ Postpartum Mothers A. Body of knowledge growing for care of lesbian, gay, bisexual, transgender, and queer (LGBTQ) families 1. Role of nonbiological lesbian co-mothers 2. Follow cue of family

B. Maintain attitude that is respectful, caring, open 1. Quality, patient-centered care for any woman 2. Ask for guidance regarding special needs or requests 3. Postpartum instructions on intercourse and contraception might need to be individualized and amended

XI.

Nursing Care of the Postpartum Mother with Special Needs

A. Women with physical, developmental, or intellectual disabilities, those suffering from chronic health conditions → at risk during this time period B. Postpartum time period → great growth, challenges, learning opportunities 1. Developmental or intellectual disabilities → risk 2. Present information in easy-to-understand format

C. Needs assessment 1. Community and private resources

XII.

Nursing Care of the Postpartum Mother with a History of Sexual Abuse

A. Tend to have more anxiety and stress related to procedures, interactions, and being touched in general 1. Difficulty establishing trust

B. Ensure privacy, safety, trust C. Screened for PPD prior to discharge D. Support groups E. Privately question all patients regarding feeling safe returning to home environment

XIII.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

A. Relinquishing mother → chooses an adoption plan or one who has conceived via traditional or gestational means and is acting as a surrogate mother 1. Traditional adoption becoming more rare 2. Reasons for choosing adoption vary a) Single parenting b) Inability to care financially for child c) Unable to care for another child, multiple children d) Do not have desire, maturity to be mothers e) Complicated psychosocial issues f) Personal and complex 3. Private and public agencies 4. Adoptive parents may be openly involved in the labor and birth 5. Use critical thinking and flexibility

B. Compassionate patient-centered care 1. Communicate plan to other staff 2. Act as primary support if woman alone 3. Respect amount of contact requested 4. Respectful communication a) Adoption plan b) Finding family to parent your child 5. Acknowledge significance of birth mother’s experience a) Loss and grief b) At risk for disenfranchised grief → grieving process, resolution c) Refer to support group, organization, therapist, clergy

XIV.

Discharge Information A. Frequently discharge within 24 to 48 hours 1. Home health services

B. Preparation for discharge begins on admission 1. See Key Facts to Remember: Discharge Teaching, p. 910 2. Woman should contact caregiver if she develops any signs of possible complications: a) Fever b) Change in lochia c) Evidence of mastitis 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Evidence of thrombophlebitis e) Evidence of urinary tract infection f) Evidence of infection g) Continued mood changes, signs of postpartum depression h) Severe pelvic pain, abdominal tenderness i) Chest pain or shortness of breath j) Signs of preeclampsia such as headache or swelling of the face or extremities 3. Woman should review literature she has received 4. Woman should be given phone numbers of postpartum unit, lactation consultant, nursery 5. Woman should be given information on local agencies, support groups 6. Information regarding feeding methods 7. Scheduled appointments 8. Woman should understand procedure for obtaining copies of birth certificate 9. New parents should be able to provide home care 10. Parents should be aware of signs, symptoms in infant that indicate possible problems 11. Parents should be given information about postpartum mood and anxiety disorders

C. Reassurance of couple’s ability to be successful parents 1. Address follow-up visits as appropriate 2. Family approach as appropriate, with father, siblings

XV.

Evaluation of the Postpartum Family 1. Mother and infant remain healthy, safe, free of injury or complications 2. Mother verbalizes comfort, uses self-comfort measures as appropriate 3. Mother verbalizes feelings, concerns related to birth event and newborn 4. Mother performs appropriate self-care measures 5. New parents demonstrate safe, effective care of baby 6. Parents and newborn display positive bonding behaviors 7. Mother–newborn dyad demonstrates successful breastfeeding a) Parents describe safe formula preparation; demonstrate safe bottle feeding b) Mother describes appropriate breast care

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

8. Mother is rested, verbalizes understanding of importance of gradual return to activities 9. Mother identifies sources of support to assist with newborn care and family responsibilities 10. Mother states plan for follow-up healthcare for herself and infant 11. Mother identifies signs, symptoms of maternal newborn complications and reasons to seek care before routine follow-up visits 12. Cesarean birth mother states in own words reason for cesarean birth, verbalizes feelings 13. Cesarean birth mother verbalizes comfort and maintains mobility 14. Obese patient remains free of injury or complications 15. Adolescent mother expresses her feelings about the childbearing experience and verbalizes knowledge of resources for continued support 16. Woman relinquishing newborn verbalizes rationale for decision a) Demonstrates acceptance of decision 17. All women and their husbands or partners have been supported a) Culturally (1) Special considerations related to age, sexual preference, ethnic background b) Abilities c) Histories 18. The mother and father/partner are aware of symptoms of postpartum mood and anxiety disorders 19. All components of nursing care designed to achieve outcomes identified for the woman and her family

XVI.

Focus Your Study

XVII.

Activities 1. Individual Have students prepare drug cards for the following medications: • Percocet 5/325 • Vicodin • Rubella virus vaccine • RhoGAM • Ibuprofen • Lortab • Mylicon 2. Small Group Divide the class into small groups of three to five students. Have each group brainstorm and pick two areas of new-mother teaching the group feels are often left out or underemphasized. 19 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Encourage the groups to draw on personal experience, if possible. Have each group prepare a teaching plan for the new mother on these two areas and cite their references in APA format. 3. Large Group Lead a class discussion on diversity in parenting. Focus on the cultures and ethnic groups common to your area. Be sure to include alternative lifestyle, surrogacy, and single parenting by choice in your discussion. The goal of the discussion is the following: • Identify areas of education that might be different for the new family. • Identify areas of education that might be necessary for nurses.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 34 Home Care of the Postpartum Family Role of Length of Stay and Professional Guidelines for Discharge………………

Considerations for the Home Visit..................................................................

Home Care: The Newborn...............................................................................

Home Care: The Mother and Family...............................................................

Other Types of Follow-Up Care.......................................................................

Focus Your Study.............................................................................................

Activities..........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Role of Length of Stay and Professional Guidelines for Discharge

A. 1998 Newborns’ and Mothers’ Health Protection Act (NMHPA) 1. Provides minimum stay of 48 hours for uncomplicated vaginal birth a) 96 hours following uncomplicated cesarean birth b) American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) → decision to discharge made by providers caring for newborn and mother in consultation with family c) See Table 34–1: Minimal Criteria for Discharge of Healthy Term Newborns, p. 916

II.

Considerations for the Home Visit

A. Purpose and Timing of the Home Visit 1. 60% of women attend postpartum visit at 4 to 6 weeks after birth 2. Focuses on assessment, teaching, counseling a) Days 3 to 6 (1) Peak potential for newborn jaundice, weight loss, dehydration 3. Postpartum home care → expanding information, reinforcing self- and infant care a) Assess home safety b) Exercise critical thinking, creativity

B. Fostering a Caring Relationship with the Family 1. Birthing center strives to enhance family autonomy → institutional constraints a) Home visit very different b) Nurse is visitor 2. Goals a) Regard for patient b) Genuineness c) Empathy d) Trust and rapport 3. See Table 34–2: Fostering a Caring Relationship, p. 917

C. Planning the Home Visit 1. Identify purpose of visit 2. Gather anticipated materials and equipment 3. Communicate with primary healthcare provider(s), review inpatient records 4. Personal contact to arrange appointment a) Identify purpose and goals 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Maintain safety 1. Nurses exposed to safety hazards with traveling and during home visits 2. Risks 3. Basic safety rules a) Confirm address b) Outline route vis GPS if available c) Provide schedule of visits to supervisors d) Notify when leaving for visit, when finished with visit e) Carry cellular phone with battery charged f) Carry hard copy of agency, emergency phone numbers g) Ensure vehicle well maintained h) Wear a name tag, carry identification i) Carry flashlight j) Avoid wearing any jewelry k) Lock personal belongings in trunk, out of sight l) Call patients to confirm at home, expecting nurse m) Identify all individuals present in home at start of visit n) Pay attention to body language of all present during visit o) If any threatening, sexually inappropriate behavior, presence of weapons, threatening pets, illegal substance use, or issues that make the nurse feel unsafe occur, terminate p) Be aware of personal body language and how it might be interpreted q) Have car keys in hand before returning to vehicle r) Lock the doors and drive away upon return to the vehicle at the completion of visits s) Inform supervisor immediately of any threatening situation, assault, or injury t) Notify authorities if a crime has been committed 4. Drive neighborhood before visit a) Two nurses together b) Violence in progress → do not enter, call 911 5. Home care agencies → violence protection programs a) Policies, safety education b) Escort as necessary c) Code phrases, set plan for unsafe situations d) Independent personal safety training 6. Review plans before accepting employment 7. Be aware of surroundings

E. Carrying Out the Home Visit 1. Introduce self, confirm location a) Introductions to others

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Where to sit 2. Uniform assessment tool → determine actions a) Direct physical care b) Conduct patient and family teaching c) Consult with physician, midwife, specialist d) Refer woman or family to appropriate community agencies e) Schedule additional home visits or telephone follow up 3. Nurse needs excellent assessment skills a) Observing variations from norm b) Critical thinking c) Problem solving d) Effective communication

III.

