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Evolve Key Points and Questions for Test 2 Maternal Child Care

Key Points for Ch.13


Labor and birth are affected by the five Ps: passenger, passageway, powers, position of the
woman, and psychologic response.
Because of its size and relative rigidity, the fetal head is a major factor in determining the
course of birth.
The diameters at the plane of the pelvic inlet, the midpelvis, and the outlet plus the axis of the
birth canal determine whether vaginal birth is possible and the manner in which the fetus passes
down the birth canal.
Involuntary uterine contractions act to expel the fetus and placenta during the first stage of
labor; these are augmented by voluntary bearing-down efforts during the second stage.
The first stage of labor lasts from the time dilation begins to the time when the cervix is fully
dilated.
The second stage of labor lasts from the time of full cervical dilation to the birth of the infant.
The third stage of labor lasts from the infants birth to the expulsion of the placenta.
The fourth stage of labor is the first 2 hours after birth.
The cardinal movements of the mechanism of labor are engagement, descent, flexion, internal
rotation, extension, restitution and external rotation, and expulsion of the infant.
Although the events precipitating the onset of labor are unknown, many factors, including
changes in the maternal uterus, cervix, and pituitary gland, are thought to be involved.
A healthy fetus with an adequate utero fetoplacental circulation is able to compensate for the
stress of uterine contractions.
As the woman progresses through labor, various body systems adapt to the birth process.
Questions from ch. 13
1. A primigravida asks the nurse about signs she can look for that would indicate that the onset of
labor is getting closer. The nurse should describe:
A. weight gain of 1 to 3lbs.
B. quickening.
C. fatigue and lethargy.

D. bloody show. Correct


Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal
movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually
experience a burst of energy or the nesting instinct. Passage of the mucous plug (operculum) also
termed pink/bloody show occurs as the cervix ripens.

2. The nurse should tell a primigravida that the definitive sign indicating that labor has begun
would be:
A. progressive uterine contractions with cervical change. Correct
B. lightening.
C. rupture of membranes.
D. passage of the mucous plug (operculum).
Regular, progressive uterine contractions that increase in intensity and frequency are the
definitive sign of true labor along with cervical change. Lightening is a premonitory sign
indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during
labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is
getting closer

3. On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm,
1. What is a correct interpretation of the data?
A. The fetal presenting part is 1 cm above the ischial spines. Correct
B. Effacement is 4 cm from completion.
C. Dilation is 50% completed.
D. The fetus has achieved passage through the ischial spines.
Rationale:
Station of 1 indicates that the fetal presenting part is above the ischial spines and has not yet
passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100%
indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation.
Progress of effacement is referred to by percentages, with 100% indicating full effacement and

dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines
with internal rotation would be indicated by a plus station such as +1.

4. In order to accurately assess the health of the mother accurately during labor, the nurse should
be aware that:
A. the womans blood pressure increases during contractions and falls back to prelabor normal
between contractions.
B. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal
hypoxia.
C. having the woman point her toes reduces leg cramps.
D. the endogenous endorphins released during labor raise the womans pain threshold and
produce sedation. Correct
Rationale:
Blood pressure increases during contractions but remains somewhat elevated between them. Use
of the Valsalva maneuver is discouraged during second stage labor because of a number of
potentially unhealthy outcomes, including fetal hypoxia.
Pointing the toes can cause leg
cramps, as can the process of labor itself.
D.
In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the
presenting part, decreases the mothers perception of pain.

5. The nurse knows that the second stage of labor, the descent phase, has begun when:
A. the amniotic membranes rupture.
B. the cervix cannot be felt during a vaginal examination.
C. the woman experiences a strong urge to bear down. Correct
D. the presenting part is below the ischial spines.
Rupture of membranes has no significance in determining the stage of labor. The second stage of
labor begins with full cervical dilation. During the descent phase of the second stage of labor, the
woman may experience an increase in the urge to bear down. Many women may have an urge to
bear down when the presenting part is below the level of the ischial spines. This can occur during
the first stage of labor, as early as 5 cm of dilation.

6. Nurses can help their clients by keeping them informed about the distinctive stages of labor.
What description of the phases of the first stage of labor is accurate?
A. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours
B. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours Correct
C. Lull: no contractions; dilation stable; duration of 20 to 60 minutes
D. Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2
hours
The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm;
brownish to pale pink mucus; and a duration of 6 to 8 hours. The active phase is characterized by
moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. No official
lull phase exists in the first stage. The transition phase is characterized by strong to very
strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

7. Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be
increased?
A. Semirecumbent
B. Sitting
C. Squatting Correct
D. Side-lying
Rationale:
A. A semirecumbent position does not assist in increasing the size of the pelvic outlet.
B. Although sitting may assist with fetal descent, this position does not increase the size of the
pelvic outlet.
C. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this
can facilitate the second stage of labor by increasing the pelvic outlet.
D. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet.

8. Concerning the third stage of labor, nurses should be aware that:

A. the placenta eventually detaches itself from a flaccid uterus


B. the duration of the third stage may be as short as 3 to 5 minutes Correct
C. it is important that the dark, roughened maternal surface of the placenta appear before the
shiny fetal surface
D. the major risk for women during the third stage is a rapid heart rate
Rationale:
A. The placenta cannot detach itself from a flaccid (relaxed) uterus.
B. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The
duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal
limits.
C. Which surface of the placenta comes out first is not clinically important.
D. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk
of hemorrhage increases as the length of the third stage increases.

9. The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that
the 5 Ps of labor and birth are: (Select all that apply.)
A. passenger. Correct
B. placenta.
C. passageway. Correct
D. psychologic response. Correct
E. powers. Correct
F. position. Correct
At least five factors affect the process of labor and birth. These are easily remembered as the five
Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of
the mother, and psychologic response.

10. Nurses can advise their patients that which of these signs precede labor? (Select all that
apply.)

A. A return of urinary frequency as a result of increased bladder pressure Correct


B. Persistent low backache from relaxed pelvic joints Correct
C. Stronger and more frequent uterine (Braxton Hicks) contractions Correct
D. A decline in energy, as the body stores up for labor
E. Uterus sinks downward and forward in first-time pregnancies.
After lightening a return of the frequent need to urinate occurs as the fetal position causes
increased pressure on the bladder. In the run-up to labor, women often experience persistent low
backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of
labor, it is common for Braxton Hicks contractions to increase in both frequency and strength.
Bloody show may be passed. A surge of energy is a phenomenon that is common in the days
preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks
before term.

11. The maternity nurse should notify the health care provider about which assessment findings
during labor? (Select all that apply.)

A. Positive urine drug screen Correct


B. Blood glucose level of 78 mg/dL
C. Increased systolic blood pressure during first stage Correct
D. Elevated white blood cell count
E. Oral temperature of 99.8 F
F. Respiratory rate of 10 breaths/min Correct
The health care provider should be alerted to a positive urine drug screen, because certain drugs
will have an effect on pain medications that can be safely administered. The respiratory rate
usually increases during labor. A rate of 10 is low and needs to be reported. Decreased blood
glucose levels (due to exertion and glucose consumption for energy), and increased systolic

blood pressure, elevated white blood cell count (due to stress response), and a slightly elevated
temperature (up to 100.4 F) are expected findings during labor.

Chapter 14 Key ponts Referred pain occurs when pain that originates in the uterus radiates to the abdominal wall,
lumbosacral area of the back, iliac crests, gluteal area, thighs, and lower back.
During most of the first stage of labor, the woman usually has discomfort only during
contractions and is free of pain between contractions.
Nonpharmacologic pain and stress management strategies are valuable for managing labor
discomfort alone or in combination with pharmacologic methods.
Nonpharmacologic measures are often simple and safe, have few if any major adverse
reactions, are relatively inexpensive, and can be used throughout labor. In addition, they provide
the woman with a sense of control over her childbirth as she makes choices about the measures
that are best for her.
The gate-control theory of pain and the stress response are the bases for many of the
nonpharmacologic methods of pain relief.
Different approaches to childbirth preparation stress varying breathing techniques to provide
distraction, thereby reducing the perception of pain and helping the woman maintain control
throughout contractions.
Other ways women decrease pain are to use relaxation techniques, massage, hot and cold
application, acupuncture, transcutaneous electrical nerve stimulation, water therapy, intradermal
water block, aromatherapy, music, hypnosis, and biofeedback.
The type of analgesic or anesthetic to be used is determined by maternal and health care
provider preference, the stage of labor, and the method of birth.
Sedatives may be appropriate for women in prolonged early labor when there is a need to
decrease anxiety or to promote sleep or therapeutic rest.
Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse narcotic effects,
especially respiratory depression.
Pharmacologic control of pain during labor requires collaboration among the health care
providers and the laboring woman.

The nurse must understand medications, their expected effects, potential side effects, and
methods of administration.
Maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks.
Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response.
The use of opioid agonist-antagonist analgesics in women with preexisting opioid dependence
may cause symptoms of abstinence syndrome (opioid withdrawal).
Epidural anesthesia and analgesia are the most effective pharmacologic pain relief methods for
labor that are available. Therefore, they are used by most women in the United States.
General anesthesia is rarely used for vaginal birth but may be used for cesarean birth or
whenever rapid anesthesia is needed in an emergency childbirth situation.
Chapter 14 Evolve Questions

1. A laboring woman becomes anxious during the transition phase of the first stage of labor and
develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed.
The nurses immediate response would be to:
A. encourage the woman to breathe more slowly.
B. help the woman breathe into a paper bag. Correct
C. turn the woman on her side.
D. administer a sedative.
Just telling her to breathe more slowly does not ensure a change in respirations. The woman is
exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and
respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on
her side will not solve this problem. Administration of a sedative could lead to neonatal
depression since this woman, being in the transition phase, is near the birth process. The sidelying position would be appropriate for supine hypotension.

2. A woman is in the second stage of labor and has a spinal block in place for pain management.
The nurse obtains the womans blood pressure and notes that it is 20% lower than the baseline
level. Which action should the nurse take?
A. Encourage her to empty her bladder.

B. Decrease her intravenous (IV) rate to a keep vein-open rate.


C. Turn the woman to the left lateral position or place a pillow under her hip. Correct
D. No action is necessary since a decrease in the womans blood pressure is expected.
Encouraging the woman to empty her bladder will not help the hypotensive state and may cause
her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or
increased to maintain the appropriate perfusion. Turning the woman to her left side is the best
action to take in this situation since this will increase placental perfusion to the infant while
waiting for the doctors or nurse midwifes instruction. Hypotension indicated by a 20% drop
from preblock level is an emergency situation and action must be taken.

3. A woman in latent labor who is positive for opiates on the urine drug screen is complaining of
severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring
pattern. The nurses MOST appropriate analgesic for pain control is:
A. fentanyl (Sublimaze). Correct
B. promethazine (Phenergan).
C. butorphanol tartrate (Stadol).
D. nalbuphine (Nubain).
Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short
acting. This patient may require higher than normal doses to achieve pain relief due to her opiate
use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to
augment the desirable effects of the opioid analgesics but has few of those drugs undesirable
effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a
patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may
precipitate withdrawals in a patient with a history of opiate use.

4. A woman is experiencing back labor and complains of constant, intense pain in her lower
back. An effective relief measure is to use:
A. counterpressure against the sacrum. Correct
B. pant-blow (breaths and puffs) breathing techniques.
C. effleurage.

D. biofeedback.
Counterpressure is steady pressure applied by a support person to the sacral area with the fist or
heel of the hand. This technique helps the woman cope with the sensations of internal pressure
and pain in the lower back. Pant-blow breathing techniques are usually helpful during
contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in
rhythm with breathing during contractions. It is used as a distraction from contraction pain;
however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques
are not always successful in reducing labor pain. Using this technique effectively requires strong
caregiver support.

5. Nurses should be aware of the difference experience can make in labor pain, such as:
A. sensory pain for nulliparous women often is greater than for multiparous women during
early labor. Correct
B. affective pain for nulliparous women usually is less than for multiparous women throughout
the first stage of labor.
C. women with a history of substance abuse experience more pain during labor.
D. multiparous women have more fatigue from labor and therefore experience more pain.
Sensory pain is greater for nulliparous women because their reproductive tract structures are less
supple. Affective pain is greater for nulliparous women during the first stage but decreases for
both nulliparous and multiparous during the second stage. Women with a history of substance
abuse experience the same amount of pain as those without such a history. Nulliparous women
have longer labors and therefore experience more fatigue.

6. With regard to what might be called the tactile approaches to comfort management, nurses
should be aware that:
A. either hot or cold applications may provide relief, but they should never be used together in
the same treatment.
B. acupuncture can be performed by a skilled nurse with just a little training.
C. hand and foot massage may be especially relaxing in advanced labor when a womans
tolerance for touch is limited. Correct
D. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic
vibrations.

Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure,
acupuncture, which involves the insertion of thin needles, should be done only by a certified
therapist. The woman and her partner should experiment with massage before labor to see what
might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect
energy fields in the body.

7. With regard to systemic analgesics administered during labor, nurses should be aware that:
A. systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal
blood-brain barrier.
B. effects on the fetus and newborn can include decreased alertness and delayed sucking.
Correct
C. IM administration is preferred over IV administration.
D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.
Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal bloodbrain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV
administration is preferred over IM administration because the drug acts faster and more
predictably. PCAs result in decreased use of an analgesic.

8. After change of shift report, the nurse assumes care of a multiparous patient in labor. The
woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and
down her thighs. Before implementing a plan of care, the nurse should understand that this type
of pain is:
A. visceral.
B. referred. Correct
C. somatic.
D. afterpain.

Visceral pain is that which predominates the first stage of labor. This pain originates from
cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is
located over the lower portion of the abdomen. As labor progresses the woman often experiences
referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall,

the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only
during a contraction and is free from pain between contractions. Somatic pain is described as
intense, sharp, burning, and well localized. This results from stretching of the perineal tissues
and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the
third stage of labor or afterward during the early postpartum period is uterine. This pain is very
similar to that experienced in the first stage of labor.

9. When monitoring a woman in labor who has just received spinal analgesia, the nurse should
report which assessment findings to the health care provider? (Select all that apply.)
A. Maternal blood pressure of 108/79
B. Maternal heart rate of 98
C. Respiratory rate of 14 breaths/min
D. Fetal heart rate of 100 beats/min Correct
E. Minimal variability on a fetal heart monitor Correct
After induction of the anesthetic, maternal blood pressure, pulse, and respirations and fetal heart
rate and pattern must be checked and documented every 5 to 10 minutes. If signs of serious
maternal hypotension (e.g., the systolic blood pressure drops to 100 mm Hg or less or the blood
pressure falls 20% or more below the baseline) or fetal distress (e.g., bradycardia, minimal or
absent variability, late decelerations) develop, emergency care must be given.

10. After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum
unit complains of a severe headache. The nurse should anticipate which actions in the patients
plan of care? (Select all that apply.)
A. Keeping the head of bed elevated at all times
B. Administration of oral analgesics Correct
C. Avoid caffeine
D. Assisting with a blood patch procedure Correct
E. Frequent monitoring of vital signs Correct
The nurse should suspect the patient is suffering from a postdural puncture headache (PDPH).
Characteristically, assuming an upright position triggers or intensifies the headache, whereas

assuming a supine position achieves relief (Hawkins and Bucklin, 2012). Conservative
management for a PDPH includes administration of oral analgesics and methylxanthines (e.g.,
caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may
provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and
beneficial relief measure for PDPH. Close monitoring of vital signs is essential.
Ch. 15 Key Points
Because labor is a period of physiologic stress for the fetus, frequent monitoring of fetal status
is part of the nursing care during labor. The fetal oxygen supply must be maintained during labor
to prevent fetal compromise and promote newborn health after birth.
The goals of intrapartum FHR monitoring are to identify and differentiate the normal
(reassuring) patterns from the abnormal (nonreassuring) patterns, which can indicate fetal
compromise.
Fetal well-being during labor is gauged by the response of the FHR to UCs.
Standardized definitions for many common FHR patterns have been adopted for use in clinical
practice by the ACNM, ACOG, and AWHONN.
The monitoring of fetal well-being includes FHR and UA assessment and assessment of
maternal vital signs.
Intermittent auscultation (IA) involves listening to fetal heart sounds at periodic intervals to
assess the FHR. IA of the fetal heart can be performed with a Pinard stethoscope, Doppler
ultrasound, an ultrasound stethoscope, or a DeLee-Hillis fetoscope. IA is easy to use,
inexpensive, and less invasive than EFM. It is often more comfortable for the woman and gives
her more freedom of movement.
The purpose of EFM is the ongoing assessment of fetal oxygenation. FHR tracings are analyzed
for characteristic patterns that suggest fetal hypoxic events and metabolic acidosis during labor.
The technique of continuous internal FHR or UA monitoring provides a more accurate
appraisal of fetal well-being during labor than external monitoring because it is not interrupted
by fetal or maternal movement or affected by maternal size.
The five essential components of the FHR tracing are baseline rate, baseline variability,
accelerations, decelerations, and changes or trends over time.
Assessing FHR and UA patterns, implementing independent nursing interventions, and
reporting abnormal patterns to the physician or nurse-midwife are the nurses responsibilities.

The AWHONN and ACOG have established and published health care provider standards and
guidelines for FHR monitoring.
The emotional, informational, and comfort needs of the woman and her family must be
addressed when the mother and her fetus are being monitored.
Documentation of fetal assessment is initiated and updated according to institutional protocol.
Ch. 15 Evolve Questions 1. When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate
from 55 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this
decrease in baseline to:
A.

maternal hyperthyroidism.

B.

initiation of epidural anesthesia that resulted in maternal hypotension.


Correct

C.

maternal infection accompanied by fever.

D.

alteration in maternal position from semirecumbent to lateral.

Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described
and results from the hypoxia that would occur when uteroplacental perfusion is reduced by
maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before
and during induction of the anesthesia to maintain an adequate cardiac output and blood
pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position
enhances placental perfusion and should result in a reassuring FHR pattern.
Awarded 0.0 points out of 1.0 possible points.
2. On review of a fetal monitor tracing, the nurse notes that for several contractions, the
fetal heart rate decelerates as a contraction begins and returns to baseline just before it
ends. The nurse should:
A.

describe the finding in the nurses notes. Correct

B.

reposition the woman onto her side.

C.

call the physician for instructions.

D.

administer oxygen at 8 to 10 L/min with a tight face mask.

An early deceleration pattern from head compression is described. No action other than
documentation of the finding is required since this is an expected reaction to compression of the
fetal head as it passes through the cervix. These actions would be implemented when non
reassuring or ominous changes are noted. These actions would be implemented when non
reassuring or ominous changes are noted. These actions would be implemented when non
reassuring or ominous changes are noted.

3. What finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?
A.

FHR does not change as a result of fetal activity.

B.

Average baseline rate ranges between 100 and 140 beats/min.

C.

Mild late deceleration patterns occur with some contractions.

D.

Variability averages between 6 to 10 beats/min. Correct

FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min.
Late deceleration patterns are never reassuring, although early and mild variable decelerations
are expected, reassuring findings. Variability indicates a well-oxygenated fetus with a
functioning autonomic nervous system.

4. Late deceleration patterns are noted when assessing the monitor tracing of a woman
whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying

position, and her vital signs are stable and fall within a normal range. Contractions are
intense, last 90 seconds, and occur every 1 to 2 minutes. The nurse's IMMEDIATE
action would be to:
A.

change the woman's position.

B.

stop the Pitocin. Correct

C.

elevate the womans legs.

D.

administer oxygen via a tight mask at 8 to 10 L/min.

The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration
patterns noted are most likely related to alteration in uteroplacental perfusion associated with the
strong contractions described. The immediate action would be to stop the Pitocin infusion since
Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be
appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.
5. You are evaluating the fetal monitor tracing of your client, who is in active labor.
Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80.
You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal
examination. The cervix has not changed. Five minutes have passed, and the FHR
remains in the 80s. What additional nursing measures should you take?
A.

Notify nursery nurse of imminent delivery.

B.

Insert a Foley catheter.

C.

Start oxytocin (Pitocin).

D.

Notify the primary health care provider immediately (HCP). Correct

This is not the most important nursing measure at this time. The patient needs to be evaluated by
the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to
continue in an abnormal or nonreassuring pattern, a cesarean section may be warranted. This
would require the insertion of a Foley catheter; however, the physician must make that
determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration,
the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is
infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider
should be notified immediately.
6. When using intermittent auscultation (IA) to assess uterine activity, nurses should be
aware that:
A.

the examiners hand should be placed over the fundus before, during, and
after contractions. Correct

B.

the frequency and duration of contractions are measured in seconds for


consistency.

C.

contraction intensity is given a judgment number of 1 to 7 by the nurse and


client together.

D.

the resting tone between contractions is described as either placid or


turbulent.

The assessment is done by palpation; duration, frequency, intensity, and resting tone must be
assessed. The duration of contractions is measured in seconds; the frequency is measured in
minutes. The intensity of contractions usually is described as mild, moderate, or strong. The
resting tone usually is characterized as soft or relaxed.
7. A nurse caring for a woman in labor understands that increased variability of the fetal
heart rate might be caused by:
A.

narcotics.

B.

barbiturates.

C.

methamphetamines. Correct

D.

tranquilizers.

Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates
may also result in a significant decrease in variability as these are known to cross the placental
barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause increased
variability. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.
8. The nurse caring for a laboring woman is aware that maternal cardiac output can be
increased by:
A.

change in position. Correct

B.

oxytocin administration.

C.

regional anesthesia.

D.

intravenous analgesic.

Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus
on the ascending vena cava when the woman is in a supine position. This reduces venous return
to the womans heart, as well as cardiac output, and subsequently reduces her blood pressure.
The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin
administration may reduce maternal cardiac output. Regional anesthesia may reduce maternal
cardiac output. Intravenous analgesic may reduce maternal cardiac output.
9. Fetal well-being during labor is assessed by:

A.

the response of the fetal heart rate (FHR) to uterine contractions (UCs).
Correct

B.

maternal pain control.

C.

accelerations in the FHR.

D.

an FHR greater than 110 beats/min.

Fetal well-being during labor can be measured by the response of the FHR to UCs. In general,
reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160
beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal
movement. Maternal pain control is not the measure used to determine fetal well-being in labor.
Although FHR accelerations are a reassuring pattern, they are only one component of the criteria
by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be
reassuring, it is only one component of the criteria by which fetal well-being is assessed. More
information is needed to determine fetal well-being.

10. The most important nursing action when the nurse observes this fetal heart pattern is to:

A.

document the finding. Correct

B.

position mother on left side.

C.

apply 10 L of oxygen via face mask.

D.

notify the health care provider.

The fetal heart strip shows an early deceleration indicating expected head compression during
contractions. Documenting this finding is appropriate. The other answers are correct actions for a
late deceleration.

11. The nurses priority action when observing this fetal heart pattern is:

A.

notify the health care provider.

B.

assist with vaginal examination to assess for cord prolapse.

C.

change maternal position. Correct

D.

assist with amnioinfusion.

The usual priority is as follows:


1.
Change maternal position (side to side, knee chest).
2.
Discontinue oxytocin if infusing.
3. Administer oxygen at 8 to 10 L/min by nonrebreather face mask.
4.
Notify physician or nurse-midwife.
5. Assist with vaginal or speculum examination to assess for cord prolapse.
6. Assist with amnioinfusion if ordered.
7. Assist with birth (vaginal assisted or cesarean) if pattern cannot be corrected
Ch. 16 Key Points
The first stage of labor begins with the onset of regular uterine contractions and ends with
complete cervical effacement and dilation. The first stage of labor consists of three phases: the
latent phase (through 3 cm of dilation), the active phase (4 to 7 cm of dilation), and the transition
phase (8 to 10 cm of dilation).
The onset of labor may be difficult to determine for both nulliparous and multiparous women.
The familiar environment of her home is most often the ideal place for a woman during the
latent phase of the first stage of labor.
The nurse assumes much of the responsibility for assessing the progress of labor and keeping
the primary health care provider informed about progress in labor and deviations from expected
findings.
The FHR and pattern reveal the fetal response to the stress of the labor process.
It is important for the nurse to assess uterine contraction frequency, intensity, duration and
resting tone.
Assessment of the laboring womans urinary output and bladder is critical to ensure her
progress and to prevent injury to the bladder.
Regardless of the actual labor and birth experience, the womans or couples perception of the
birth experience is most likely to be positive when events and performances are consistent with
expectations, especially in terms of maintaining control and adequacy of pain relief.

The womans level of anxiety may increase when she does not understand what is being said to
her about her labor because of the medical terminology used or because of a language barrier.
Coaching, emotional support, and comfort measures help the woman use her energy
constructively in relaxing and working with the contractions.
The progress of labor is enhanced when a woman changes her position frequently during the
first stage of labor.
Doulas provide a continuous supportive presence during labor that can have a positive effect on
the process of childbirth and its outcome.
The cultural beliefs and practices of a woman and her significant others, including her partner,
can have a profound influence on their approach to labor and birth.
Siblings present for labor and birth need preparation and support for the event.
The second stage of labor is the stage in which the infant is born. This stage begins with full
cervical dilation (10 cm) and complete effacement (100%) and ends with the babys birth.
Women with a history of sexual abuse often experience profound stress and anxiety during
childbirth.
Inability to palpate the cervix during vaginal examination indicates that complete effacement
and full dilation have occurred and is the only certain, objective sign that the second stage has
begun.
Women may have an urge to bear down at various times during labor; for some it may be
before the cervix is fully dilated, and for others it may not occur until the active phase of the
second stage of labor.
When encouraged to respond to the rhythmic nature of the second stage of labor, the woman
normally changes body positions, bears down spontaneously, and vocalizes (open-glottis
pushing) when she perceives the urge to push (Ferguson reflex).
Women should bear down several times during a contraction
using the open-glottis pushing method. They should avoid sustained closed-glottis pushing
because this inhibits oxygen transport to the fetus.
Nurses can use the role of advocate to prevent routine use of episiotomy and reduce the
incidence of lacerations by empowering women to take an active role in their childbirth and
educating health care providers about approaches to managing childbirth that reduce the
incidence of perineal trauma.

Objective signs indicate that the placenta has separated and is ready to be expelled; excessive
traction (pulling) on the umbilical cord before the placenta has separated can result in maternal
injury.
During the fourth stage of labor the womans fundal tone, lochial flow, and vital signs should
be assessed frequently to ensure that she is physically recovering well after giving birth.
Most parents and families enjoy being able to handle, hold, explore, and examine the baby
immediately after the birth.
The woman who has given birth by cesarean or received regional anesthesia for a vaginal birth
requires special attention during the recovery period. A PAR score is determined for each woman
on arrival and is updated as part of every 15-minute assessment. Components of the PAR score
include activity, respirations, blood pressure, level of consciousness, and color.
Ch. 16 Evolve Questions
1. Which characteristic is associated with false labor contractions?
A.

Painless

B.

Decrease in intensity with ambulation Correct

C.

Regular pattern of frequency established

D.

Progressive in terms of intensity and duration

True labor contractions are painful. Although false labor contractions decrease with activity, true
labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern
of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.
2. A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an
expectant parents class. Which aspect of their birth plan would be considered unrealistic
and require further discussion with the nurse?

A.

My husband and I have agreed that my sister will be my coach since he


becomes anxious with regard to medical procedures and blood. He will be nearby
and check on me every so often to make sure everything is OK.

B.

We plan to use the techniques taught in the Lamaze classes to reduce the
pain experienced during labor.

C.

We want the labor and birth to take place in a birthing room. My husband
will come in the minute the baby is born.

D.