Home Care: The Newborn

A. Can provide positive feedback, suggest alternatives 1. Each newborn has variations 2. Birthing unit nursery staff available 3. Should have been taught caregiving methods before discharge a) Complete teaching, review of initial teaching b) Questions regarding infant care, feeding, signs of illness

B. Home visits associated with reduction in adverse undetected health issues and cost savings C. Physical Assessment of the Newborn at Home 1. Newborn physical exam a) General appearance b) Vital signs c) Skin d) Respiratory e) Cardiovascular f) Neurologic g) Gastrointestinal h) Genitourinary i) Musculoskeletal j) Behavioral state k) Parent–newborn interaction

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Screening exams done 3. Assessment of late preterm infants a) Born between 34 and 36 6/7 gestational weeks 4. Risk for complications 5. Home health visit within 24 to 48 hours of discharge a) Assess frequency, duration of breastfeedings b) Frequency and amount of formula c) Input, output, weight, hydration status d) Parent education e) Hyperbilirubinemia more likely f) Instructions on hand washing, avoiding infection g) Ongoing assessment

D. Positioning and Handling of the Newborn 1. Demonstrate methods of positioning, handling newborn a) See Figure 34–2: Various positions for holding a newborn …, p. 921 2. Cradle hold 3. Upright position 4. Football hold

E. Skin Care and Bathing 1. Maintains temperature, barrier a) Port of entry 2. Bath demonstration best way to provide information a) Bathing every other day → avoid drying skin b) Neutral pH cleansing agents c) Immersion baths safe prior to cord separation d) See Box 34–1: Bath Supplies, p. 921 e) May use dishpan, kitchen sink, large bowl f) Washcloths (2) (1) Towels (2) (2) Blankets (2) (3) Unperfumed mild skin cleanser (4) Shampoo (5) Petrolatum product or diaper ointment, if indicated (6) Diapers (7) Clean clothes g) Silence phone, don’t answer door—never leave baby unattended

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Sponge bath →Tub/container filled with 5 inches of water → warm to touch: a) 38°C to < 40°C (100°F to < 104°F) b) Flat, protected surface → never leave unattended c) Wrap dampened washcloth around index finger once d) Eye wiped from inner to outer canthus e) Different portion for each eye f) Then ears → washcloth around index finger, external ear, behind ear g) Rinse washcloth → wipe remainder of face h) Neck washed carefully → mild soap i) Bathe upper and lower body separately j) Neck, face clean, dry → unwrap blanket, remove T-shirt, wet chest, back, arms with washcloth k) Lather hands → wash → rinse → dry → wrapped l) Unwrap legs → wet → lather → rinse → dry m) Dry skin → emollient (1) Avoid baby oil, baby powder n) Genital area cleansed after each diaper o) Uncircumcised males → clean penis daily p) Wrapped in terry cloth towel, patted dry q) Wash hair last r) Football hold, head tilted downward s) Moisten hair, lather t) Rinse, towel dry 4. Tub bath a) Wash face, eyes, ears, neck as in sponge bath b) Immerse in sink, baby tub c) Hold securely d) Slippery when wet e) Sock over supporting arm f) See Figure 34–3 When bathing the newborn …, p. 922 g) Double blanket in clean, dry blankets h) Dress when dry

F. Cord Care 1. Teaching a) Wash hands before and after handling cord b) Keep cord clean and dry c) Keep cord exposed to air, loosely covered d) Keep diaper folded below cord e) Clean cord if it becomes soiled with urine or stool f) Dry cord thoroughly after cleansing

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Inspect cord during each diaper change, bath a) May smell earthy, small amount of mucus present → normal b) Notify healthcare provider if any drainage, foul smell, redness, swelling, discoloration

G. Nail Care 1. May adhere to skin within first days of life 2. Cutting is contraindicated 3. Separate, break off 4. File with newborn file when infant asleep 5. Socks or mittens on hands

H. Dressing the Newborn 1. Needs to wear T-shirt, diaper, sleeper a) Dress more warmly if home maintained at 60°F to 69°F b) Cover head outdoors c) Protect with shade from sun 2. Diaper shapes vary a) Prefolded, disposable → rectangular b) Cloth diapers → triangular or kite-folded c) See Figure 34–4: Two basic cloth diaper shapes ..., p. 924 d) Launder separately with mild soap e) Presoak diapers 3. Swaddling the newborn a) Helps newborn maintain body temperature b) Provides feeling of closeness and security c) Effective in quieting crying baby d) See Figure 34–5: Steps in wrapping a baby, p. 924

I. Temperature Assessment, Fever, and Illness 1. Provide opportunities for discussion and demonstration for taking temperature 2. Take only when signs of illness are present 3. 36.5°C to 37.4°C (97.7°F to 99.3F°) considered normal 4. Rectal method considered gold standard → risk of trauma 5. Tympanic not recommended or found accurate in young infants 6. Axillary safe for babies < 4 weeks a) Add 0.4 C to estimate rectal temperature

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Infrared scanning thermometers commercially available 8. Recommend purchasing thermometer designed to measure infant temperature a) Ensure no mercury thermometer 9. Use same thermometer and measurement site during the course of one illness 10. Under 90 days of age → see provider if newborn has a rectal temperature of 100.4°F or axillary of 99.4 F 11. Other signs of systemic infection a) Subtle manifestations b) Temperature instability c) Poor feeding d) Abdominal distention e) Inability to tolerate feedings f) Apnea g) Alterations in behavior h) “Just not acting right”

J. Stools and Urine 1. Appearance, frequency of newborn’s stools concern a) Babies expected one meconium stool on first day b) One to two stools on day 2 c) One to three stools daily by days 3 to 4 d) One to four stools daily on days 4 to 7 e) Formula-fed babies may have one to two stools daily f) Stools darker, more formed 2. Show pictures so family knows what to expect 3. Urination a) One in first 24 hours b) Twice in second 24 hours c) Three to five voids days 3 to 5 d) By day 5, five or more wet diapers per day 4. Diaper area care a) Diaper area cleansed, well dried with each diaper change b) Diaper dermatitis (1) Short periods of time air-drying with no diaper (2) Minimal soap required (3) Alcohol-free wipes c) Irritant diaper dermatitis (IDD) → Localized, nonimmunologic reaction to the friction, occlusion, moisture, urine, feces, chemicals in the diaper environment d) Even with proper care → some type of diaper rash e) Petrolatum provides protection from wetness, promotes healing 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

f) Commercial products g) Petrolatum, zinc oxide h) Lanolin may be allergenic i) If rash persists more than 2 to 3 days contact healthcare provider

K. Sleeping 1. Sudden infant death syndrome (SIDS) preventions 2. Sudden unexpected death of an infant less than 12 months of age not explained by autopsy, site investigation, clinical history 3. 2011 “Back to Sleep” guidelines 4. Preventions a) Babies should sleep on their backs (1) See Figure 34–6: Babies should be placed on their backs when sleeping, p. 926 b) Firm crib mattress c) Room sharing without bed sharing d) Loose bedding and soft objects removed from crib e) Smoking exposure should be avoided before and after birth f) Alcohol and illicit drug exposure avoided g) Babies should be breastfed unless contraindicated (1) Exclusive breastfeeding for at least 6 months ideal h) Babies should not be offered a pacifier while falling asleep i) Babies should not be overheated j) Babies should receive their immunizations k) Positioning devices not recommended l) Babies should not sleep with cardiorespiratory monitors attached unless prescribed m) Babies should have tummy time n) Pregnant women should follow the recommended schedule for prenatal care 5. AAP guidelines for healthy infants 6. Crib safety a) Observe crib, bassinet, cradle, mat, other devices b) Crib should be a recent model with mattress that fits snugly and designed to prevent entrapment and suffocation c) Consumer Product Safety Commission (CSPC) updated requirements for crib safety in 2010

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

L. Proper Positioning 1. Placed in supine position to sleep 2. Encourage to hold infants upright for 10 to 15 minutes after feedings 3. Remind parents to teach caregivers

M. Sleep–Wake States 1. Several periods of reactivity 2. Deep sleep 3. Light sleep 4. Drowsy awake state 5. Quiet alert state 6. Active alert state 7. Crying state 8. Response to unpleasant stimuli → Individual patterns after 2 to 3 days 9. Comfort by swaddling, rocking, or other reassuring activities 10. See Figure 34–7: Picking up babies and consoling them …, p. 929

N. Injury Prevention 1. Accidental injuries fifth leading cause of death in infants under 1 year a) Suffocation b) Homicide c) Motor vehicle accident d) Drowning e) Fire/burns f) Natural/environment g) Most common nonfatal accidental injuries < 1 year of age in 2014 were falls, strikes, bites or stings, foreign bodies, inhalation/suffocation, fires/burns 2. Share information regarding common injuries, accidents 3. Care seat safety 4. Observe environment → observe for childproof changes to be made 5. Abusive head trauma (AHT) a) Previously called shaken baby syndrome (SBS) → non-accidental traumatic brain injury that results from violent shaking

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Swelling, increased cranial pressure, bleeding result → may sustain permanent neurologic damage b) Risks (1) Infant crying (2) If male caregiver; less educated, young, substance-abusing, poorly supported, (3) Single parent; history of poor impulse control; history of prior military service; history of abuse as a child; and living in poverty c) The Period of PURPLE Crying (1) P: Peak of crying (2) U: Unexpected/unexplained (3) R: Resists soothing (4) P: Pain-like face (5) L: Long lasting (6) E: Evening and late afternoon d) Educate parents on techniques (1) Singing, swaddling, gentle rhythmic movements, white noise, offering a pacifier before the baby is crying vigorously 6. Colic as a parental stressor a) Manifested by persistent, unexplained, inconsolable crying b) Can continue for several hours each day, often in evening (1) Can start 2 to 3 weeks of age through 4 to 6 months (2) Etiology unknown; gastrointestinal in nature c) Interventions (1) Dietary (a) Maternal hypoallergenic diet may be helpful for breastfed babies (b) Switching from cow’s-milk formula to a soy or hydrolyzed formula for those who are formula-fed (2) Pharmacologic agents (a) Simethicone, herbal agents, sugar dicyclomine, cimetropium bromide (3) Manipulative techniques (a) Infant massage (4) No definitive treatment d) Guidance (1) Strain on family relationships (2) Risk for abuse (3) Lay baby down safely to take a break

O. Newborn Screening and Immunization Program 1. Screening tests a) Detect disorders than can cause physical, intellectual, and developmental complications, death b) Second blood specimen after 7 to 14 days

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Newborn hearing screenings administered prior to discharge 3. Ensure family has information on childhood immunization schedule 4. Confirm Tdap status of mother

IV.