We do not want the fetal monitor used during labor since it will interfere
with movement and doing effleurage. Correct

These are acceptable requests during labor and delivery. These are acceptable requests during
labor and delivery. These are acceptable requests during labor and delivery. Since monitoring is
essential to assess fetal well-being, it is not a factor that can be determined by the couple. The
nurse should fully explain its importance. The option for intermittent electronic monitoring could
be explored if this is a low-risk pregnancy and as long as labor is progressing normally.
3. The nurse should realize that the most common and potentially harmful maternal
complication of epidural anesthesia is:
A.

severe postpartum headache.

B.

limited perception of bladder fullness.

C.

increase in respiratory rate.

D.

hypotension. Correct

Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic because it
would be with a low spinal (saddle block) anesthetic. Limited perception of bladder fullness is an

effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially
serious complication. Epidural anesthesia can lead to vasodilation and a drop in blood pressure
that could interfere with adequate placental perfusion. The woman must be well hydrated before
and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.
4. When managing the care of a woman in the second stage of labor, the nurse uses various
measures to enhance the progress of fetal descent. These measures include:
A.

encouraging the woman to try various upright positions, including squatting


and standing. Correct

B.

telling the woman to start pushing as soon as her cervix is fully dilated.

C.

continuing an epidural anesthetic so that pain is reduced and the woman can
relax.

D.

coaching the woman to use sustained, 10- to 15-second, closed-glottis


bearing-down efforts with each contraction.

Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate
when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one
factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the
woman to labor down (allowing more time for fetal descent, thereby reducing the amount of
pushing needed) if she is able. The epidural may mask the sensations and muscle control needed
for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver,
which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting
perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7
seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

5. Evidence-based care practices designed to support normal labor and birth recommend
which practice during the immediate newborn period?
A.

The healthy newborn should be taken to the nursery for a complete


assessment.

B.

After drying, the infant should be given to the mother wrapped in a receiving
blanket.

C.

Encourage skin-to-skin contact of mother and baby. Correct

D.

The father or support person should be encouraged to hold the infant while
awaiting delivery of the placenta.

Although this is the practice in many facilities, it is neither evidence-based nor supportive of
family-centered care. This is a common practice and more family friendly than separating mother
and baby; however, ideally the baby should be placed skin to skin. The unwrapped infant should
be placed on the womans bare chest or abdomen, then covered with a warm blanket. Skin-toskin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic
adjustment to extrauterine life, and fosters early breastfeeding. The father or support person is
likely anxious to hold and admire the newborn. This can happen after the infant has been placed
skin to skin and breastfeeding has been initiated.

6. Which description of the phases of the second stage of labor is accurate?


A.

Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45


minutes

B.

Active phase: overwhelmingly strong contractions, Ferguson reflux activated,


duration is 5 to 15 minutes

C.

Descent phase: significant increase in contractions, Ferguson reflux activated,


average duration varies Correct

D.

Transitional phase: woman laboring down, fetal station is 0, duration is 15


minutes

The latent phase is the lull, or laboring down, period at the beginning of the second stage. It
lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The descent
phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the
duration varies, depending on a number of factors. The transition phase is the final phase in the
second stage of labor; contractions are strong and painful.
7. Which test is performed to determine if membranes are ruptured?
A.

Urine analysis

B.

Fern test Correct

C.

Leopold maneuvers

D.

Artificial Rupture of Membranes (AROM)

A urine analysis should be performed on admission to labor and delivery. This test is used to
identify the presence of glucose and protein. In many instances a sterile speculum examination
and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic
fluid. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude.
AROM is the procedure of artificially rupturing membranes, usually with a device known as an
amnihook.

8. A woman who is 39 weeks pregnant expresses fear about her impending labor and how
she will manage. The nurses best response is:
A.

Dont worry about it. Youll do fine.

B.

Its normal to be anxious about labor. Lets discuss what makes you afraid.
Correct

C.

Labor is scary to think about, but the actual experience isnt.

D.

You may have an epidural. You wont feel anything.

This statement negates the womans fears and is not therapeutic. This statement allows the
woman to share her concerns with the nurse and is a therapeutic communication tool. This
statement negates the womans fears and offers a false sense of security. This statement is not
true. A number of criteria must be met for use of an epidural. Furthermore, many women still
experience the feeling of pressure with an epidural.

9. Vaginal examinations should be performed by the nurse under which of these


circumstances. (Select all that apply.)
A.

An admission to the hospital at the start of labor Correct

B.

When accelerations of the fetal heart rate (FHR) are noted

C.

On maternal perception of perineal pressure or the urge to bear down Correct

D.

When membranes rupture Correct

E.

When bright, red bleeding is observed

Vaginal examinations should be performed when the woman is admitted to the hospital or
birthing center at the start of labor. An accelerated FHR is a positive sign; variable decelerations,
however, merit a vaginal examination. When the woman perceives perineal pressure or the urge
to bear down is an appropriate time to perform a vaginal examination. After rupture of
membranes (ROM) a vaginal examination should be performed. The nurse must be aware that
there is an increased risk of prolapsed cord immediately after ROM. Examinations are never
done by the nurse if vaginal bleeding is present since the bleeding could be a sign of placenta
previa and a vaginal examination could result in further separation of the low-lying placenta.

10. For the labor nurse, care of the expectant mother begins with which situations? (Select all
that apply.)
A.

The onset of progressive, regular contractions Correct

B.

The bloody, or pink, show Correct

C.

The spontaneous rupture of membranes Correct

D.

Formulation of the womans plan of care for labor

E.

Moderately painful contractions

Labor care begins with the onset of progressive, regular contractions. The woman and the nurse
can formulate their plan of care before labor or during treatment. Labor care begins when the
blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their
plan of care before labor or during treatment. Labor care begins when amniotic fluid is
discharged from the vagina. The woman and the nurse can formulate their plan of care before
labor or during treatment. Labor care begins when progressive, regular contractions begin, the
blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The
woman and the nurse can formulate their plan of care before labor or during treatment. Pain is
subjective. The onset of progressive, regular contractions signals the beginning of labor; not the
intensity of the pain.
Ch.17 Key Points
Preterm labor consists of uterine contractions with cervical change (e.g., effacement and
dilation) that occur between 20 and 37 completed weeks of pregnancy; preterm birth is any birth
that occurs before the completion of 37 weeks of pregnancy.
Complications related to preterm birth account for more newborn and infant deaths than any
other cause.
The incidence of preterm birth in the United States varies considerably by race.
Preterm birth describes length of gestation, whereas low birth weight describes only weight at
the time of birth.

Preterm birth is divided into two categories: spontaneous and indicated. Spontaneous preterm
birth occurs after an early initiation of the labor process and comprises nearly 75% of all preterm
births in the United States. Indicated preterm birth occurs as a means to resolve maternal or fetal
risk related to continuing the pregnancy.
The cause of preterm labor is unknown and is assumed to be multifactorial.
Preconception counseling and care for women, especially those with a history of preterm birth,
may identify correctable risk factors and provide a means to encourage women to participate
in health-promoting activities.
Because the onset of preterm labor can often be mistaken for normal discomforts of pregnancy,
nurses should teach all pregnant women how to detect the early symptoms of preterm labor and
to call their primary health care provider when symptoms occur.
Bed rest, still a commonly prescribed intervention for preterm labor, has many deleterious side
effects and has never been shown to decrease preterm birth rates; modified bed rest is
recommended.
The best reason to use tocolytic therapy is to achieve sufficient time to administer
glucocorticoids in an effort to accelerate fetal lung maturity and reduce the severity of respiratory
complications in infants born preterm. In addition, time is allowed for transport of the woman
before birth to a center equipped to care for preterm infants.
When preterm birth appears inevitable, magnesium sulfate may be administered to reduce or
prevent neonatal neurologic morbidity
If fetal or early neonatal death is expected, the parents and members of the health care team
need to discuss the situation before the birth and decide on a management plan that is acceptable
to everyone.
Premature rupture of membranes (PROM) is the spontaneous rupture of the amniotic sac and
leakage of amniotic fluid beginning before the onset of labor at any gestational age. Preterm
premature rupture of membranes is associated with approximately 10% of all preterm births in
the United States.
Vigilance for signs of infection is an essential part of the care for women with preterm PROM.
A postterm pregnancy poses a risk to both the mother and the fetus.
Dysfunctional labor results from differences in the normal relationships among any of the five
factors affecting labor and is characterized by differences in the pattern of progress in labor.

Malpresentation (the fetal presentation is something other than cephalic or head first) is another
commonly reported complication of labor and birth. Breech presentation is the most common
form.
Obese women are at risk for several complications during labor and birth, including cesarean
birth. Even routine procedures require more time and effort to accomplish when the woman is
obese.
Labor should not be induced electively until the woman has reached at least 39 weeks of
gestation.
Cervical ripening using chemical or mechanical measures can increase the success of labor
induction.
Amniotic membrane stripping or sweeping is a method of inducing labor through the release of
prostaglandins and oxytocin.
Oxytocin is a hormone normally produced by the posterior pituitary gland. It stimulates uterine
contractions and aids in milk let-down. Synthetic oxytocin (Pitocin) may be used either to
induce labor or to augment a labor that is progressing slowly because of inadequate uterine
contractions.
Expectant parents benefit from learning about operative obstetrics (e.g., forceps- or vacuumassisted or cesarean birth) during the prenatal period.
Maternal indications for forceps-assisted birth include a prolonged second stage of labor and
the need to shorten the second stage of labor for maternal reasons. Fetal indications include an
abnormal FHR tracing or certain abnormal presentations, arrest of rotation, or extraction of the
head in a breech presentation.
Vacuum-assisted birth is a birth method involving the attachment of a vacuum cup to the fetal
head, using negative pressure to assist in the birth of the head. It is generally not used to assist
birth before 34 weeks of gestation. Indications for its use are the same as those for outlet forceps.
Prerequisites for use include a completely dilated cervix, ruptured membranes, engaged head,
vertex presentation, and no suspicion of CPD.
The basic purpose of cesarean birth is to preserve the life and health of the mother and her
fetus.
Possible maternal complications related to cesarean birth include aspiration, hemorrhage,
atelectasis, endometritis, abdominal wound dehiscence or infection, urinary tract infection,
injuries to the bladder or bowel, and complications related to anesthesia.

The attitude of the nurse and other health care team members can influence the womans
perception of herself after a cesarean birth. The caregivers should stress that the woman is a new
mother first and a surgical patient second.
Unless contraindicated, a vaginal birth may be possible after a previous cesarean birth. A trial
of labor (TOL) is the observance of a woman and her fetus for a reasonable period of
spontaneous active labor to assess the safety of vaginal birth for the mother and infant. It may be
initiated if the mothers pelvis is of questionable size or shape or if the fetus is in an abnormal
presentation or position. By far the most common reason for a TOL is if the woman wishes to
have a vaginal birth after a previous cesarean birth.
Labor management that emphasizes one-on-one support of the laboring woman by another
woman (doula, nurse, or nursemidwife) can reduce the rate of cesarean birth and increase the
VBAC rate.
The major risk associated with meconium-stained amniotic fluid is the development of
meconium aspiration syndrome (MAS) in the newborn. The presence of a team skilled in
neonatal resuscitation is required at the birth of any infant with meconiumstained amniotic fluid.
Shoulder dystocia is an uncommon obstetric emergency that increases the risk for fetal and
maternal morbidity and mortality during the attempt to accomplish birth vaginally.
Umbilical cord prolapse may be occult (hidden, rather than visible) at any time during labor,
whether or not the membranes are ruptured. It is most common to see frank prolapse directly
after rupture of membranes. Contributing factors include a long cord, malpresentation, or an
unengaged presenting part. Prompt recognition of a prolapsed umbilical cord is very important.
During labor and birth, the major risk factor for uterine rupture is a scarred uterus as a result of
previous cesarean birth or other uterine surgery. Prevention is the best treatment.
Amniotic fluid embolus (AFE) is a rare but devastating complication of pregnancy
characterized by the sudden, acute onset of hypoxia, hypotension, cardiovascular collapse, and
coagulopathy. Care must be instituted immediately. Cardiopulmonary resuscitation
is often necessary.
Ch.17 Evolve Questions
1. A laboring womans amniotic membranes have just ruptured. The immediate action of the
nurse would be to:
A.

assess the fetal heart rate (FHR) pattern. Correct

B.

perform a vaginal examination.

C.

inspect the characteristics of the fluid.

D.

assess maternal temperature.

The first nursing action after the membranes are ruptured is to check the FHR. Compression of
the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR
pattern, characteristically variable decelerations. The same initial action should follow artificial
rupture of the membranes (amniotomy). These are all important and should be done after the
FHR and pattern are assessed. These are all important and should be done after the FHR and
pattern are assessed. These are all important and should be done after the FHR and pattern are
assessed.

2. A woman is evaluated to be using an effective bearing-down effort if she:


A.

begins pushing as soon as she is told that her cervix is fully dilated and
effaced.

B.

takes two deep, cleansing breaths at the onset of a uterine contraction and at
the end of the contraction. Correct

C.

uses the Valsalva maneuver by holding her breath and pushing vigorously for
a count of 12.

D.

continues to push for short periods between uterine contractions throughout


the second stage of labor.

Bearing-down efforts should begin during the active-descent phase of the second stage of labor
when the urge to bear down (Fresno reflex) is perceived. Cleansing breaths at the onset of a
contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in

the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid
closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced.
Open-glottis pushing is recommended. The woman should push with contractions to combine the
force of both powers of labor: uterine and abdominal. Pushing gently between contractions is
only advised when the fetal head is being delivered.

3. In planning for an expected cesarean birth for a woman who has given birth by cesarean
previously and who has a fetus in the transverse presentation, the nurse includes which
information?
A.

Because this is a repeat procedure, you are at the lowest risk for
complications.

B.

Even though this is your second cesarean birth, you may wish to review the
preoperative and postoperative procedures. Correct

C.

Because this is your second cesarean birth, you will recover faster.

D.

You will not need preoperative teaching because this is your second cesarean
birth.