Home Care: The Mother and Family A. Assessment of Mother and Family at Home 1. Specifically 2. Progression of lochia 3. Fever or malaise 4. Dysuria or difficulty voiding 5. Pain in the pelvis or perineum 6. Painful, reddened hot spots or shooting pains in the breasts during or between feedings 7. Areas of redness, edema, tenderness, warmth of legs 8. Also discuss diet, fatigue, ability to rest, sleep, pain management, signs of postpartum complications, activity, sexuality issues, self-care ability, social support system, cultural or religious practices 9. Physical assessment 10. Psychologic assessment 11. Attachment, adjustment to parental role, maternal emotions, sibling adjustment, educational needs 12. Provide teaching to mother and family

B. Postpartum Fatigue 1. Inform mothers it may be significant problem 2. Emphasize nutrition, periods of uninterrupted sleep 3. Continued vitamins and iron

C. Breastfeeding Concerns Following Discharge 1. Healthy People 2020 goal to increase infants breastfed from 74 to 89.1% exclusively until 3 to 6 months of age and increase number breastfed until 6 to 12 months 2. Benefits to mother, infant, society 3. Anticipatory guidance and support a) Home visit time to promote continued breastfeeding 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Infant to be seen by 3 to 5 days of age → assess weight, jaundice, hydration, elimination 4. Breastfeeding assessment a) Observe feeding episode (1) Positioning (2) Latch on (3) Let-down (4) Sucking pattern (5) Nipple condition (6) Infant response (7) Maternal response (8) Use tool to assess, like LATCH Scoring 5. Concerns related to the breastfeeding baby a) Infant weight remain within 10% of birth weight b) Assist with techniques to increase milk production, promote milk transfer (1) Every 2-hour feedings (2) Nurse can assist with pumping or hand expressing c) Assistance in awakening to feed at least eight times/day in first week of life d) Feeding cues e) Concerns related to breast milk supply (1) Audible swallowing (2) Milk at mouth f) Continue nursing on demand at least every 3 hours 6. Concerns related to maternal breastfeeding difficulties a) Newborn should maintain weight within 10% of birth weight (1) If experiencing a 7 to 9% newborn weight loss with techniques to increase milk production and promote better milk transfer (2) Encourage feeding every 2 hours (3) Assess milk production (4) Quiet alert state is ideal for latch-on b) Signs of adequate milk transfer during the first week of life (1) Baby swallows audibly during feedings. (2) Mother’s nipple is moist after feedings. (3) Baby has moist mucous membranes and skin is elastic. (4) Mother and baby both appear satisfied and comfortable after feedings. (5) Baby passes three to five loose yellow stools per day by day 4 or 5 (6) Six or more diapers are saturated with clear urine each day by the end of the first week (7) Baby actively suckles eight or more times in 24 hours for a total of 140 minutes or more c) Concerns related to maternal breastfeeding difficulties d) Nipple soreness (1) Sensation of massaging, stretching as infant elongates nipple 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Erythema, edema, abrasions, fissures, cracks, bruises, blisters, bleeding → mechanical trauma f) Observe latching g) Rotate positions when feeding infant h) Observe baby’s oral cavity for anatomical concerns i) Baby will suck rapidly at beginning of feeding j) Nipple elongated at end of feeding k) Comfort measures l) Warm water compresses, avoiding soap on breasts m) Gently massage before feeding stimulates let-down n) Air-drying (1) See Figure 34–9: Air-drying the nipples can help prevent cracking and fissures, p. 937 o) Breast shells over nipples between feedings p) Talk with lactation consultant or provider q) Home-care nurse can make recommendations 7. Flat or inverted nipples a) Most able to breastfeed b) Cold pack will evert a flat nipple c) Side-lying position d) Use of a pump before latch-on 8. Breast engorgement a) Fullness versus engorgement b) Engorgement → hard, painful, warm, taught and shiny c) May be accompanied by fever d) Warm compresses, showers before nursing e) Breast massage f) Cold compresses applied after nursing g) Cabbage compresses h) Ultrasound i) Milk expression j) Anti-inflammatory medication effective k) Acupuncture l) Pumping m) Unrelieved → involution, decreased milk synthesis 9. Plugged ducts a) Areas of tenderness, redness, heat, palpable lump b) May be relieved by massage c) Frequent feedings 10. Mastitis a) Plugged ducts, milk stasis → increase risk for mastitis b) Stress, cracked nipples, fatigue, abundant milk supply c) Symptoms: 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Fever e) Hot, red, tender area on breast f) Flulike symptoms g) Treatment h) Continue breastfeedings i) Moist heat j) Increased fluids k) Rest l) Analgesics m) Antibiotics 11. Effects of medications and alcohol a) Analgesics as directed by primary healthcare provider b) Acetaminophen or nonsteroidal anti-inflammatory (NSAIDs) safe for use during breastfeeding c) Alcohol passes into breast milk d) Not recommended for breastfeeding women e) Consume after breastfeeding 12. Breastfeeding and the working mother a) Help woman to explore options, solve problems related to breastfeeding b) If not pumped supply will decrease c) Begin pumping before returning to work d) Methods of maintaining breast milk e) Use of side-lying position when nursing before, after work f) Normal to have feelings of anxiety, guilt, doubt when returning to work 13. Weaning a) Process that begins with introduction of sources other than breast milk b) Ends when child no longer breastfeeds c) Provide anticipatory guidance and support to extend breastfeeding as long as possible d) Gradual approach physically, emotionally comfortable for mothers, babies 14. Developing cultural competence a) Cultures vary tremendously b) Home-care nurse needs to individualize care 15. Breastfeeding referrals and social support a) Support from family, social contacts important b) Providers of care need to be knowledgeable c) Local support groups

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Formula Feeding 1. AAP recommends iron-fortified formula until 1 year if not breastfed 2. Human milk substitute 3. Ready-to-feed 4. Liquid concentrates 5. Powder forms 6. Mix formula exactly as package directs 7. World Health Organization (WHO) guidelines for preparation of powdered formula

Other Types of Follow-Up Care A. Return Visits 1. Up to three visits 2. At 24 hours after discharge, 2 visits over next week

B. Telephone Follow-Up 1. Additional information, address questions 2. Telephone assessment a) Listen skillfully, open-ended questions b) Typically within 3 days of discharge or earlier c) Caring attitude d) Plan of care include e) Counseling f) Teaching g) Referral h) High level of learning readiness i) Advice line

C. Postpartum Classes and Support Groups 1. More common 2. Series of structured classes a) Socialize b) Provide support c) Parenting topics d) Nutrition e) Exercise f) Concerns

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

D. Support Programs Utilizing Technology 1. Use of phone apps, online support groups, internet discussion boards, social media, and peer support online technologies 2. Evaluate reliability 3. Encourage websites affiliated with government organizations, universities, healthcare organizations

VI.

Focus Your Study

VII.

Activities 1. Individual Have students make a list of equipment that might be appropriate for the home-care nurse to carry into the day 5 postpartum home visit. Instruct students to include sources, if any. 2. Small Group Divide the class into small groups of three to five students. Have each group research the community for new-parent resources of any kind and prepare a list in a format to share with the class. 3. Large Group Invite a home-care agency nurse to speak to the class about the job and the following particulars: equipment, hours, patient care, the positives of the job, and the negatives of the job.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 35 The Postpartum Family at Risk Care of the Woman with Postpartum Hemorrhage.......................................

Care of the Woman with a Reproductive Tract Infection or Wound Infection…………………………………………………………………………………………..

Care of the Woman with a Urinary Tract Infection…………………………………….

Care of the Woman with Postpartum Mastitis...............................................

Care of the Woman with Postpartum Thromboembolic Disease..................

Care of the Woman with a Postpartum Psychiatric Disorder........................

Focus Your Study.............................................................................................