This statement is not accurate. Maternal and fetal risks are associated with every cesarean
section. This statement is the most appropriate. This statement is not accurate. Physiologic and
psychologic recovery from a cesarean section is multifactorial and individual to each client each
time. Preoperative teaching should always be performed regardless of whether the client has
already had this procedure.

4. For a woman at 42 weeks of gestation, which finding requires more assessment by the
nurse?
A.

Fetal heart rate of 116 beats/min

B.

Cervix dilated 2 cm and 50% effaced

C.

Score of 8 on the biophysical profile

D.

One fetal movement noted in 1 hour of assessment by the mother Correct

A fetal heart rate of 116 beats/min is a normal finding at 42 weeks of gestation. Cervical dilation
of 2 cm with 50% effacement is a normal finding in a 42-week gestation woman. A score of 8 on
the BPP is a normal finding in a 42-week gestation pregnancy. Self-care in a postterm pregnancy
should include performing daily fetal kick counts three times per day. The mother should feel
four fetal movements per hour. If fewer than four movements have been felt by the mother, she
should count for 1 more hour. Fewer than four movements in that hour warrants evaluation.

5. A pregnant womans amniotic membranes rupture. Prolapsed cord is suspected. Which


intervention is the nurses top priority?
A.

Place the woman in the knee-chest position. Correct

B.

Cover the cord in a sterile towel saturated with warm normal saline.

C.

Prepare the woman for a cesarean birth.

D.

Start oxygen by face mask.

A. The woman is assisted into a position (e.g., modified Sims position, Trendelenburg
position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off
the cord.
B.
If the cord is protruding from the vagina, it may be covered with a sterile towel soaked in
saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing
priority.
C.
If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery.

Cesarean birth is indicated only if cervical dilation is not complete.


D. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete.
This intervention should be initiated after pressure is relieved on the cord. Not only should the
woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers
to lift the presenting part off the cord.

6. A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse
recognizes that the oxytocin should be discontinued immediately if there is evidence of:
A.

uterine contractions occurring every 8 to 10 minutes

B.

a fetal heart rate (FHR) of 180 with absence of variability Correct

C.

the client needing to void

D.

rupture of the clients amniotic membranes

The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that
occur every 8 to 10 minutes do not qualify as hyperstimulation. This FHR is nonreassuring. The
oxytocin should be immediately discontinued and the physician should be notified. This is not an
indication to discontinue the oxytocin induction immediately or to call the physician. Unless a
change occurs in the FHR pattern that is nonreassuring or the client experiences uterine
hyperstimulation, the oxytocin does not need to be discontinued. The physician should be
notified that the clients membranes have ruptured.

7. With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be
aware that:
A.

the drugs can be given efficaciously up to the designated beginning of term at


37 weeks.

B.

there are no important maternal (as opposed to fetal) contraindications.

C.

its most important function is to afford the opportunity to administer antenatal


glucocorticoids. Correct

D.

if the client develops pulmonary edema while on tocolytics, IV fluids should


be given.

Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits.
There are important maternal contraindications to tocolytic therapy. Buying time for antenatal
glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics.
Tocolytic-induced edema can be caused by IV fluids.
8. With regard to dysfunctional labor, nurses should be aware that:
A.

women who are underweight are more at risk.

B.

women experiencing precipitous labor are about the only dysfunctionals not
to be exhausted. Correct

C.

hypertonic uterine dysfunction is more common than hypotonic dysfunction.

D.

abnormal labor patterns are most common in older women.

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

9. A nurse providing care to a woman in labor should be aware that cesarean birth:

A.

is declining in frequency in the United States.

B.

is more likely to be done for the poor in public hospitals who do not get the
nurse counseling that wealthier clients do.

C.

is performed primarily for the benefit of the fetus. Correct

D.

can be either elected or refused by women as their absolute legal right.

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

10. Which statement is most likely to be associated with a breech presentation?


A.

Least common malpresentation

B.

Descent is rapid

C.

Diagnosis by ultrasound only

D.

High rate of neuromuscular disorders Correct

Breech is the most common malpresentation affecting 3% to 4% of all labors. Descent is often
slow because the breech is not as good a dilating wedge as is the fetal head. Diagnosis is made
by abdominal palpation and vaginal examination. It is confirmed by ultrasound. Fetuses with
neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less
capable of movement within the uterus.

11. A woman at 26 weeks of gestation is being assessed to determine whether she is


experiencing preterm labor. What findings indicate that preterm labor may be occurring?
(Select all that apply.)
A.

Estriol is found in maternal saliva. Correct

B.

Irregular, mild uterine contractions are occurring every 12 to 15 minutes.

C.

Fetal fibronectin is present in vaginal secretions.

D.

The cervix is effacing and dilated to 2 cm. Correct

E.

Fetal heart rate of 150 beats/minute

Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of
gestation. Levels of salivary estriol have been shown to increase before preterm birth. Irregular,
mild contractions that do not cause cervical change are not considered a threat. The presence of
fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict
preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are
other physiologic clues of preterm labor, such as cervical changes. Cervical changes such as
shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor.
Changes in the cervix accompanied by regular contractions indicate labor at any gestation.
E.
Fetal heart rate is normal.
.
12. The labor and delivery nurse is admitting a woman complaining of being in labor. The
nurse completes the admission database and notes that which factors may prohibit the
woman from having a vaginal birth? (Select all that apply.)
A.

Unstable coronary artery disease Correct

B.

Previous cesarean birth Correct

C.

Placenta previa Correct

D.

Initial blood pressure of 132/87

E.

History of three spontaneous abortions

Indications for cesarean birth include:


Maternal

Specific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease)

Specific respiratory disease (e.g., Guillain-Barr syndrome)

Conditions associated with increased intracranial pressure

Mechanical obstruction of the lower uterine segment (tumors, fibroids)

Mechanical vulvar obstruction (e.g., extensive condylomata)

History of previous cesarean birth


Fetal
Abnormal fetal heart rate (FHR) or pattern

Malpresentation (e.g., breech or transverse lie)


Active maternal herpes lesions

Maternal human immunodeficiency virus (HIV) with a viral load of more than 1000
copies/mL

Congenital anomalies
Maternal-Fetal

Dysfunctional labor (e.g., cephalopelvic disproportion, failure to progress in labor)

Placental abruption

Placenta previa

Elective cesarean birth (cesarean on maternal request)


The blood pressure can be elevated because of pain and is not necessarily a contraindication to
vaginal birth until further assessment is completed. Having a history of three spontaneous
abortions is not a contraindication to vaginal birth.
Ch.18 Key Points
Describe the anatomic and physiologic changes that occur during the postpartum period.

Discuss characteristics of uterine involution and lochial flow and describe ways to measure
them.
List expected values for vital signs and blood pressure, deviations from normal findings, and
probable causes of the deviations.
The uterus involutes rapidly after birth and returns to the true pelvis within 2 weeks.
The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is
responsible for triggering many of the anatomic and physiologic changes in the puerperium.
Assessment of lochia and fundal height is essential to monitor the progress of normal involution
and to identify potential problems.
Postbirth uterine discharge (lochia), initially is bright red (lochia rubra) and may contain small
clots. For the first 2 hours after birth, the amount of uterine discharge should be about that of a
heavy menstrual period. After that time, the lochial flow should steadily decrease.
The cervix is soft immediately after birth. The ectocervix (portion of the cervix that protrudes
into the vagina) appears bruised and has some small lacerationsoptimal conditions for the
development of infection.
Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the
absence of rugae. The greatly distended, smooth-walled vagina gradually decreases in size and
regains tone, although it never completely returns to its prepregnancy state.
Significant hormonal changes occur during the postpartal period.
Kidney function returns to normal within 1 month after birth. Marked diuresis, decreased
bladder sensitivity, and overdistention of the bladder can lead to problems with urinary
elimination.
The return of ovulation and menses is determined in part by whether the woman breastfeeds her
infant.
During the first 24 hours after birth, there is little, if any, change in the breast tissue. The
breasts gradually become fuller and heavier as the colostrum transitions to mature milk by about
72 to 96 hours after birth.
Few alterations in vital signs are seen after birth under normal circumstances.
Hypercoagulability, vessel damage, and immobility predispose the woman to
thromboembolism.

Pregnancy-induced hypervolemia, combined with several postpartum physiologic changes,


allows the woman to tolerate considerable blood loss at birth.
Ch. 18 Evolve Questions 1. Following the birth of her baby, a woman expresses concern about the weight she gained
during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in
describing the expected pattern of weight loss, should begin by telling this woman that:
A.

return to prepregnant weight is usually achieved by the end of the postpartum


period.

B.

fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb
weight loss.

C.

the expected weight loss immediately after birth averages about 11 to 13 lbs.
Correct

D.

lactation will inhibit weight loss since caloric intake must increase to support
milk production.

Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week
postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 lbs. The
expected weight loss immediately following delivery is 11 to 13 lbs, followed by a gradual
decrease and a return to prepregnancy weight in 2 to 3 months. Weight loss continues during
breastfeeding since fat stores developed during pregnancy and extra calories consumed are used
as part of the lactation process.

2. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:
A.

wear a snug, supportive bra. Correct

B.

allow warm water to soothe the breasts during a shower.

C.

express milk from breasts occasionally to relieve discomfort.

D.

place absorbent pads with plastic liners into her bra to absorb leakage.

A snug, supportive bra limits milk production and reduces discomfort by supporting the tender
breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would
increase circulation, thereby increasing discomfort. Expressing milk results in continued milk
production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.
3. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the
womans bladder is distended because her fundus is now 3 cm above the umbilicus and to
the right of the midline. In the immediate postpartum period, the most serious
consequence likely to occur from bladder distention is:
A.

urinary tract infection.

B.

excessive uterine bleeding. Correct

C.

a ruptured bladder.

D.

bladder wall atony.

A urinary tract infection may result from overdistention of the bladder, but it is not the most
serious consequence. Excessive bleeding can occur immediately after birth if the bladder
becomes distended, because it pushes the uterus up and to the side and prevents it from
contracting firmly. A ruptured bladder may result from a severely overdistended bladder.
However, vaginal bleeding most likely would occur before the bladder reaches this level of
overdistention. Bladder distention may result from bladder wall atony. The most serious concern
associated with bladder distention is excessive uterine bleeding.

4. What statement by a newly delivered woman indicates that she knows what to expect
about her menstrual activity after childbirth?

A.

My first menstrual cycle will be lighter than normal and then will get heavier
every month thereafter.

B.

My first menstrual cycle will be heavier than normal and will return to my
prepregnant volume within three or four cycles. Correct

C.

I will not have a menstrual cycle for 6 months after childbirth.

D.

My first menstrual cycle will be heavier than normal and then will be light
for several months after.

She can expect her first menstrual cycle to be heavier than normal, and the volume of her
subsequent cycles to return to prepregnant levels within three or four cycles. This is an accurate
statement and indicates her understanding of her expected menstrual activity. Most women
experience a heavier than normal flow during the first menstrual cycle, which occurs by 3
months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and
the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.
5. With regard to afterbirth pains, nurses should be aware that these pains are:
A.

caused by mild, continual contractions for the duration of the postpartum


period.

B.

more common in first-time mothers.

C.

more noticeable in births in which the uterus was overdistended. Correct

D.

alleviated somewhat when the mother breastfeeds.

The cramping that causes afterbirth pains arises from periodic, vigorous contractions and
relaxations that persist through the first part of the postpartum period. Afterbirth pains are more
common in multiparous women because first-time mothers have better uterine tone. A large baby

or multiple babies overdistend the uterus. Breastfeeding intensifies afterbirth pain because it
stimulates contractions.
6. Postbirth uterine/vaginal discharge, called lochia:
A.

is similar to a light menstrual period for the first 6 to 12 hours.

B.

is usually greater after cesarean births.

C.

will usually decrease with ambulation and breastfeeding.

D.

should smell like normal menstrual flow unless an infection is present.


Correct

Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily
decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with
ambulation and breastfeeding. An offensive odor usually indicates an infection.
7. Which description of postpartum restoration or healing times is accurate?
A.

The cervix shortens, becomes firm, and returns to form within a month
postpartum.

B.

Rugae reappear within 3 to 4 weeks. Correct

C.

Most episiotomies heal within a week.

D.

Hemorrhoids usually decrease in size within 2 weeks of childbirth.

The cervix regains its form within days; the cervical os may take longer. Rugae are never again
as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function

resumes. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease
in size.

8. With regard to the condition and reconditioning of the urinary system after childbirth,
nurses should be aware that:
A.

kidney function returns to normal a few days after birth.

B.

diastasis recti abdominis is a common condition that alters the voiding reflex.

C.

fluid loss through perspiration and increased urinary output account for a
weight loss of more than 2 kg during the puerperium. Correct

D.

with adequate emptying of the bladder, bladder tone usually is restored 2 to 3


weeks after childbirth.

Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the
separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Excess fluid
loss through other means occurs as well. Bladder tone usually is restored 5 to 7 days after
childbirth.
9. As part of the postpartum assessment, the nurse examines the breasts of a primiparous
breastfeeding woman who is 1-day postpartum. Expected findings include:
A.

little if any change Correct

B.

leakage of milk at let-down

C.

swollen, warm, and tender on palpation

D.

a few blisters and a bruise on each areola

E.

small amount of clear, yellow fluid expressed

Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may
leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth.
Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with
the breastfeeding techniques being used.
E.
Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts during
the first 24 hours.

10. After completing a postpartum assessment on woman who delivered 20 hours ago, the
nurse should report which assessment findings to the health care provider? (Select all
that apply.)
A.

Temperature 100.0 F

B.

Pulse 110 beats/min Correct

C.

Respiratory rate 12 breaths/min

D.

Blood pressure 125/78

E.

Temperature 38 C Correct

During the first 24 hours postpartum, temperature may increase to 38 C (100.4 F) Pulse,
remains elevated for the first hour or so after childbirth. It then begins to decrease to a
nonpregnant rate. A rapid pulse may indicate hypovolemia. Respiratory rate is normal. Blood
pressure is altered slightly if at all postpartum.
Ch.19 Key Points
Postpartum care is modeled on the concept of health.
Cultural beliefs and practices affect the patients response to the puerperium.