Activities..........................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Care of the Woman with Postpartum Hemorrhage

A. Early (immediate or primary) postpartum hemorrhage (PPH) → first 24 hours after childbirth B. Late (secondary) postpartum hemorrhage → 24 hours to 6 weeks after birth 1. PPH cause of significant maternal mortality and morbidity a) Blood loss greater than 500 mL following childbirth vaginal delivery; 1000 mL following cesarean delivery; 1500 mL during repeat cesarean birth b) Drop in maternal hematocrit levels of more than 10% or more from predelivery baseline or excessive bleeding that causes hemodynamic instability or need for blood transfusion c) Can occur intra-abdominally

C. Early (Primary) Postpartum Hemorrhage 1. Blood volume and cardiac output increased 2. Normal mechanism for hemostasis after expulsion of placenta → contraction of interlacing uterine muscles a) Uterine atony → 80% of PPH cases b) Lacerations c) Retained placental fragments d) Hematomas e) Uterine inversion or rupture f) Problems of placental implantation g) Coagulation disorders 3. Uterine atony a) Contributing factor (1) Overdistention of uterus (2) Prolonged or precipitous labor (3) Oxytocin augmentation or induction of labor (4) Grand multiparity (5) Use of anesthesia (6) Prolonged third stage of labor (7) Preeclampsia (8) Asian or Hispanic heritage (9) Operative birth (10) Retained placental fragments (11) Placenta previa or accrete, placental abruption (12) Obesity b) 4 Ts (1) Tone (2) Trauma 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Tissue (4) Thrombin c) May be slow and steady or sudden and massive (1) Vaginally or large clots (2) Maternal vital signs may not change until significant blood loss has occurred d) Ideally prevented e) Prior history of PPH increases the woman’s risk by double in subsequent pregnancy (1) Active management of third stage of labor, controlled traction on umbilical cord, uterine massage → prevent half of cases of postpartum hemorrhage f) Clinical therapy (1) Stop hemorrhage, correct hypovolemia, treat underlying cause (2) Excessive bleeding → bimanual massage (a) See Figure 35–1: A. Manual compression of the uterus and massage with the abdominal hand will usually effectively control hemorrhage from uterine atony. B. Manual removal of placenta ..., p. 948 (3) Uterine stimulants (a) Oxytocin (b) Ergotamine (c) Prostaglandin analog (d) Misoprostol (e) See Table 35–1: Uterine Stimulants Used to Prevent and Manage Uterine Atony, p. 949 (4) Management by uterine tamponade (a) Use of Bakri balloon (i) Inserted into the uterine cavity and inflated with 300–500 mL of isotonic saline to provide pressure against the uterine walls (b) Permits any continuous bleeding from uterus to be visualized (c) Antibiotics administered while balloon in place (d) If bleeding controlled, tamponade removed after 24 hours (e) Uncontrolled, uterus packed with 4-inch-wide sterile gauze (5) Management by uterine artery embolization (a) Vaginal delivery with unsuccessful tamponade effort → uterine artery embolization (b) Catheter inserted to embolized bleeding vessel → alternative to hysterectomy (6) Surgical management of postpartum hemorrhage (a) Exploratory laparotomy with variety of uterine compression techniques (b) B-Lynch compression (brace suture) (c) Uterine artery surgically ligated to control bleeding (d) Hysterectomy is procedure of last resort (i) Ends childbearing (ii) Emotional distress 4. Lacerations of the genital tract a) Factors that predispose 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Nulliparity (2) Epidural anesthesia (3) Precipitous childbirth (4) Macrosomia (5) Forceps- or vacuum-assisted birth (6) Use of oxytocin b) Bright red blood in presence of firmly contracted uterus c) Episiotomies → blood loss slow, steady bleeding 5. Retained placental fragments a) Can be cause of early PPH → generally most common cause of late PPH b) Partial separation of placenta during massage of fundus before spontaneous separation c) Inspect placenta for intactness after delivery d) Uterine exploration e) Sonography may be used f) Curettage may be necessary 6. Vulvar, vaginal, and pelvic hematomas a) Result of injury to blood vessel from birth trauma b) May happen rapidly with 250–200 ml of blood c) Risks factors (1) Episiotomy (2) Forceps- or vacuum-assisted births (3) Genital tract laceration (4) Primiparity (5) Macrosomia (6) Prolonged second stage of labor (7) Preeclampsia (8) Clotting disorder (9) History of vulvar varicosities d) Small → ice packs, analgesia → may resolve over a few days (1) Heat after 24 hours e) Larger → evacuated with incision and drainage, broad spectrum antibiotics (1) Ligation of vessel (2) Urinary catheter due to packing (3) Risk for infection 7. Uterine inversion a) Prolapse of uterine fundus to, or through, cervix b) Often associated with: (1) Abnormal adherence of the placenta (2) Weakness of uterine musculature or uterine abnormalities (3) Rapid labor (4) Uterine relaxation secondary to anesthesia, drugs (5) Excess traction of cord or vigorous manual removal of placenta 4 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Immediate repositioning of uterus within pelvis (1) Under intravenous tocolysis or general anesthesia 8. Coagulation disorders a) Postpartum bleeding with no identifiable cause b) Disseminated intravascular coagulation (DIC) → preeclampsia, amniotic fluid embolism, sepsis, abruptio placentae, prolonged intrauterine fetal demise syndrome

D. Late Postpartum Hemorrhage 1. Hemorrhage 24 hours to 12 weeks after birth 2. Subinvolution → failure to return to normal size of placental site, retention of placental tissue a) Site of placental implantation last area of uterus to regenerate (1) Postpartum fundal height greater than expected (2) Lochia often fails to progress normally (3) Retained placental tissue → confirm with pelvic ultrasonography b) Commonly diagnosed during routine postpartum examination (1) Enlarged, softer-than-normal uterus c) Oral administration of methylergonovine maleate (1) 0.2 mg every 3 to 4 hours for 24 to 48 hours d) Antibiotics if infection present

E. Nursing Management for the Woman with Postpartum Hemorrhage 1. Nursing Assessment and Diagnosis a) Regular and frequent assessment of fundal position, evidence of uterine tone, contractility b) Monitor bladder for evidence of increasing distention c) Assessment for bleeding → peripads d) Examine perineal area for signs of hematomas e) Notify physician/CNM if hematoma suspected f) Ice packs during first hour after birth → for 8 to 12 hours g) Alert for signs of impending hypovolemic shock 2. Diagnoses may include: a) Fluid Volume: Deficient b) Tissue Perfusion: Peripheral, Risk for Ineffective c) Bleeding, Risk for 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Boggy, soft uterus → massaged until firm, clots removed (2) Weigh perineal pads (3) Catheterize if unable to void (4) Risk factors, frequent massage → maintain vascular access 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(5) Elevate legs to 30 degrees → promote oxygenation, venous return (6) See Key Facts to Remember: Nursing Actions During Postpartum Hemorrhage, p. 951 (7) Call for assistance per protocol (8) Administration of fluid replacement and transfusion, prescribed medications (9) Keep woman comfortable (10) Nothing by mouth (NPO) in case of surgery (11) Anticipate intensive monitoring → prepare woman and family for transfer to intensive care setting (12) Anticipate, request additional resources (13) Provide family with information (14) Collaboration and communication with team (15) Preparing for medical interventions such as IV infusions, blood transfusions, oxygen therapy, medications (16) Monitor urinary output (17) Blood and blood products b) Fluid replacement (1) Normal saline and lactated ringers (2) Rapid administration of warmed crystalloids (3) 3 mL solution per 1 mL of estimated blood lost ratio (4) Careful monitoring c) Monitor for transfusion reactions d) Evaluate for signs of anemia e) Plan activities for adequate rest f) Fatigue associated with blood loss → may need additional assistance caring for infant g) Father can support recovery 4. Health promotion education a) Woman and family need clear written explanations of normal postpartum course (1) Signs of abnormal bleeding (2) Fundal massage (3) Perineal care 5. Community-based nursing care a) Routine discharge instructions (1) Manage fatigue and weakened condition (2) Mother to take care of baby, delegate everything else b) Rise slowly to minimize risk of orthostatic hypotension c) May need assistance caring for newborn d) Needs rest, extra time to rest after activities e) Risk for depression f) Nutritional needs including high in iron g) Count perineal pads for several days h) Risk for infection i) Assess coping strategies j) Realistic information 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

6. Evaluation a) Signs of postpartum hemorrhage are detected quickly, managed effectively b) Maternal–infant attachment maintained successfully c) Woman able to identify abnormal changes that might occur following discharge (1) Understands importance of notifying caregiver if they develop

II.

Care of the Woman with a Reproductive Tract Infection or Wound Infection

A. Puerperal infections 1. Infection of reproductive tract associated with childbirth that occurs at any time up to 6 weeks postpartum a) Occurs at any time up to 6 weeks postpartum b) Most common → endometritis c) Peritonitis d) Respiratory complications e) Acute pyelonephritis f) Thrombophlebitis g) Breast engorgement 2. Preventive measures 3. Prognosis directly related to stage of disease at diagnosis, causative organism, appropriateness of treatment, state of health and immune system 4. Puerperal morbidity → temperature of 38°C (100.4°F) or higher, with temperature occurring on any 2 of first 10 days postpartum, exclusive of the first 24 hours, and when taken by mouth by a standard technique at least four times a day 5. Normal vaginal, cervical bacteria pathogenic a) Following rupture of membranes, during labor and delivery → contamination of cavity can easily occur

B. Postpartum Endometritis 1. Metritis → inflammation of the endometrium portion of the uterine lining a) 1 to 3% of vaginal births b) Primarily affects placental implantation side c) 30% to 35% cesarean births d) Same pathogenesis as vaginal delivery e) Aerobic and anaerobic organisms f) Initial 24 to 36 hours postpartum → group B streptococcus g) Late-onset postpartum endometritis/metritis → genital mycoplasmas and Chlamydia trachomatis

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Risks factors for postpartum uterine infection a) Cesarean birth b) Premature rupture of amniotic membranes (PPROM) c) Prolonged labor preceding cesarean birth d) Multiple vaginal examinations during labor e) Compromised health status f) Use of fetal scalp electrode or intrauterine pressure catheter for internal monitoring during labor g) Obstetric trauma h) Chorioamnionitis i) Preexisting bacterial vaginosis or Chlamydia trachomatis j) Instrument-assisted childbirth—vacuum or forceps k) Manual removal of the placenta or uterine exploration after delivery l) Retained placental fragments m) Lapses in aseptic technique by surgical staff n) Diabetes mellitus o) Immunocompromised status 3. Foul-smelling lochia, fever, uterine tenderness on palpitation, lower abdominal pain, tachycardia, chills 4. Antibiotics prior to surgery decreases incidence by up to 60%

C. Postpartum Wound Infections 1. Classic signs a) Redness, warmth, edema, purulent drainage, gaping of previously approximated wound, pain b) Cesarean delivery → concurrent endometritis (1) May have cellulitis without exudate (2) Culture exudate 2. Clinical therapy a) History and physical, cultures, blood tests, urinalysis b) Localized infection treated with broad-spectrum antibiotics, sitz baths, analgesics c) Evidence of pus → opened and drained (1) Packed and repacked two to three times daily d) Antibiotics with coverage against Staphylococcus aureus (1) Intravenous antibiotics for endometritis (2) Generally improve within 2 days of starting (a) If afebrile and asymptomatic for 24 hours → discontinue (i) If fever continues after 48 hours → continue workup

D. Nursing Management for the Postpartum Woman with Puerperal Infection 1. Nursing Assessment and Diagnosis a) Inspect perineum or abdominal wound site every 8 to 12 hours 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) REEDA scale (1) Redness, edema, ecchymosis, discharge, approximation c) Fever, malaise, abdominal pain, foul-smelling lochia, larger than expected uterus, tachycardia, other signs of infections → noted and reported 2. Diagnoses may include: a) Injury, Risk for b) Pain, Acute c) Parenting, Risk for Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Standard precautions (2) Aseptic technique (3) Teaching self-care to prevent infection (4) Draining wound → clear instructions about wound care, hand washing, linens (a) Ongoing assessment of urine specific gravity, intake and output (5) Medications and IVs as ordered (6) Promoting maternal–infant attachment (7) Breastfeeding mother can pump (8) Bonding with father (a) See Nursing Care Plan: For the Woman with a Puerperal Infection, p. 956 b) Community-based nursing care (1) Assistance when discharged from hospital (2) Instruction in care of newborn including feeding, bathing, cord care, immunizations, significant observations that should be reported (3) Instructions regarding activity, rest, medications, diet, signs and symptoms for complications c) Evaluation (1) Infection quickly assessed, treatment instituted successfully without further complications (2) Woman understands nature of infection and purpose of therapy (a) Carries out any ongoing antibiotic therapy necessary after discharge (3) Maternal–newborn attachment maintained

III.

Care of the Woman with a Urinary Tract Infection

A. Overdistention of the Bladder 1. Trauma, effects of anesthesia, nulliparity, instrumental childbirth, prolonged labor 2. Clinical therapy a) Draining bladder with straight catheter one time (1) Recurs → indwelling catheter for 24 hours

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Nursing Management for the Postpartum Woman with a Urinary Tract Infection 1. Nursing Assessment and Diagnosis a) Overdistended bladder appears as large mass, reaching to umbilicus, displacing uterine fundus upward and to one side 2. Diagnoses include: a) Infection, Risk for b) Urinary Retention 3. Nursing Plan and Implementation a) Diligent monitoring of bladder b) Encourage to void c) Medicate for pain prior to voiding d) Ice packs to perineum to minimize edema e) Warm water, sitz bath f) Aseptic technique if catheterization necessary g) Clamp catheter if urine amount reaches 800 mL (1) Document, vital signs (2) Unclamp place on gravity drainage 4. Evaluation a) Woman voids adequately to meet demands of increased fluid shifts during postpartum period b) Woman does not develop infection due to stasis of urine c) Woman actively incorporates self-care measures to decrease bladder distention

C. Cystitis (Lower Urinary Tract Infection) 1. Retention of residual urine, bacteria, bladder traumatized by childbirth a) Ascends from urethra to bladder b) Escherichia coli → most common cause 2. Clinical therapy a) Clean-catch, midstream urine sample b) Assist woman c) Antibiotic therapy before culture and sensitivity (1) Frequently trimethoprim-sulfamethoxazole-double strength (Bactrim DS, Septra DS) d) Antispasmodic or urinary analgesic agents, such as phenazopyridine hydrochloride (Pyridium)

D. Nursing Management for the Postpartum Woman with Cystitis 1. Nursing Assessment and Diagnosis a) Void every 2 hours to prevent urinary stasis b) Report symptoms of incomplete emptying of bladder or dysuria c) Symptoms of acute cystitis 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) Usually start 2 to 3 days after birth (a) Pyelonephritis → systemic symptoms 2. Diagnoses may include: a) Pain, Acute b) Health Management, Ineffective 3. Nursing Plan and Implementation a) Screening for asymptomatic bacteriuria in pregnancy b) Frequent emptying of bladder during labor and postpartum c) Catheterization technique (1) Nursing actions to prevent overdistention 4. Health promotion education: avoiding postpartum UTIs a) Postpartum perineal hygiene b) Maintain good fluid intake c) Empty bladder frequently d) Void before and following intercourse e) Cotton-crotch underwear f) Evaluation (1) Woman identifies signs of UTI (a) Condition treated successfully (2) Woman uses self-care measures to prevent the recurrence of UTI (a) Part of her personal hygiene routine (3) Woman continues with any long-term therapy or follow up as appropriate for the diagnosis (4) Maternal–newborn attachment maintained (a) Woman able to care for newborn effectively

IV.

Care of the Woman with Postpartum Mastitis A. Infection of interlobar connective tissue in the breast that occurs primarily in lactating women 1. Onset is usually between the third and fourth week postpartum or any other time that nursing frequency decreases 2. Local to abscess, septicemia 3. Staphylococcus aureus, Haemophilus parainfluenzae, H. influenzae, E. coli, Streptococcus 4. Fever; chills; headache; flulike symptoms; warm reddened, painful area of breast, often wedge shaped a) See Figure 35–2: Mastitis, p. 960 b) Bacteria invade breast tissue after it has been traumatized in some way c) Milk stasis: milk favorable medium d) See Table 35–4: Factors Affecting Development of Postpartum Mastitis, p. 961 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) See Concept Map: Medical Diagnosis: Milk Stasis, p. 962 5. Candida albicans causative organism → baby will often have thrush 6. Clinical therapy a) Clinical diagnosis in most cases b) Midstream milk collection c) Frequent and complete emptying of the breasts d) Antibiotics (penicillinase-resistant penicillins) e) Rest f) Increased fluid intake (1) At least 2 to 2.5 L/day g) Supportive bra h) Local application of warm, moist heat or ice packs i) Analgesics (1) Nonsteroidal anti-inflammatory agents j) Continue breastfeeding (1) Increasing cases of methicillin-resistant Streptococcus aureus (MRSA) → breast milk culture if first round of antibiotic therapy not effective k) Candida infections (1) Antifungal creams or ointments (2) Oral fluconazole (Diflucan) l) Abscess formation (1) Incision and drainage (2) Continued breastfeeding recommended

B. Nursing Management for the Postpartum Woman with Mastitis 1. Nursing Assessment and Diagnosis a) Daily assessment of breast consistency, skin color, surface temperature, nipple condition, presence of pain b) Observe breastfeeding for technique c) Consultation with lactation specialist d) Assess for contributing factors 2. Diagnoses may include: a) Trauma, Risk for b) Breastfeeding, Ineffective 3. Nursing Plan and Implementation a) Prevention easier than treatment b) Meticulous hand washing c) Prompt attention to blocked milk duct d) Rotate position of infant for feeding e) Manually express milk f) Apply warm, moist compresses prior to breastfeeding 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

g) Switch breasts h) Early identification of, and intervention for, sore nipples essential 4. Discharge planning and home care teaching a) Woman to be aware of importance of: b) Regular, complete emptying breasts & stasis (1) Role of letdown (2) Correct positioning of infant (3) Proper latch on (4) Complete course of antibiotics c) All flulike symptoms considered sign of mastitis d) See Table 35–4: Symptoms of Engorgement, Plugged Duct, and Mastitis, p. 962 5. Community-based nursing care a) Home care nurse may suspect mastitis b) Assist mother to obtain appropriate breast pump c) Referral to lactation consultant, La Leche League 6. Evaluation a) Woman aware of signs and symptoms of mastitis b) Woman reports signs and symptoms of mastitis early (1) Treated successfully c) Woman can continue breastfeeding if she chooses d) Woman understands self-care measures she can use to prevent recurrence