The nursing care plan includes assessments to detect deviations from normal, comfort measures
to relieve discomfort or pain, and safety measures to prevent injury or infection.
Nursing care is provided in the context of the family unit and focuses on assessment and
support of the womans physiologic and emotional adaptation after birth.
During the early postpartum period, components of nursing care include assisting the mother
with rest and recovery from the process of labor and birth, assessing physiologic and psychologic
adaptation after birth, preventing complications, educating regarding self-management and infant
care, and supporting the mother and her partner during the initial transition to parenthood.
Common nursing interventions in the postpartum period include the following: evaluating and
treating the boggy uterus and the full urinary bladder; providing for nonpharmacologic and
pharmacologic relief of pain and discomfort associated with the episiotomy, lacerations,
afterbirth pains, or breastfeeding; and instituting measures to promote or suppress lactation.
Postpartum fatigue (PPF) is more than just feeling tired; it is a complex phenomenon affected
by a combination of physiologic, psychologic, and situational variables. Fatigue is common in
the early postpartum period and involves both physiologic and psychologic components.
Early ambulation is associated with a reduced incidence of venous thromboembolism (VTE); it
also promotes the return of strength. Free movement is encouraged once anesthesia wears off
unless an opioid analgesic has been administered.
From their initial contact with the postpartum woman, nurses prepare the new mother for the
time when she will return home. Planning for discharge begins with the first interaction among
the nurse, the woman, and her family and continues until they leave the hospital or birthing
facility
Early postpartum discharge will continue as a result of consumer demand, medical necessity,
discharge criteria for low risk childbirth, and cost-containment measures.
Early discharge classes, telephone follow-up, home visits, warm lines, and support groups are
effective means of facilitating physiologic and psychologic adjustments in the postpartum
period.
Ch. 19 Evolve Questions
1. When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm,
2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse
should:
A.

massage the fundus.

B.

administer Methergine, 0.2 mg PO, that has been ordered prn.

C.

assist the woman to empty her bladder. Correct

D.

recognize this as an expected finding during the first 24 hours following birth.

A firm fundus should not be massaged since massage could overstimulate the fundus and cause it
to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already
firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of
midline. The recommended action would be to empty the bladder. If the bladder remains
distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding,
and an action is required.
.
2. The nurse examines a woman 1 hour after birth. The womans fundus is boggy, midline,
and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots.
The nurses initial action would be to:
A.

place her on a bedpan to empty her bladder.

B.

massage her fundus. Correct

C.

call the physician.

D.

administer Methergine, 0.2 mg IM, which has been ordered prn.

There is no indication of a distended bladder; thus having the woman urinate will not alleviate
the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by
the profuse lochia and passage of clots. The first action would be to massage the fundus until
firm. The physician can be called after massaging the fundus, especially if the fundus does not
become or remain firm with massage. Methergine can be administered after massaging the
fundus, especially if the fundus does not become or remain firm with massage.

3. Perineal care is an important infection control measure. When evaluating a postpartum


womans perineal care technique, the nurse would recognize the need for further
instruction if the woman:
A.

uses soap and warm water to wash the vulva and perineum.

B.

washes from the symphysis pubis back to the episiotomy.

C.

changes her perineal pad every 2 to 3 hours.

D.

uses the peribottle to rinse upward into her vagina. Correct

These are all appropriate measures. These are all appropriate measures. These are all appropriate
measures. The peribottle should be used in a backward direction over the perineum. The flow
should never be directed upward into the vagina since debris would be forced upward into the
uterus through the still-open cervix.
4. Which measure would be least effective in preventing postpartum hemorrhage?
A.

Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered

B.

Encourage the woman to void every 2 hours

C.

Massage the fundus every hour for the first 24 hours following birth Correct

D.

Teach the woman the importance of rest and nutrition to enhance healing

Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can
help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be

massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and
nutrition are helpful for enhancing healing and preventing hemorrhage.

5. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has
completely saturated a perineal pad within 15 minutes. The nurses first action is to:
A.

begin an IV infusion of Ringers lactate solution.

B.

assess the womans vital signs.

C.

call the womans primary health care provider.

D.

massage the womans fundus. Correct

The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first
action. Blood pressure is not a reliable indicator of impending shock from an impending
hemorrhage; assessing vital signs should not be the nurses first action. The physician should be
notified after the nurse completes assessment of the woman. The nurse should assess the uterus
for atony. Uterine tone must be established to prevent excessive blood loss.

6. Excessive blood loss after childbirth can have several causes; however, the most common
is:
A.

vaginal or vulvar hematomas.

B.

unrepaired lacerations of the vagina or cervix.

C.

failure of the uterine muscle to contract firmly. Correct

D.

retained placental fragments.

Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine
muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a
possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common
cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing
bladder distention. Although retained placental fragments is a possible cause of excessive blood
loss, uterine muscle failure (uterine atony) is the most common cause.

7. Baby-friendly hospitals mandate that infants be put to breast within what time frame after
birth?
A.

1 hour Correct

B.

30 minutes

C.

2 hours

D.

4 hours

Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth
(BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after
delivery. In many countries this is the norm; however, the Baby-Friendly Hospital Initiative
(BFHI) mandates 1 hour. Ideally an infant should go no longer than 2 hours after delivery before
being put to breast. This is much too long to wait to initiate breastfeeding, whether the hospital is
baby-friendly or not.
8. Two hours after giving birth a primiparous woman becomes anxious and complains of
intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at
the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse
suspects:
A.

bladder distention

B.

uterine atony

C.

constipation

D.

hematoma formation Correct

Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the
right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this
time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are
characteristic of hematoma formation.
9. Which findings would be a source of concern if noted during the assessment of a woman
who is 12 hours postpartum? (Select all that apply.)
A.

Postural hypotension

B.

Temperature of 100.4 F

C.

Bradycardiapulse rate of 55 beats/min

D.

Pain in left calf with dorsiflexion of left foot Correct

E.

Lochia rubra with foul odor Correct

Postural hypotension is an expected finding related to circulatory changes after birth A


temperature of 100.4 F in the first 24 hours most likely indicates dehydration, which is easily
corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in
the initial postpartum period. These findings indicate a positive Homans sign and are suggestive
of thrombophlebitis and should be investigated. Lochia with odor may indicate infection.

10. A postpartum woman preparing for discharge asks the nurse about resuming sexual
activity. Which information is appropriate to include in the patient teaching? (Select all
that apply.)
A.

Do not perform Kegel exercises to decrease pelvic floor muscle healing time.

B.

If breastfeeding, sexual interest may be delayed.

C.

Fatigue may affect interest in sexual activity. Correct

D.

Sexual activity can usually be safely resumed by 5 to 6 weeks after birth.


Correct

E.

Water-soluble lubrication may increase comfort. Correct

F.

The female-on-top position may be more comfortable than other positions.


Correct

Kegel exercises are usually recommended and can strengthen the pubococcygeal muscle.
Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding
mothers. The amount of psychologic energy expended by the mother in child care activities may
lead to fatigue and decreased interest in sexual activity. Most women can safely resume sexual
activity by 5 to 6 weeks after birth. A water-soluble gel or jelly is recommended for lubrication.
A position in which the mother has control of the depth of insertion of the penis, such as the
female-on-top position may be more comfortable than other positions.
Ch.20 Key Points
The birth of a baby necessitates changes in the existing interactional structure of a family.
Attachment is developed and maintained by proximity and interaction with the infant through
which the parent becomes acquainted with the infant, identifies the infant as an individual, and
claims the infant as a member of the family. Attachment is strengthened through the use of
sensual responses or interactions by both partners in the parent-infant interaction.

The concept of attachment includes mutuality; that is, the infants behaviors and characteristics
elicit a corresponding set of maternal behaviors and characteristics.
One of the most important areas of assessment for the nurse is careful observation of specific
behaviors thought to indicate the formation of emotional bonds between the newborn
and family, especially the mother. Assessment of parent infant attachment relies more on skillful
observation and interviewing.
The parent-infant relationship is strengthened through the use of touch, eye contact, voice, odor,
entrainment, biorhythmicity, reciprocity, and synchrony.
Women go through predictable stages in becoming a mother.
Many mothers exhibit signs of postpartum blues (baby blues).
Fathers experience emotions and adjustments during the transition to parenthood that are
similar to and also distinctly different from those of mothers.
Modulation of rhythm, modification of behavioral repertoires, and mutual responsivity
facilitate infant-parent adjustment.
Many factors influence adaptation to parenthood (e.g., age, same sex parenting, culture, social
support, socioeconomic level, expectations of what the child will be like).
Sibling adjustment to a new baby requires creative parental interventions.
Grandparents can have a positive influence on the postpartum family.
Ch. 20 Evolve Questions
1. When making a visit to the home of a postpartum woman 1 week after birth, the nurse
should recognize that the woman would characteristically:
A.

express a strong need to review events and her behavior during the process of
labor and birth.

B.

exhibit a reduced attention span, limiting readiness to learn.

C.

vacillate between the desire to have her own nurturing needs met and the need
to take charge of her own care and that of her newborn. Correct

D.

have reestablished her role as a spouse/partner.

This is characteristic of the taking-in stage, which lasts for the first few days after birth. This is
characteristic of the taking-in stage, which lasts for the first few days after birth. One week after
birth the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts
for as long as 4 to 5 weeks after birth. This reflects the letting-go stage, which indicates that
psychosocial recovery is complete.
.
2. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby,
stating that she is too tired and just wants to sleep. The nurse should:
A.

tell the woman she can rest after she feeds her baby.

B.

recognize this as a behavior of the taking-hold stage.

C.

record the behavior as ineffective maternal-newborn attachment.

D.

take the baby back to the nursery, reassuring the woman that her rest is a
priority at this time. Correct

The woman should not be told what to do and needs to care for her own well-being. The takinghold stage occurs about 1 week after birth. Because the woman needs to rest does not indicate
ineffective maternal-newborn attachment. The behavior described is typical of this stage and not
a reflection of ineffective attachment unless it persists. Mothers need to reestablish their own
well-being to effectively care for their baby.

3. Parents can facilitate the adjustment of their other children to a new baby by:
A.

having the children choose or make a gift to give to the new baby on its
arrival home. Correct

B.

emphasizing activities that keep the new baby and other children together.

C.

having the mother carry the new baby into the home so she can show him or
her to the other children.

D.

reducing stress on other children by limiting their involvement in the care of


the new baby.

Having the sibling make or choose a gift for the new baby helps to make the child feel a part of
the process. Special time should be set aside just for the other children without interruption from
the newborn. Someone other than the mother should carry the baby into the home so she can give
full attention to greeting her other children. Children should be actively involved in the care of
the baby according to their ability without overwhelming them.

4. Primiparous woman is in the taking-in stage of psychosocial recovery and adjustment


following birth. Recognizing the needs of women during this stage, the nurse should:
A.

foster an active role in the baby's care.

B.

provide time for the mother to reflect on the events of and her behavior
during childbirth. Correct

C.

recognize the woman's limited attention span by giving her written materials
to read when she gets home rather than doing a teaching session now.

D.

promote maternal independence by encouraging her to meet her own hygiene


and comfort needs.

Once the mothers needs are met, she would be more able to take an active role, not only in her
own care but also the care of her newborn. Women express a need to review their childbirth
experience and evaluate their performance. Short teaching sessions, using written materials to

reinforce the content presented, are a more effective approach. The focus of the taking-in stage is
nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and
nutrition.
.
5. The nurse observes several interactions between a postpartum woman and her new son.
What behavior, if exhibited by this woman, does the nurse identify as a possible
maladaptive behavior regarding parent-infant attachment?
A.

Talks and coos to her son

B.

Seldom makes eye contact with her son Correct

C.

Cuddles her son close to her

D.

Tells visitors how well her son is feeding

Talking and cooing to her son is a normal infant-parent interaction. The woman should be
encouraged to hold her infant in the en face position and make eye contact with him. Cuddling is
a normal infant-parent interaction. Sharing her sons success at feeding is a normal infant-parent
interaction.
6. In follow-up appointments or visits with parents and their new baby, it may be useful if
the nurse can identify parental behaviors that can either facilitate or inhibit attachment.
What is a facilitating behavior?
A.

The parents have difficulty naming the infant.

B.

The parents hover around the infant, directing attention to and pointing at the
infant. Correct

C.

The parents make no effort to interpret the actions or needs of the infant.

D.

The parents do not move from fingertip touch to palmar contact and holding.

Reluctance to name the baby is an inhibiting behavior. Hovering over the infant, as well as
obviously paying attention to the baby, is a facilitating behavior. Failure to interpret the actions
and needs of the infant is an inhibiting behavior. Lack of fingertip, palmar touch, and holding
represents an inhibiting behavior.

7. Which statement regarding postpartum depression (PPD) is essential for the nurse to be
aware of when attempting to formulate a plan of care?
A.

PPD symptoms are consistently severe.

B.

This syndrome affects only new mothers.

C.

PPD can easily go undetected. Correct

D.

Only mental health professionals should teach new parents about this
condition.

PPD symptoms range from mild to severe, with women having good days and bad days.
Screening should be done for mothers and fathers. PPD may also occur in new fathers. PPD can
go undetected because parents do not voluntarily admit to this type of emotional distress out of
embarrassment, fear, or guilt. The nurse should include information on PPD and how to
differentiate this from the baby blues for all clients on discharge. Nurses also can urge new
parents to report symptoms and seek follow-up care promptly if they occur.

8. When working with parents who have some form of sensory impairment, nurses should
consider which information when writing a plan of care?
A.

One of the major difficulties visually impaired parents experience is the


skepticism of health care professionals Correct

B.

Visually impaired mothers cannot overcome the infants need for eye-to-eye
contact

C.

The best approach for the nurse is to assess the parents capabilities rather
than focusing on their disabilities Correct

D.

Technologic advances, including the Internet, can provide deaf parents with a
full range of parenting activities and information Correct

E.