Care of the Woman with Postpartum Thromboembolic Disease A. Venous thromboembolism (VTE) 1. Formation of blood clot (thrombus) at an area of impeded blood flow in a superficial or deep vein 2. Thrombophlebitis: inflammation in vein wall a) Pulmonary embolism (1) Rare, life threatening (2) Thrombi formed in deep leg veins, carried to pulmonary artery, obstructing blood flow to one or both lungs 3. Three major causes (Virchow’s triad) a) Hypercoagulability of blood b) Venus stasis c) Injury to the epithelium of blood vessel 4. Risk factors include: a) Cesarean birth b) Immobility (prolonged) c) Obesity 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Cigarette smoking e) Previous thromboembolic disease or strong family history f) Trauma to extremity g) Varicose veins h) Diabetes mellitus i) Advanced maternal age j) Multiparity k) Anemia l) Malignancy m) Inherited coagulation pathway deficiency n) Proteins C and S deficiency 5. Direct factors a) Increased amounts of certain blood clotting factors b) Postpartum thrombocytosis c) Release of thromboplastin substances from tissue of the decidua, placenta, fetal membranes d) Increased amounts of fibrinolysis inhibitors

B. Superficial vein disease 1. SVD → most common clot involves saphenous vein 2. More common in postpartum women than during pregnancy a) Preexisting varices 3. Tenderness in portion of vein, local heat and redness, normal temperature or low grade fever 4. Palpable cord 5. Local heat, elevation of affected limb, analgesic agents

C. Deep Vein Thrombosis 1. Women with history of thrombosis a) Obstetric complications (polyhydramnios, preeclampsia, and operative birth) increase incidence 2. Clinical manifestations may include: a) Edema of ankle and leg b) Initial low-grade fever c) Tenderness or pain d) Palpable cord e) Changes in limb color f) Difference in limb circumference (1) >2 cm g) Pain depending on location of vein involved 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

h) Positive Homans sign i) Diagnosis confirmed by objective testing.

D. Pulmonary Embolism 1. PE → thrombus from lower extremity or pelvis lodges in pulmonary vascular bed a) Restricts circulation to corresponding area of lung b) Catastrophic event with high mortality rate c) Size of the clot may be microscopic or large enough to occlude the branches of the pulmonary artery 2. Diagnosis difficult a) Nonspecific dyspnea b) Pleuritic chest pain c) Cough d) Cyanosis e) Tachypnea and tachycardia f) Panic g) Syncope h) Sudden hypotension 3. Clinical emergency a) Elevate head of bed b) Oxygen by face mask at 8 to 10 L per minute c) Narcotics for pain d) Imaging tests 4. Clinical therapy a) Immediate administration of anticoagulants (1) Unfractionated heparin drug of choice (2) International normalized ratio (INR) 2.0 to 3.0 with oral warfarin for 2 days (3) Strict bedrest (4) Elevation of leg (5) Analgesics b) Walking when symptoms subside c) Continue warfarin sodium for 3 months or more d) Elastic support stocking e) Vena cava filtering device if woman cannot be anticoagulated

E. Nursing Management for the Postpartum Woman with Thromboembolic Disease 1. Nursing Assessment and Diagnosis a) History b) Factors predisposing to development of thrombosis c) Alert to complaints of pain in leg, inguinal area, lower abdomen d) Assess legs for edema, temperature change, pain with palpation

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Diagnoses include: a) Tissue Perfusion: Peripheral, Ineffective b) Pain, Acute c) Parenting, Risk for Impaired d) Family Processes, Interrupted e) Knowledge, Deficient 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Evaluate women with varicosities for need for support hose during labor and postpartum b) Maintain heparin therapy c) Provide for comfort measures d) Monitor for signs of PE e) Assess for bleeding related to heparin f) Instruct to avoid prolonged sitting, standing g) Avoid crossing legs h) Frequent breaks when traveling i) Identify history 4. Health promotion education a) Taught drug and safety factors re: Coumadin b) Educated about foods high in vitamin K 5. Community-based nursing care a) Answer questions, clarify instructions b) Assess plans couple has for bed rest for mother c) Father may be assuming multiple roles d) Other concerns e) Resources as required f) All couples taught about signs and symptoms 6. Evaluation a) Woman seeks treatment for thrombophlebitis early (1) Managed successfully without further complications b) At discharge, woman able to explain purpose, dose regimen, necessary precautions associated with any prescribed medications c) Woman can discuss self-care measures and ongoing therapies indicated d) Woman has bonded successfully with newborn (1) Able to care for baby effectively

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

VI.

Care of the Woman with a Postpartum Psychiatric Disorder

A. Types of Postpartum Psychiatric Disorders 1. Adjustment reaction with depressed mood 2. Postpartum mood episodes with psychotic features 3. Peripartum major mood episodes 4. Also known as postpartum depression 5. Adjustment reaction with depressed mood is the mildest condition a) Disrupted mood, commonly known as postpartum blues, or as maternal or baby blues b) Up to 85% characterized as mood lability and emotional hypersensitivity c) Does not consistently affect woman’s ability to function d) Self limiting e) Lasts from a few hours to 1 to 14 days f) Factors contributing (1) Primiparas (2) Emotional letdown that follows labor and childbirth (3) Physical discomfort typical in early postpartum (4) Fatigue (5) Anxiety about caring for newborn after discharge (6) Depression during pregnancy or previous depression unrelated to pregnancy (7) Severe premenstrual syndrome (PMS) g) Provide reassurance, validate existence h) Anticipatory guidance i) Partner encouraged to watch for and report signs that new mother not returning to more normal mood 6. Peripartum major mood episodes a) Postpartum depression (PPD) (1) Clinical depression b) Risk factors (1) History of major depression (2) Depression during pregnancy (3) History of postpartum depression or bipolar illness (4) Stressful life events (5) Primiparity (6) Ambivalence about maintaining pregnancy (7) Occurrence of postpartum blues (8) Lack of social support (9) Lack of stable, supportive relationship with parents or partner (10) Woman’s dissatisfaction with herself, including body image problems, eating disorders

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(11) Complications of delivery (12) Loss of newborn (13) Age (adolescence increases risk) c) First 4 weeks after childbirth → period of greatest risk (1) See Figure 35–3: Postpartum depression occurs in 10 to 20% of all postpartum women, p. 970 d) Women with postpartum depression at risk for suicide e) Screen for PPD f) Safety priority (1) Woman’s and her child(ren) (2) Question about depression, suicidal thoughts, infant at risk (3) May attempt suicide g) Woman and family need information about illness, course, risk of recurrence h) Outcomes good with antidepressants and psychotherapy (1) Serotonin reuptake inhibitors (SSRIs) (2) Monoamine oxidase inhibitors (MAOIs) rarely used (3) Medications excreted into breast milk (a) Prozac not recommended (4) Electroconvulsive therapy (ECT) for more rapid treatment of severe depression, mania, high risk for suicide 7. Postpartum mood episodes with psychotic features (postpartum psychosis) a) Usually evident first few days after childbirth b) Rare → considered emergency → risk of suicide, infanticide c) Clinical features (1) Sleep disturbances (2) Depersonalization (3) Confusion; irrational, disorganized thinking; bizarre behaviors; delusions; hallucinations (4) Psychomotor disturbances d) Risk factors (1) Previous postpartum psychosis (2) History of bipolar disorder (3) Family history of mood disorder e) May experience delusions, auditory ortactile hallucinations (1) Infant “better off dead” (2) Terrible crazy mother (3) Child may appear neglected f) Provision for safety of woman and infant (1) Immediate referral to psychiatric care (2) Inpatient admission g) Breastfeeding with psychotropic medications (1) Evaluate risk (a) Severity of symptoms 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Benefits of breastfeeding (c) Potential risks to baby if psychotropics used (d) Preferences of woman (2) Monitor infant 8. Posttraumatic stress disorder (PTSD) a) Development of characteristic symptoms following exposure to one or more traumatic events b) At risk (1) Prior psychiatric histories (2) Facts of labor and birth distorted c) Clinical features (1) Feeling numb (2) Dazed, unaware of environment (3) Intrusive thoughts (4) Flashbacks (5) Difficulty thinking (6) Difficulty sleeping (7) Irritability (8) Avoidance of others, reminders of traumatic event d) Clinical therapy (1) Medications (2) Individual or group psychotherapy (3) Practical assistance with child care (4) Support groups

B. Nursing Management for the Postpartum Woman with a Psychiatric Disorder 1. Nursing Assessment and Diagnosis a) Factors predisposing woman b) Prenatal questionnaire c) Anticipatory guidance of challenges of new motherhood d) Screening tools (1) Edinburgh Postnatal Depression Scale (EPDS) (a) Early management (2) Postpartum Depression Screening Scale (PDSS) e) Observe for objective signs of depression f) Listen for statements (1) Anxiety prominent feature for some women (2) Fatigue (3) Assessment of suicide risk (a) SAL → specific plan, accessible weapon or means, lethality of weapon g) Family members of depressed woman should be alert to signals

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nursing diagnoses include: a) Coping, Ineffective b) Parenting, Risk for Impaired c) Violence: Self-Directed, Risk for 3. Nursing Plan and Implementation a) Offer realistic information b) Anticipatory guidance c) Social support teaching guides d) Alert mother, partner, family members to possibility of postpartum blues e) Information, emotional support, assistance providing care for infant 4. Community-based nursing care a) Home visits, especially early discharge b) Telephone follow-up c) Screening at well-child follow-ups d) Family problem e) Harder to understand → education of partner and family f) Practical matters of running household 5. Evaluation a) Woman’s signs of depression identified (1) She receives therapy quickly b) Newborn is cared for effectively by father/partner or another support person until mother able to provide care c) Mother and newborn remain safe d) Newborn integrated into family

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students prepare drug cards on the following medications: • Oxytocin • Ergotamine • Prostaglandin • Misoprostol • Gelfoam • Polyvinyl alcohol • Ampicillin • Bactrim DS • Septra DS • Dicloxacillin • Cephalexin • Diflucan • Heparin • Warfarin sodium

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Small Group Divide the class into small groups of three to five students. Have each group role play telephone follow-up conversations for depression assessment in the postpartum woman. Have the groups document the questions asked. 3. Large Group Lead the class through the following two drills. At the closure of each drill, review the group’s performance and facilitate a class discussion on the drill. A. Mock postpartum hemorrhage drill: • Identification of bleeding • Delegations of tasks • Documentation of tasks • Vital signs • IV infusions • Notification of provider • Positioning on bed • Oxygen therapy • Massaging fundus B. Mock pulmonary embolus drill: • Assessment of symptoms • Delegation of tasks • Documentation of tasks • Vital signs • IV infusions • Notification of provider • Positioning on bed • Oxygen therapy

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 36 Grief and Loss in the Childbearing Family Common Causes of Perinatal Loss.....................................................................

Maternal Physiologic Implications.....................................................................

Postbirth Evaluation...........................................................................................

The Experience of Loss.......................................................................................

Frameworks for Understanding Perinatal Loss..................................................

Special Issues for Consideration.........................................................................

Focus Your Studies..............................................................................................

Activities..............................................................................................................

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Common Causes of Perinatal Loss

A. Occur from 20 weeks gestation up to 7 days after birth B. Incidence of fetal death after 20 weeks → 5.96/1000 total births C. Perinatal mortality rate (PMR) is defined as death around the time of delivery and includes both fetal deaths and early infant deaths D. Causes 1. Unknown 2. Physiologic maladaptations including asphyxia 3. Congenital malformations 4. Pregnancy complications a) Preeclampsia or eclampsia, diabetes, systemic lupus erythematosus, renal disease, thyroid disorders, cholestasis of pregnancy, abruptio placentae, placenta previa, diabetes, renal disease, cord accidents, fetal growth restriction, and alloimmunization 5. Inaccurate gestational age designation 6. Infections a) Especially in developing countries

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

7. Multiple gestations 8. Lower education attainment 9. Advanced maternal age 10. Obesity

E. Risk factors 1. Previous still birth or IUGR 2. Maternal race or ethnicity 3. Age 4. Multiple gestation 5. Number of previous pregnancies 6. Twin pregnancies 7. Teenagers 8. Unmarried women 9. Maternal overweight and obesity

F. Early diagnosis of congenital anomalies 1. Increased use of elective termination

G. Reproductive advances → increase incidence of fetal death H. Infection 1. Causal factors a) Severe maternal illness b) Infecting placenta c) Infecting fetus causing congenital deformity incompatible with life d) Infecting fetus, damaging vital organ e) Precipitating preterm labor fetus dying in labor

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Ascending bacterial organisms

I. Maternal conditions 1. Hypertensive disorders 2. Diabetes mellitus 3. Thyroid, liver, or renal disease 4. Connective tissue disease (lupus) 5. Cholestasis

J. Maladaptations that can cause still birth 1. Antiphospholipid syndrome 2. Heritable thrombophilias 3. Red cell and/or platelet alloimmunization 4. Congenital anomaly and malformations 5. Chromosomal abnormalities 6. Fetomaternal hemorrhage 7. Fetal growth restriction 8. Placental abnormalities 9. Umbilical cord pathology 10. Multifetal gestation 11. Amniotic band sequence 12. Central nervous system lesions

II.

Maternal Physiologic Implications

A. Greatest maternal risks are from prolonged retention of deceased fetus 1. Disseminated intravascular coagulation (DIC) 2. Infection → endometritis, sepsis 3. Acute renal failure 4. Shock or hypotension 5. Maternal death

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

1. May retain live fetus 2. Follow prothrombin time (PT), partial prothrombin time (PTT), fibrinogen, platelet count

C. Clinical therapy 1. Woman may report absence of fetal activity 2. Diagnosis of IUFD confirmed by ultrasound a) Fetal heart with absence of heart action b) Maternal estriol levels fall c) Spontaneous labor within 2 weeks of fetal death 3. Induction within few days or weeks a) Wait until emotionally prepared if possible, schedule an induction b) Mode dependent on gestational age, readiness of cervix c) Laminaria tents → less than 16 gestational weeks d) Misoprostol 800 mcg vaginally e) repeated for second dose no earlier than 3 hours and typically within 7 days if no response to first doseOr Oxytocin (1) Preferred in women with prior uterine surgery f) Previous low transverse incision cesarean birth over 28 gestational weeks (1) Recommend cervical ripening

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

III.

Postbirth Evaluation

A. Causative factor identification through postmortem exam assists families to progress through mourning B. Maternal, fetal, placental testing 1. See Table 36–1: Tests to Determine Cause of Fetal Loss, p. 979 2. Blood tests, x-rays 3. Ultrasound 4. Autopsy/MRI 5. Cultures 6. Chromosomal studies

C. Visual inspection of baby, umbilical cord & placenta D. Autopsy 1. Best to determine cause 2. If parents decline, MRI study

IV.

The Experience of Loss 1. Bereavement → suffered event of loss 2. Grief → individual’s reaction to the loss 3. Mourning → process by which individuals incorporate the experience into their lives 4. Unanticipated loss can be devastating, traumatic 5. Perinatal loss → disenfranchised grief a) Silent loss

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Frameworks for Understanding Perinatal Loss A. Models and theories 1. No consensus for which model is cornerstone

B. Grieving process variable 1. Dependent on many factors 2. Nonlinear 3. Intensity of experience

C. Dual process model 1. Two competing sphere: Loss and restoration

D. Attachment theory 1. Nine events a) Planning pregnancy b) Confirming pregnancy c) Accepting pregnancy d) Feeling fetal movement e) Accepting the fetus as individual f) Giving birth g) Seeing baby h) Touching baby i) Giving care to baby j) See Table 36–2: Psychologic Process of Becoming a Parent, p. 980 2. First five levels a) Naming baby, future plans, nursery preparations, personal stories b) Continuing bonds to be connected to deceased infant 3. Meaning reconstruction a) Redefining ourselves, interactions with words after significant loss (1) Why me? (2) 70 to 85% find themselves searching for meaning early in the los (3) Are we still parents? b) Facilitate process if struggling with meaning (1) Caregiver should not initiate process 4. Understand framework for process manifestations can be explored a) Early responses (1) Shock (2) Numbness (3) Denial 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Protest (5) Disorientation (6) Guilt (7) Confusion b) Denial protective mechanism to prevent meltdown (1) Hope second opinion will be different c) Move quickly from shock, confusion, denial into intense emotions d) Anger is common (1) Despair, longing for event not to have occurred e) See Evidence-Based Practice: Perinatal Grief Intensity Scale, p. 981

VI.

Special Issues for Considerations

A. Factors will influence couple’s response to perinatal loss 1. Gender 2. Age 3. Personality type 4. Family dynamics 5. Cultural and religious beliefs 6. Socioeconomic status 7. Early pregnancy 8. Multifetal pregnancy loss 9. Grief from infertility

B. Individual and Family Issues 1. Age a) Couples in 30s → may feel running out of time (1) May have living children as well b) Couples in 20s → may be first significant death c) Adolescent → physical, emotional responses (1) Adolescent who attaches meaning to her pregnancy has the highest rate of grief reaction and life impact (2) Younger the adolescent, greater physical and emotional responses to the loss were experienced as compared to older adolescents (3) Rely on peer support 2. Family dynamic a) Presence or lack of cohesion b) Strong family ties fare better

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) “Lie and deny” family difficult to assess (1) Family deals with bad news and loss events as though they have not occurred d) Persistent denial → gentle review of facts 3. Gender issues a) Intuitive styles of coping (1) Feel way through loss (2) Prefer care with emphasis on emotional, psychosocial support (3) Initiate discussion of thoughts, feeling concerning loss (4) Share that spouses commonly unable to be emotionally available to each others b) Instrumental styles of coping (1) More cognitive skills to navigate loss (2) Value care with emphasis on problem solving (3) Address that parent who seems detached, unaffected by loss is not uncaring (a) More men fall into this category (4) They value acceptance, acknowledgment of pain, information regarding loss c) Inform couples that both styles are acceptable d) Reassure couples that the feelings will not always remain so intense 4. Other features of bereaved individuals a) Overall features that place them at increased risk (1) Insecurity (2) Anxiety (3) Low self-esteem (4) Previous psychiatric history (5) Excessive anger or guilt (6) Physical disability or illness (7) Previous unresolved losses (8) Inability to express emotion (9) Concurrent problems of living

C. Societal Issues 1. Spirituality → a) May bring comfort or precipitate spiritual crisis 2. Spirituality → human search for meaning and connectedness to life, others, God, universe 3. Religion → structured efforts conducted in a systematic approach to attain holiness 4. Six themes affecting spiritual needs a) Honest exchange of information b) Empathy and presence c) Continuing bonds d) Spiritual rites e) Attachment with others f) Grief support 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Important for nurse not to answer rhetorical questions 6. Act as family advocate → contact clergy, spiritual advisor, hospital chaplain 7. Some commonalities within culture groups a) Grieving and rituals 8. Culture a) Culture can influence needs, beliefs b) See Table 36–4: Common Cultural Practices: Grief, Bereavement, and Perinatal Loss, pp. 984–986