Childbirth education and other materials are available in Braille. Correct

The skepticism, open or hidden, of health care professionals throws up an additional and
unneeded hurdle for the parents. Other sensory output can be provided by the parent, other
people can participate, and other coping devices can be used. After the parents capabilities have
been assessed (including some the nurse may not have expected), the nurse can help find ways to
assist the parents that play to their strengths. The Internet affords an extra teaching tool for the
deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound
into light flashes to help pick up a childs cry. Sign language is acquired readily by young
children. Childbirth education and other materials are available in Braille.

9. The maternity nurse promoting parental-infant attachment should incorporate which


appropriate cultural beliefs into the plan of care? (Select all that apply.)
A.

Asian mothers are encouraged to return to work as soon as possible.

B.

Jordanian mothers have a 40-day lying-in after birth. Correct

C.

Japanese mothers rest for the first 2 months after childbirth. Correct

D.

Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake.

E.

Encourage Vietnamese mothers to cuddle with the newborn.

Asian mothers must remain at home with the baby up to 30 days after birth and are not supposed
to engage in household chores, including care of the baby. Jordanian mothers have a 40-day
lying-in after birth, during which their mothers or sisters care for the baby. Japanese mothers rest
for the first 2 months after childbirth. Hispanic practice involves many food restrictions after
childbirth, such as avoiding fish, pork, and citrus foods. Vietnamese mothers may give minimal
care to their babies and refuse to cuddle or further interact with the baby to ward off evil
spirits.
10. When helping a woman cope with postpartum blues, the nurse should offer what
appropriate suggestions? (Select all that apply.)
A.

The father should take over care of the baby, because postpartum blues are
exclusively a female problem.

B.

Get plenty of rest. Correct

C.

Plan to get out of the house occasionally. Correct

D.

Asking for help will not foster independence.

E.

Use La Leche League or community mental health centers. Correct

Suggestions for coping with postpartum blues include:

Remember that the blues are normal and that both the mother and the father or partner
may experience them.

Get plenty of rest; nap when the baby does if possible. Go to bed early, and let friends and
family know when to visit and how they can help. (Remember, you are not Supermom.)

Use relaxation techniques learned in childbirth classes (or ask the nurse to teach you and
your partner some techniques).

Do something for yourself. Take advantage of the time your partner or family members care
for the babysoak in the tub (a 20-minute soak can be the equivalent of a 2-hour nap), or go for
a walk.


Plan a day out of the housego to the mall with the baby, being sure to take a stroller or
carriage, or go out to eat with friends without the baby. Many communities have churches or
other agencies that provide child care programs such as Mothers Morning Out.
Talk to your partner about the way you feelfor example, about feeling tied down, how the
birth met your expectations, and things that will help you (do not be afraid to ask for specifics).

If you are breastfeeding, give yourself and your baby time to learn.

Seek out and use community resources such as La Leche League or community mental
health centers.
Ch.21 Key Points
PPH is the most common and most serious type of excessive obstetric blood loss.
Causes of PPH are uterine atony, retained placenta, lacerations of the genital tract, hematomas,
inversion of the uterus, and subinvolution of the uterus.
Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of body
organs can become severely compromised and death can ensue.
The potential hazards of therapeutic interventions can further compromise the woman with
hemorrhagic disorders.
When bleeding is continuous and there is no identifiable source, coagulopathy can be the cause.
The womans coagulation status must be assessed quickly and continuously. Causes of
coagulopathies can include pregnancy complications such as idiopathic or immune
thrombocytopenic purpura (ITP), von Willebrand disease (vWD), or DIC.
Postpartum infection is a major cause of maternal morbidity and mortality throughout the
world, and endometritis is the most common postpartum infection.
Postpartum UTIs are common because of trauma experienced during labor.
Structural disorders of the uterus and vagina related to pelvic relaxation are often the delayed
but direct result of childbearing. These can include uterine displacement and prolapse, cystocele
and rectocele, genital fistulas, and urinary incontinence.
Mood disorders account for most mental health disorders in the postpartum period.
Suicidal thoughts or attempts are among the most serious symptoms of PPD.
Antidepressant medications are the usual treatment for PPD; however, specific precautions are
needed for breastfeeding women.

Anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder, panic


disorder and panic attacks, specific phobias, social anxiety disorder, and post-traumatic stress
disorder. Common characteristics of these disorders are irrational fear, worry, and tension;
physical symptoms such as trembling, nausea and vomiting, dizziness, dyspnea, and insomnia
are often seen.
Treatment of postpartum onset of panic disorder requires a combination of medication,
education, supportive measures, and psychotherapy.
Maternal death can be caused by a variety of complications. In many cases, the death of a
mother is sudden and unexpected. Any instance of maternal death is tragic for the family, as well
as for the nurses and other health professionals who were involved in her care.
Nurses and other health care professionals provide empathetic care and support for families
who have experienced maternal loss.
Ch.21 Evolve Questions
1. Two hours after giving birth, a primiparous woman becomes anxious and complains of
intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at
the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would
suspect:
A.

bladder distention.

B.

uterine atony.

C.

constipation.

D.

hematoma formation. Correct

Bladder distention would result in an elevation of the fundus above the umbilicus and deviation
to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is
unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial
flow are characteristic of hematoma formation.
2. Postpartum women experience an increased risk for urinary tract infection. A prevention
measure the nurse could teach the postpartum woman would be to:

A.

acidify the urine by drinking three glasses of orange juice each day.

B.

maintain a fluid intake of 1 to 2 L/day.

C.

empty her bladder every 4 hours throughout the day.

D.

perform perineal care on a regular basis. Correct

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

3. The first and most important nursing intervention when a nurse observes profuse
postpartum bleeding is to:
A.

call the womans primary health care provider

B.

administer the standing order for an oxytocic

C.

palpate the uterus and massage it if it is boggy Correct

D.

assess maternal blood pressure and pulse for signs of hypovolemic shock

The most important nursing intervention is to stop the bleeding. Once the nurse has applied firm
massage of the uterine fundus, the primary health care provider should be notified or the nurse
can delegate this task to another staff member. This intervention is appropriate after assessment
and immediate steps have been taken to control the bleeding. The initial management of
excessive postpartum bleeding is firm massage of the uterine fundus. Vital signs will need to be
ascertained after fundal massage has been applied.

4. Which postpartum conditions are considered medical emergencies that require immediate
treatment?
A.

Inversion of the uterus and hypovolemic shock Correct

B.

Hypotonic uterus and coagulopathies

C.

Subinvolution of the uterus and idiopathic thrombocytopenic purpura

D.

Uterine atony and disseminated intravascular coagulation (DIC)

Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic
uterus can be managed with massage and oxytocin. Coagulopathies should be identified before
delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious
conditions, they do not always require immediate treatment. ITP can be safely managed with
corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric
complications; however, uterine inversion is a medical emergency requiring immediate
intervention.

5. Which postpartum infection is most often contracted by first-time mothers who are
breastfeeding?
A.

Endometritis

B.

Wound infections

C.

Mastitis Correct

D.

Urinary tract infections (UTIs)

Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth
and not limited to first-time mothers. Wound infections are also a common postpartum
complication. Sites of infection include both a cesarean incision and the episiotomy or repaired
laceration. The gravidity of the mother and her feeding choice are not factors in the development
of a wound infection. Mastitis is infection in a breast, usually confined to a milk duct. Most
women who suffer this are first-timers who are breastfeeding. UTIs occur in 2% to 4% of all
postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and
epidural anesthesia.
.
6. Despite popular belief, there is a rare type of hemophilia that affects women of
childbearing age. von Willebrand disease is the most common of the hereditary bleeding
disorders and can affect males and females alike. It results from a factor VIII deficiency
and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy,
there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum
as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that
should be considered first for the client with von Willebrand disease who experiences a
postpartum hemorrhage is:
A.

cryoprecipitate

B.

factor VIII and vWf

C.

desmopressin Correct

D.

Hemabate

Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other
modalities are considered safer. Treatment with plasma products, such as factor VIII and vWf,
are an acceptable option for this client. Because of the repeated exposure to donor blood products
and possible viruses, this is not the initial treatment of choice. Desmopressin is the primary
treatment of choice. This hormone can be administered orally, nasally, and intravenously. This
medication promotes the release of factor VIII and vWf from storage. Although the
administration of this prostaglandin is known to promote contraction of the uterus during
postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

7. Herbal remedies have been used with some success to control PPH after initial
management. Some herbs have homeostatic actions, whereas others work as oxytocic
agents to contract the uterus. What herbal remedy is a commonly used oxytocic agent?
A.

Witch hazel

B.

Ladys mantel

C.

Blue cohosh Correct

D.

Yarrow

Witch hazel is a homeostatic herb. Ladys mantle is a homeostatic remedy. Blue cohosh, cotton
root bark, motherwort, and shepherds purse are oxytocic agents that promote uterine
contraction. Yarrow is not an oxytocic agent, it is a homeostatic.

8. The priority nursing intervention for a woman who suffered a perineal laceration is to:
A.

apply a cold compress.

B.

establish hemostasis. Correct

C.

administer analgesia.

D.

administer a stool softener.

Bleeding should be stopped first. After bleeding has been controlled, the care of the woman with
lacerations of the perineum includes analgesia administration, hot or cold applications, and stool

softeners. Stool softeners may be used to assist the woman in reestablishing bowel habits without
straining and putting stress on the suture lines.

9. Thromboembolic conditions that are of concern during the postpartum period include
(Select all that apply.)
A.

Amniotic fluid embolism (AFE)

B.

Superficial venous thrombosis Correct

C.

Deep vein thrombosis Correct

D.

Pulmonary embolism Correct

E.

Disseminate intravascular coagulation (DIC)

An AFE occurs during the intrapartum period when amniotic fluid containing particles of debris
enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A
superficial venous thrombosis includes involvement of the superficial saphenous venous system.
With deep vein thrombosis the involvement varies but can extend from the foot to the iliofemoral
region. A pulmonary embolism is a complication of deep vein thrombosis occurring when part of
a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and
obstructs blood flow to the lungs. DIC is an imbalance between the bodys clotting and
fibrinolytic systems. Its a pathologic form of clotting that consumes large amounts of clotting
factors.

10. Nursing care management for mothers and fathers suffering grief from the loss of their
baby includes: (Select all that apply.)
A.

using therapeutic communication and caring techniques. Correct

B.

listening as parents tell their story of loss and grief. Correct

C.

avoiding asking any questions about the loss of parents.

D.

giving advice from personal experiences.

E.

insisting parents name the baby in order to be remembered.

The nurse should utilize therapeutic communication and caring techniques. The nurse should
listen patiently while people tell their story of loss and grief. It may be necessary to ask questions
that help people talk about their grief. The nurse should resist the temptation to give advice or
use clichs in offering support. A caution about naming is important. Naming is an individual
decision that should never be imposed on parents. Beliefs and individual needs vary greatly,
sometimes based upon cultures and religious preferences as well.
Ch.22 Key Points
By full term the newborns various anatomic and physiologic systems have reached a level of
development and functioning that permits a physical existence apart from the mother.
The neonates most critical adaptation to extrauterine life is to establish effective respirations.
Signs of respiratory distress can include nasal flaring, intercostal or subcostal retractions (indrawing of tissue between the ribs or below the rib cage), or grunting with respirations.
Close monitoring of the infants vital signs is important for early detection of impending
problems. Persistent tachycardia can be associated with anemia, hypovolemia, hyperthermia, or
sepsis. Persistent bradycardia can be a sign of a congenital heart block
or hypoxemia.
Serious infection is not tolerated well by the newborn. Events other than infection (i.e.,
prolonged crying, maternal hypertension, asymptomatic hypoglycemia, hemolytic disease,
meconium aspiration syndrome, labor induction with oxytocin, surgery, difficult labor, high
altitude, and maternal fever) can cause neutrophilia in the newborn.
Heat loss in the healthy term newborn may exceed the capacity to produce heat; this can lead to
metabolic and respiratory complications that threaten the newborns well-being.

Renal dysfunction resulting from physiologic abnormalities can range from the lack of a steady
stream of urine to gross anomalies such as hypospadias and exstrophy of the bladder. Enlarged or
cystic kidneys can be identified as masses during abdominal palpation. Some kidney anomalies
also can be detected by ultrasound examination during pregnancy.
The time, color, and character of the infants first stool should be noted. Failure to pass
meconium can indicate bowel obstruction related to conditions such as an inborn error of
metabolism or a congenital disorder.
Physiologic jaundice occurs in 60% of term infants and 80% of preterm infants.
Jaundice is considered pathologic if it appears within the first 24 hours of life, if serum
bilirubin levels increase by more than 6 mg/dL in 24 hours, or if serum bilirubin exceeds 15
mg/dL at any time.
At birth most of the circulating antibodies in the newborn are immunoglobulin (Ig) G
antibodies that were transported across the placenta from the maternal circulation. IgG is key to
immunity to bacteria and viruses.
All newborns, and preterm newborns especially, are at high risk for infection during the first
several months of life. During this period infection is one of the leading causes of morbidity and
mortality.
Close observation of the newborns skin color can lead to early detection of potential problems.
Any pallor, plethora, petechiae, central cyanosis, or jaundice should be noted and described.
Nurses must inspect the infant closely for ambiguous genitalia and other abnormalities.
Abnormalities of the skeletal system can be congenital, developmental, drug induced, or the
result of intrapartum or postnatal factors. Signs of DDH, additional digits or webbing of digits,
and any other abnormality should be documented and reported to the primary health care
provider.
Some reflex behaviors are important for the newborns survival.
The healthy newborn has sensory abilities that indicate a state of readiness for social
interaction. Sleep-wake states, gestational age, time, stimuli, and medication influence the
newborns behavior. Newborn behavior progresses from self-regulation of
autonomic processes to social interaction.
Each full-term newborn has a predisposed capacity to handle the multitude of stimuli in the
external world.