D. Specific Circumstances 1. Infertility a) Ongoing struggle and face difficulties and decisions (1) Treatment available (2) Waiting (3) Psychologic roller coaster (4) When to discontinue treatment b) Assess where woman is in process c) Support decisions d) Finally experiencing a pregnancy → heightened anxiety, additional reassurances will need to be offered 2. Early pregnancy loss a) Ectopic, molar, blighted ovum, spontaneous abortion b) Devastating for many couples c) Attachment based on the level of emotional bonding d) May have guilt, especially mother e) Assessment of future pregnancies (1) Couples may have no desire to try again f) Prepare couples for fact that others will often underestimate impact of loss g) Early pregnancy remembrance box h) See Figure 36–1: Early pregnancy remembrance box, p. 987 3. Multifetal pregnancy loss a) MPL → statistics for increased prematurity rates, death during infancy for twins, higher order multiples (1) Twins 2.5 times higher mortality rate, triplets or higher 5 times b) MPL can be spontaneous, elective termination or selective reduction c) Loss of one baby can be from intrauterine demise, twin-to-twin transfusion, complications of monoamniotic twinning, placental problems, adverse intrapartum events, delayed interval delivery, postoperative complications, prematurity d) Issues affecting parents (1) Malformation, birth defects (2) Options and impact of difficult decisions 10 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Sudden death of infant fear and anxiety for surviving infants (4) Prospect of infertility because of previous abortions (5) Last attempt at in vitro fertilization (6) Guilt (7) Cohabitation of mourning and joy e) Resist urge to focus on positive of surviving sibling (1) Couple imagines what lost child might have looked like, personality, etc. f) Visual memories (1) Pictures of multiples together (2) Funeral or not, may delay until mother can attend 4. Maternal death a) Death of a woman while pregnant or within 42 days of termination of pregnancy (1) Irrespective of duration and site of pregnancy (2) From any cause related to or aggravated by the pregnancy or its management (3) Not from accidental or incidental causes b) Common causes (1) Hemorrhage, hypertensive disorders, amniotic fluid embolism, infection, preexisting chronic conditions, such as diabetes and cardiovascular disease (2) Obesity playing bigger role in risks (3) Homicide, suicide c) Husband, partner, or father of child (1) Shocking and traumatic (2) Complicated by number of factors (3) May be extremely intense d) Traumatic for staff on perinatal unit (1) Nursing care continues (2) Professional debriefing Take care of self and own reactions

E. Nursing Management for a Family Experiencing Perinatal Death 1. Nursing Assessment and Diagnosis a) Clinical setting (1) Cessation of fetal movement, decrease in signs and symptoms of pregnancy (2) Establish fetal demise (3) Assess family member’s ability to adapt to loss (4) Intrapartum complication (5) Assist family in mourning process b) Diagnoses that may apply include: (1) Grieving (2) Powerlessness (3) Family Processes, Dysfunctional (4) Hopelessness (5) Spiritual Distress, Risk for 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Nursing Plan and Implementation a) Protocol of facility → holistic focus (1) Notify entire healthcare team (2) Symbol so staff aware of loss (3) Allow family to dictate own experience b) Avoiding use of clichés (1) Inappropriate remarks (a) See Table 36–5: Unhelpful Versus Helpful Interactions with Grieving Families, p. 990 (2) Facilitate healthy mourning → active listening c) Facilitating the family’s mourning process (1) Paradigm shift → normal mourning (2) From encouraging intense grief response to naturally resilient, will recover in their own time (3) Stoic response not always counterproductive (a) Not only is early intervention not always necessary, it can even be harmful (4) Simple caring guidelines (5) Goals (a) Help family navigate medical/healthcare system (b) Facilitate process by allowing them to dictate their own experience d) The caring theory (1) Five attributes of caregiver (a) Knowing (i) Attempting to understand event as it has meaning in life of parents (b) Being with (i) Emotionally present, as a human being (c) Doing for (i) Restating of the golden rule (d) Enabling (i) Facilitation of parents’ passage through life transitions and unfamiliar events (e) Maintaining belief (i) Believing in parents’ capacity to get through event and face future with meaning e) The art of responding (1) See Table 36–6: The Essential Elements of Responding Effectively to the Needs of Grieving Families, p. 991 3. Preparing the family for the birth and death a) Known or suspected fetal demise → private room away from other laboring women (1) Sit down, introduce self, simple statement (a) “I’m so sorry. This must be hard for you. I’d like to help you through it.” (2) Allow couple to stay together as much as they wish b) Complete information about what to expect (1) See Figure 36–3: St. Joseph perinatal comfort care program …, p. 991 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Stay with couple or respect cues to be left alone d) Same nurse → therapeutic relationship e) May ask same questions repeatedly f) Interprofessional team g) Offer to contact chaplain, social worker h) Explain details of plan of care (1) Allow to make decisions (2) See Figure 36–4: St. Joseph Hospital neonatal comfort care orders, p. 993 i) Birth of terminal or stillborn infant marks beginning and end j) Help couple explore feelings, make decisions k) Birth preferences (1) Music, lights (2) Specific position (3) Have baby placed on mother’s chest immediately after birth (4) Allow father to cut umbilical cord (5) Including family members/friends at birth l) May be concerned about strange preferences (1) Reassure no right or wrong feelings m) Waves of overwhelming grief, disbelief, sadness 4. Supporting the family in decision making a) Guidance throughout process b) Simple choices c) Advocate d) Careful listening e) Any decision couple makes for themselves is the right one f) If hesitant to view infant, offer a picture to help allay fears 5. Postmortem care a) Preparing for viewing and holding (1) Maceration (a) Tissue breakdown → sloughing of the skin (b) Gloved hand for washing → disrupt skin as little as possible (2) Place in gown (3) Wrap in blanket (4) Hat to cover birth defects b) Allow parents opportunity to see the baby before seeing birth defects c) Monitor own personal reactions to infant d) Dying infant (1) Bathe quickly → return to parents (2) Allow to remain with parents as long as they desire e) See Table 36–7: Postmortem Care, p. 995 6. Supporting siblings and extended family members a) Advocate for family’s wishes 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Children included as parents wish (1) Children respond according to their age and maturity level c) Avoid euphemisms d) Children will need reassurance (1) That they are still going to be taken care of (2) That nothing they did caused the event to happen e) Extended family members → “doubly” grieving f) Family support major comfort with open communication, honest interaction 7. Actualizing the loss: Providing memories a) Mementos (1) See Figure 36–5: Foot- and handprint molds, p. 996 b) Pictures c) Hand- or footprint molds and cards d) Remembrance box (1) See Figure 36–6: Personal memory box, p. 996 8. Providing discharge care a) Three options for disposition (1) Traditional burial via funeral home (a) Family contacts funeral home directly to make arrangements (b) Burial on private land (i) State and locally dictated b) Cremation at a funeral home c) Hospital disposition (1) Not recommended d) Support decision e) Option of early discharge f) Facility protocol (1) Birthing unit, postpartum or medical unit (2) All staff notified of mother’s status g) Physical considerations, adaptation of mother h) Emotional considerations of couple i) Prepare couple for home (1) Others will not know how to respond (2) Age appropriate grieving for siblings (3) Depression common (4) Cope better if adequately prepared j) Nurse experiences many of grief reactions as parents k) Closure of intrapartum event to continue process l) Refer for counseling m) Schedule follow-up phone calls to assess family’s functioning 9. Referring the family to community services a) Established protocol for families 14 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Specialized groups c) Internet technology allowed large numbers of individuals to share resources 10. Perinatal hospice a) Compassionate structured program providing context to find meaning b) Offer parents support and guidance c) Interprofessional team 11. Care of the couple who has experienced loss in a previous pregnancy a) Previous loss → enters subsequent pregnancy with conflicting feelings b) May relive experience c) Kind, compassionate, and patient d) Potential of unresolved grief e) Interventions to decrease anxiety (1) Early ultrasound (2) Weekly visits for a period of time to hear fetal heartbeat (3) Additional antepartum testing (4) Non-stress test, biophysical profiles f) See Nursing Care Plan: For a Family Experiencing Perinatal Loss, p. 999 12. Evaluation a) Challenging and rewarding b) Expected outcomes include: (1) Family members feel free to express their feelings about the death of their baby if they desire to do so (2) Family members participate in decision making regarding preferences for labor, birth, and immediate postpartum period (3) Family members participate in decision of whether to see their baby and other decisions about the baby (4) The family has resources available for continued support (5) Family members know the community resources available and have names and phone numbers to use if they choose

VII.

Focus Your Studies

VIII.

Activities 1. Individual Have students research the perinatal morbidity and mortality statistics for selected cities in your state. Have each student prepare a short report on the demographics. 2. Small Group Divide the class into small groups of three to five students. Have each group research perinatal grieving. Next, have each group brainstorm on their findings to develop the appropriate therapeutic communications for difficult scenarios such as the following: • What will baby look like? 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

• • •

Why did this happen to me? I feel like such a failure. I will never get over this.

3. Large Group Invite a member of the clergy, social worker, or grief counselor who works with perinatal loss to speak with the class.