Ch.22 Evolve Questions


1. What would be a warning sign of ineffective adaptation to extrauterine life if noted when
assessing a 24-hour-old breastfed newborn before discharge?
A.

Apical heart rate of 90 beats/min, slightly irregular, when awake and active
Correct

B.

Acrocyanosis

C.

Harlequin color sign

D.

Weight loss representing 5% of the newborn's birth weight

The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The
rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn
at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic
system of a newborn. A 5% weight loss is acceptable in the newborn.

2. When caring for a newborn, the nurse must be alert for signs of cold stress, including:
A.

decreased activity level.

B.

increased respiratory rate. Correct

C.

hyperglycemia.

D.

shivering.

Infants experiencing cold stress would have an increased activity level. An increased respiratory
rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress.

Newborns are unable to shiver as a means of increasing heat production; they increase their
activity level instead.

3. The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn
after the first bowel movement. The mother expresses concern since the large amount of
thick, sticky stool is very dark green, almost black in color. She asks the nurse if
something is wrong. The nurse should respond to this mother's concern by:
A.

telling the mother not to worry since all breastfed babies have this type of
stool.

B.

explaining to the mother that the stool is called meconium and is expected of
all newborns for the first few bowel movements. Correct

C.

asking the mother what she ate at her last meal.

D.

suggesting that the mother ask her pediatrician to explain newborn stool
patterns to her.

This type of stool is the first stool that all newborns, not just breastfed babies, have. At this early
age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The
mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is
fully capable of and responsible for teaching a new mother about the characteristics of her
newborn, including expected stool patterns.

4. When weighing a newborn, the nurse should:


A.

leave its diaper on for comfort.

B.

place a sterile scale paper on the scale for infection control.

C.

keep hand on the newborn's abdomen for safety.

D.

weigh the newborn at the same time each day for accuracy. Correct

The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does
not need to be sterile. The nurses hand should be above, not on, the abdomen for safety.
Weighing a newborn at the same time each day allows for accurate weights.
Awarded 0.0 points out of 1.0 possible points.
5. Vitamin K is given to the newborn to:
A.

reduce bilirubin levels.

B.

increase the production of red blood cells.

C.

enhance ability of blood to clot. Correct

D.

stimulate the formation of surfactant.

Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red
blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce
vitamin K are formed. Vitamin K is required for the production of certain clotting factors.
Vitamin K does not stimulate the formation of surfactant.

6. The nurse notes that, when placed on the scale, the newborn immediately abducts and
extends the arms, and the fingers fan out with the thumb and forefinger forming a "C."
This response is known as a:
A.

tonic neck reflex.

B.

Moro reflex. Correct

C.

cremasteric reflex.

D.

Babinski reflex.

Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the
head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction
of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is
stroked.

7. A newborn male, estimated to be 39 weeks of gestation, would exhibit:


A.

extended posture when at rest.

B.

testes descended into scrotum. Correct

C.

abundant lanugo over his entire body.

D.

ability to move his elbow past his sternum.

The newborns good muscle tone will result in a more flexed posture when at rest. A full-term
male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will
exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn
would have the inability to move his elbow past midline.

8. A nurse caring for a newborn should be aware that the sensory system least mature at the
time of birth is:

A.

vision. Correct

B.

hearing.

C.

smell.

D.

taste.

The visual system continues to develop for the first 6 months. As soon as the amniotic fluid
drains from the ear (minutes), the infants hearing is similar to that of an adult. Newborns have a
highly developed sense of smell. The newborn can distinguish and react to various tastes.

9. An examiner who discovers unequal movement or uneven gluteal skinfolds during the
Ortolani maneuver:
A.

tells the parents that one leg may be longer than the other, but they will equal
out by the time the infant is walking.

B.

alerts the physician that the infant has a dislocated hip. Correct

C.

informs the parents and physician that molding has not taken place.

D.

suggests that if the condition does not change, surgery to correct vision
problems might be needed.

This is an inappropriate statement that may result in unnecessary anxiety for the new parents.
The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests
that the hip is dislocated. The physician should be notified. Molding refers to movement of the
cranial bones and has nothing to do with the infants hips. The Ortolani maneuver is not a
technique used to evaluate visual acuity in the newborn. This maneuver checks hip integrity.

10. The newborns nurse should alert the health care provider when which newborn reflex
assessment findings are seen? (Select all that apply.)
A.

Newborn turns head toward stimulus when eliciting rooting reflex.

B.

Newborns fingers fan out when palmar reflex checked. Correct

C.

Newborn forces tongue outward when tongue touched.

D.

Newborn exhibits symmetric abduction and extension of arms, and fingers


form C when Moro reflex elicited.

E.

Newborns toes hyperextend with dorsiflexion of big toe when sole of foot
stroked upward along lateral aspect.

The babys fingers should curl around the examiners fingers when eliciting the palmar reflex.
When eliciting rooting reflex, the characteristic response is for the baby to turn head toward
stimulus and open mouth. Extrusion is elicited by touching tongue, and newborns tongue is
forced outward. The newborn should elicit symmetric abduction and extension of the arms and
fingers form a C with the Moro reflex. The Babinski reflex is elicited by stroking upward
along the lateral aspect on the sole of the feet. The expected response is hyperextension of the
toes with dorsiflexion of the big toe.

11. In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the
first hours after birth:

Correct Responses
A. 50 to 60

In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dL during the first
several hours after birth. A blood sugar level less than 40 mg/dL in the newborn is considered
abnormal and warrants intervention. This infant can display classic symptoms of jitteriness,
lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels
should be approximately 60 to 70 mg/dL.
Ch.23 Key Points
Assessment of the newborn requires data from the prenatal, intrapartal, and postnatal periods.
The primary goal of care in the first moments after birth is to assist the newly born infant to
transition to extrauterine life by establishing effective respirations.
The immediate assessment of the newborn includes Apgar scoring and a general evaluation of
physical status.
The Apgar score permits a rapid assessment of the newborns transition to extrauterine
existence based on five signs that indicate the physiologic state of the neonate: (1) heart rate, (2)
respiratory effort, (3) muscle tone, (4) reflex irritability, and (5) generalized skin color.
The initial assessment of the newborn includes general appearance, vital signs, weight, head
circumference, body length, and a neurologic assessment of reflexes.
Knowledge of biologic and behavioral characteristics is essential for guiding assessment and
interpreting data.
Gestational age assessment provides important information for predicting risks and guiding
care management.
A frequently used method of determining gestational age is the New Ballard Score. It assesses
six external physical and six neuromuscular signs.
Birth at 37 to 38 weeks is associated with higher incidence of breastfeeding difficulties and
respiratory problems such as respiratory distress syndrome and transient tachypnea of the
newborn. These infants are also at increased risk for long-term problems such as learning
difficulties.
Despite their appearance as term infants, late preterm infants are at increased risk for
respiratory distress, temperature instability, hypoglycemia, apnea, feeding difficulties, and
hyperbilirubinemia.
Nursing care immediately after birth includes maintaining an open airway, preventing heat loss,
and promoting parent-infant interaction.
The purpose of phototherapy is to reduce the level of circulating unconjugated bilirubin or to
keep it from increasing.

Close follow-up is needed for infants who have been treated for hyperbilirubinemia.
Providing a protective environment is a key responsibility of the nurse and includes such
measures as careful identification procedures, support of physiologic functions, and ways to
prevent infection.
Selection of the appropriate equipment and site for intramuscular injection is important.
The preferred injection site for newborns is the vastus lateralis muscle.
Circumcision is the removal of all or part of the foreskin of the penis. Usually it is performed
during the first few days of life but is sometimes done at a later time for preterm or ill neonates
or for religious or cultural reasons.
The circumcision site is assessed for bleeding every 15 to 30 minutes for the first hour and then
hourly for the next 4 to 6 hours. The nurse monitors the infants urinary output and notes
the time and amount of the first voiding after the circumcision.
The newborn has social and physical needs.
Newborns require careful assessment for physiologic and behavioral manifestations of pain.
Nonpharmacologic and pharmacologic measures are used to reduce infant pain.
Before hospital discharge, nurses provide anticipatory guidance for parents regarding the
following: feeding and elimination patterns; positioning and holding; comfort measures; car seat
safety; bathing, skin care, umbilical cord care, and nail care; and signs
of illness.
All parents should have instruction in infant CPR.
Ch.23 Evolve Questions
1. The nurse must administer erythromycin ophthalmic ointment to a newborn after birth.
The nurse should:
A.

instill within 15 minutes of birth for maximum effectiveness.

B.

cleanse eyes from inner to outer canthus before administration. Correct

C.

apply directly over the cornea.

D.

flush eyes 10 minutes after instillation to reduce irritation.

Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact
between the newborn and parents, an activity that fosters bonding and attachment, especially for
fathers. The newborns eyes should be cleansed from the inner to the outer canthus before the
administration of erythromycin ointment. Erythromycin should be applied into the conjunctival
sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the
erythromycin.

2. Newborns are at high risk for injury if appropriate safety precautions are not
implemented. Parents should be taught to:
A.

place the newborn on the abdomen (prone) after feeding and for sleep.

B.

avoid use of pacifiers.

C.

use a rear-facing car seat. Correct

D.

use a crib with side rail slats that are no more than 3 inches apart.

The prone position is no longer recommended since it may interfere with chest expansion and
lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborns
need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until
breastfeeding is well established to avoid the development of nipple confusion. Your baby should
be in a rear-facing infant car safety seat from birth until age 2 years or until exceeding the car
seats limits for height and weight. Slats in a crib should be no more than 2 inches apart.

3. Following circumcision of a newborn, the nurse provides instructions to his or her parents
regarding postcircumcision care. The nurse should tell the parents to:

A.

apply topical anesthetics with each diaper change.

B.

expect a yellowish exudate to cover the glans after the first 24 hours. Correct

C.

change the diaper every 2 hours and cleanse the site with soap and water or
baby wipes.

D.

apply constant pressure to the site if bleeding occurs and call the physician.

Topical anesthetics are applied before the circumcision. Infant-comforting techniques are
generally sufficient following the procedure. Parents should be taught that a yellow exudate will
develop over the glans and should not be removed. The diaper is changed frequently, but the site
is cleansed with warm water only since soap and baby wipes can cause pain/burning and
irritation at the site. Intermittent pressure is applied if bleeding occurs.

4. When placing a newborn under a radiant heat warmer to stabilize the temperature after
birth, the nurse should:
A.

place the thermistor probe on the left side of the chest.

B.

cover the probe with a nonreflective material.

C.

recheck the temperature by periodically taking a rectal temperature.

D.

prewarm the radiant heat warmer and place the undressed newborn under it.
Correct

The thermistor probe should be placed on the upper abdomen away from the ribs. It should be
covered with reflective material. Rectal temperatures should be avoided since rectal
thermometers can perforate the intestine, and the temperature may remain normal until cold

stress is advanced. The radiant warmer should be prewarmed so the infant does not experience
more cold stress.

5. With regard to umbilical cord care, nurses should be aware that:


A.

the stump can easily become infected. Correct

B.

a nurse noting bleeding from the vessels of the cord should immediately call
for assistance.

C.

the cord clamp is removed at cord separation.

D.

the average cord separation time is 5 to 7 days.

The cord stump is an excellent medium for bacterial growth. The nurse should first check the
clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for
assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation
time is 10 to 14 days.

6. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage.
There was a nuchal cord. After birth the infant is noted to have petechiae over the face
and upper back. Information given to the infants parents should be based on the
knowledge that petechiae:
A.

are benign if they disappear within 48 hours of birth Correct

B.

result from increased blood volume

C.

should always be further investigated

D.

usually occur with forceps delivery

Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper
portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth
and no new lesions appear. Petechiae may result from decreased platelet formation. In this
situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal
cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family.
Petechiae usually occur with a breech presentation vaginal birth.

7. A mother expresses fear about changing her infants diaper after he is circumcised. What
does the woman need to be taught to take care of the infant when she gets home?
A.

Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.

B.

Apply constant, firm pressure by squeezing the penis with the fingers for at
least 5 minutes if bleeding occurs.

C.

Cleanse the penis gently with water and put petroleum jelly around the glans
after each diaper change. Correct

D.

Wash off the yellow exudate that forms on the glans at least once every day to
prevent infection.

With each diaper change, the penis should be washed off with warm water to remove any urine
or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding
with a sterile gauze square. This action is appropriate when caring for an infant who has had a
circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is
part of normal healing and not an infective process. The exudate should not be removed.

8. Which of these statements are helpful and accurate nursing advice concerning bathing the
new baby. (Select all that apply.)

A.

Newborns should be bathed every day, for the bonding as well as the cleaning

B.

Tub baths may be given before the infants umbilical cord falls off and the
umbilicus is healed. Correct

C.

Only plain warm water can be used to preserve the skins acid mantle.

D.

Powders are not recommended because the infant can inhale powder. Correct

E.

Bathe immediately after feeding while baby is calm and relaxed.

Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases
under the arms and neck need more attention. Tub baths may be given as soon as an infants
temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder
is not recommended due to the risk of inhalation. Should a parent elect to use baby powder, it
should never be sprinkled directly onto the babys skin. The parent can apply a small amount of
powder to his or her own hand and then apply to the infant. Do not bathe immediately after a
feeding period because the increased handling may cause regurgitation.

9. As part of their teaching function at discharge, nurses should tell parents that the babys
respiratory status should be protected by the following procedures: (Select all that apply.)
A.

Prevent exposure to people with upper respiratory tract infections Correct

B.

Keep the infant away from secondhand smoke Correct

C.

Avoid loose bedding, waterbeds, and beanbag chairs Correct

D.

Do not let the infant sleep on his or her back

E.

Keep a bulb suction available at home. Correct

Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand
smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them.
The infant should be laid down to sleep on his or her back for better breathing and to prevent
sudden infant death syndrome. A bulb syringe will be useful if the baby needs suctioning of the
mouth and nose at home to protect the airway.

10. At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud,
vigorous crying with active movement of all extremities; sneezing when nose is
stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score
of this newborn should be recorded as________.

Correct Responses: "9"


The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active
movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for
color since he exhibits acrocyanosis
Ch.24 Key Points
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first
6 months of life and that breastfeeding be continued as complementary foods are introduced.
Breastfeeding should continue for 1 year and thereafter as desired by the mother and her infant.
Human breast milk is species-specific and is the recommended form of infant nutrition. It
provides immunologic protection against many infections and diseases.
Extensive evidence exists concerning the health benefits of breastfeeding and human milk for
infants, with some of the benefits extending into adulthood.
Parents who choose to formula feed often make this decision without complete information and
understanding of the benefits of breastfeeding.
Cultural beliefs and practices are significant influences on infant feeding methods.

During the prenatal period, expectant parents should be informed of the benefits of
breastfeeding for infants, mothers, families, and society.
Infants should be breastfed within the first hour after birth and at least 8 to 12 times every 24
hours thereafter.
Parents should be taught to recognize the signs of effective breastfeeding.
Breast milk changes in composition with each stage of lactogenesis, during each feeding, and
as the infant grows.
Breast milk production is based on a supply-meets-demand principle: the more the infant
nurses, the greater the milk supply.
Infants go through predictable growth spurts.
Breast milk enhances retinal maturation in the preterm infant and improves neurocognitive
outcomes; it also decreases the risk of necrotizing enterocolitis.
Sore nipples are most often caused by incorrect latch.
Commercial infant formulas provide satisfactory nutrition for most infants.
Infants should be held for feedings.
The breastfeeding mother can experience some common problems. In most cases these
complications are preventable if the mother receives appropriate education about breastfeeding.
Parents should be instructed about the types of infant formulas, proper preparation for feeding,
and correct feeding technique.
Solid (complementary) food should be started at about 6 months of age.
Unmodified cows milk is inappropriate for infants less than 1 year of age.
Nurses must be knowledgeable about feeding methods and provide education and support for
families.
Ch.24 Evolve Questions
1. The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborns
weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should:
A.

encourage the mother to continue breastfeeding since it is effective in meeting


the newborns nutrient and fluid needs. Correct

B.

suggest that the mother switch to bottle-feeding since the breastfeeding is


ineffective in meeting newborn needs for fluid and nutrients.

C.

notify the physician since the newborn is being poorly nourished.

D.

refer the mother to a lactation consultant to improve her breastfeeding


technique.

Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the
first few days of life, which for this newborn would be 6.6 to 13.2 oz. Breastfeeding is effective
at this time. Breastfeeding is effective, and bottle-feeding does not need to be initiated at this
time. The infant is not undernourished, and the physician does not need to be notified. The
weight loss is within normal limits; breastfeeding is effective.
.
2. Which action of a breastfeeding mother indicates the need for further instruction?
A.

Holds breast with four fingers along bottom and thumb at top.

B.

Leans forward to bring breast toward the baby. Correct

C.

Stimulates the rooting reflex and then inserts nipple and areola into newborns
open mouth.

D.

Puts her finger into newborns mouth before removing breast.

Holding the breast with four fingers along the bottom and the thumb at top is a correct technique.
To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not
the breast to the baby. The mother would need further demonstration and teaching to correct the
ineffective action. Stimulating the rooting reflex is correct. Placing the finger in the mouth to
remove the baby from the breast is correct.

3. The nurse taught new parents the guidelines to follow regarding the bottle-feeding of
their newborn. They will be using formula from a can of concentrate. The parents would
demonstrate an understanding of the nurses instructions if they:
A.

wash the top of the can and can opener with soap and water before opening
the can. Correct

B.

adjust the amount of water added according to the weight gain pattern of the
newborn.

C.

add some honey to sweeten the formula and make it more appealing to a
fussy newborn.

D.

warm formula in a microwave oven for a couple of minutes before feeding.

Washing the top of the can and can opener with soap and water before opening the can of
formula is a good habit for a parent to get into to prevent contamination. Directions on the can
for dilution should be followed exactly and not adjusted according to weight gain to prevent
nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The
formula should be warmed in a container of hot water since a microwave can easily overheat it.
Awarded 0.0 points out of 1.0 possible points.
4. In helping the breastfeeding mother position the baby, nurses should keep in mind that:
A.

the cradle position is usually preferred by mothers who had a cesarean birth.

B.

women with perineal pain and swelling prefer the modified cradle position.

C.

whatever the position used, the infant is belly to belly with the mother.
Correct

D.

while supporting the head, the mother should push gently on the occiput.

The football position usually is preferred after cesarean birth. Women with perineal pain and
swelling prefer the side-lying position because they can rest while breastfeeding. The infant
inevitably faces the mother, belly to belly. The mother should never push on the back of the head.
It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near
the breast.

5. The maternity nurse must be cognizant that cultural practices have significant influence
on infant feeding methods. Many regional and ethnic cultures can be found within the
United States. One cannot assume generalized observations about any cultural group will
hold for all members of the group. Which statement related to cultural practices
influencing infant feeding practice is correct?
A.

A common practice among Mexican women is known as los dos. Correct

B.

Muslim cultures do not encourage breastfeeding due to modesty concerns.

C.

Latino women born in the United States are more likely to breastfeed.

D.

East Indian and Arab women believe that cold foods are best for a new
mother.

A common practice among Mexican women is los dos. This refers to combining breastfeeding
and commercial infant formula. It is based on the belief that by combining the two feeding
methods, the mother and infant receive the benefits of breastfeeding along with the additional
vitamins from formula.
B. Among the Muslim culture, breastfeeding for 24 months is customary. Muslim women
may choose to bottle-feed formula or expressed breast milk while in the hospital.
C.
Latino women born in the United States are less likely to breastfeed.
D.
East Indian and Arab women believe that hot foods, such as chicken and broccoli, are best
for the new mother. The descriptor hot has nothing to do with the temperature or spiciness of the
food.

6. Which statement regarding infant weaning is correct?


A.

Weaning should proceed from breast to bottle to cup.

B.

The feeding of most interest should be eliminated first.

C.

Abrupt weaning is easier than gradual weaning.

D.

Weaning can be mother or infant initiated. Correct

Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants less
than 6 months. If the infant is weaned before 1 year of age, iron-fortified formula rather than
cows milk should be offered. The feeding of least interest to the baby or the one through which
the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops
another feeding. Gradual weaning over a period of weeks or months is easier for both the mother
and the infant than an abrupt weaning. Weaning is initiated by the mother or the infant. With
infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to
a gradual decrease in the mothers milk supply. Mother-led weaning means that the mother
decides which feedings to drop.

7. With regard to the long-term consequences of infant feeding practices, the nurse should
instruct the obese client that the best strategy to decrease the risk for childhood obesity
for her infant is:
A.

an on-demand feeding schedule.

B.

breastfeeding. Correct

C.

lower-calorie infant formula.

D.

smaller, more frequent feedings.

All breastfed infants should be fed on demand. Breastfeeding is the best prevention strategy for
decreasing childhood and adolescent obesity. Breastfeeding also assists the woman to return to
her prepregnant weight sooner. Lower-calorie formula is an inappropriate strategy that does not
meet the infants nutritional needs. Breastfeeding is the most appropriate choice for infant
feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours
in the newborn period.
.
8. What is the PRIORITY teaching tip the nurse should provide about bottle-feeding?
A.

Infants may stool with each feeding in the first weeks.

B.

Feed newborn at least every 3 to 4 hours.

C.

Hold infant semiupright while feeding. Correct

D.

Some infants take longer to feed than others.

The infant may have a stool with each feeding in the first 2 weeks, although this amount may
decrease to one or two stools each day Newborns should be fed at least every 3 to 4 hours and
should never go longer than 4 hours without feeding until a satisfactory pattern of weight gain is
established. Infants should be held and never left alone while feeding. Never prop the bottle. The
infant might inhale formula or choke on any that was spit up. Airway is priority. Taking a few
sucks and then pausing briefly before continuing to suck again is normal for infants. Some
infants take longer to feed than others. Be patient. Keep the baby awake; encouraging sucking
may be necessary. Moving the nipple gently in the infants mouth may stimulate sucking.
Awarded 0.0 points out of 1.0 possible points.
9. Which of these statements indicate the effect of breastfeeding on the family or society at
large. (Select all that apply.)

A.

Breastfeeding requires fewer supplies and less cumbersome equipment.


Correct

B.

Breastfeeding saves families money. Correct

C.

Breastfeeding costs employers in terms of time lost from work.

D.

Breastfeeding benefits the environment. Correct

E.

Breastfeeding results in reduced annual health care costs. Correct

Breastfeeding is convenient because it does not require cleaning or transporting bottles and other
equipment. Breastfeeding saves families money because the cost of formula far exceeds the cost
of extra food for the lactating mother. Less time is lost from work by breastfeeding mothers, in
part because infants are healthier. Breastfeeding uses a renewable resource; it does not need
fossil fuels, advertising, shipping, or disposal. Breastfeeding results in reduced annual health care
costs.

10. The nurse should include which instructions when teaching a mother about the storage of
breast milk? (Select all that apply.)
A.

Wash hands before expressing breast milk. Correct

B.

Store milk in 8 to 12 oz containers.

C.

Store refrigerated milk in the door of the refrigerator.

D.

Place frozen milk in the microwave for only a few seconds to thaw.

E.

Milk thawed in the refrigerator can be stored for 24 hours. Correct

Breast milk storage guidelines for home use for full-term infants are:
Before expressing or pumping breast milk, wash your hands.
Containers for storing milk should be washed in hot, soapy water and rinsed thoroughly; they
can also be washed in a dishwasher. If the water supply may not be clean, boil containers after
washing. Plastic bags designed specifically for breast milk storage can be used for short-term
storage ( Write the date of expression on container before storing milk. A waterproof label is
best.
Store milk in serving sizes of 2 to 4 ounces to prevent waste.
Storing breast milk in the refrigerator or freezer with other food items is acceptable.
When storing milk in a refrigerator or freezer, place containers in the middle or back of the
freezer, not on the door.
When filling a storage container that will be frozen, fill only three quarters full, allowing
space at the top of the container for expansion.
To thaw frozen breast milk, place container in the refrigerator for gradual thawing or under
warm, running water for quicker thawing. Never boil or microwave.
Milk thawed in the refrigerator can be stored for 24 hours.
Thawed breast milk should never be refrozen.
Shake milk container before feeding baby and test the temperature of the milk on the inner
aspect of your wrist.
Any unused milk left in the bottle after feeding is discarded.
Ch. 25 Key Points
The identification of maternal and fetal risk factors in the antepartum and intrapartum periods is
vital for planning adequate care of high risk infants.
A small percentage of significant birth injuries may occur despite skilled and competent
obstetric care.
Many injuries are minor and resolve readily in the neonatal period without treatment. Other
trauma requires some degree of intervention; few injuries are serious enough to be fatal. The
nurses contributions to the newborns welfare begin with early observation of his or her
transition.
Nursing care of the infant with facial nerve paralysis involves helping the infant suck and the
mother with feeding techniques.
Infection in the newborn may be acquired in utero, at birth, in breast milk, or from within the
nursery.

Sepsis continues to be one of the most significant causes of neonatal morbidity and mortality.
The most common maternal infections during early pregnancy that are associated with various
congenital malformations include toxoplasmosis, herpes, CMV, rubella, parvovirus B19,
and varicella.
The adverse effects of exposure of a fetus to drugs are varied. They include transient changes
such as alterations in fetal breathing movements and irreversible effects such as fetal death,
IUGR, structural malformations, behavioral problems, or cognitive impairment.
The nurse is often the first to observe signs of newborn drug withdrawal (NAS) and acquire
information from the maternal history.
Alcohol ingestion during pregnancy is associated with both short- and long-term effects on the
fetus and newborn.
Preterm infants are at risk for problems related to the immaturity of organ systems.
Maternal-fetal Rh and ABO incompatibility may cause significant hemolysis and jaundice in
the neonatal period.
The injection of Rho(D) immunoglobulin in Rh-negative and Coombs testnegative women
minimizes the possibility of isoimmunization.
Metabolic abnormalities of diabetes mellitus in pregnancy adversely affect embryonic and fetal
development.
After or concurrent with the establishment of respiration, the most crucial need of LBW infants
is application of external warmth.
Infants respond to a great variety of stimuli, and the atmosphere and activities of the NICU are
overstimulating. Consequently, infants in NICUs are subjected to inappropriate stimulation that
can be harmful.
Family-centered care of high risk newborns includes encouraging and facilitating parental
involvement rather than isolating parents from their infant and associated care. Preparing the
parents to see their infant for the first time is an important nursing responsibility (prepares them
for their infants appearance, the equipment attached to the child, and the general atmosphere
of the unit).
The loss of an infant has special meaning for the grieving parents. It represents a loss of a part
of themselves, a loss of the potential for immortality that children represent, and the loss of the

dream child that has been fantasized about throughout the pregnancy.
Prematurity accounts for the largest number of admissions to NICUs. Immaturity of most organ
systems places infants at risk for a variety of neonatal complications.
Late-preterm infants often experience morbidities similar to those of preterm infants, including
respiratory distress, hypoglycemia requiring treatment, temperature instability, poor feeding,
jaundice, and discharge delays, as a result of illness.
Postterm infants are especially prone to fetal distress associated with the decreasing efficiency
of the placenta, macrosomia, and meconium aspiration syndrome.
The terms respiratory distress syndrome and hyaline membrane disease are most often applied
to severe lung disorder, which not only is responsible for more infant deaths than any other
disease but also carries the highest risk in terms of long-term respiratory and neurologic
complications.
The goals of oxygen therapy are to provide adequate oxygen to the tissues, prevent lactic acid
accumulation resulting from hypoxia, and at the same time avoid the potentially negative
effects of oxygen and barotrauma.
Necrotizing enterocolitis is an acute inflammatory disease of the bowel with increased
incidence in preterm infants. The precise cause of NEC is still uncertain, but it appears to occur
in infants whose GI tracts have experienced vascular compromise.
HIV transmission from mother to infant occurs transplacentally at various gestational ages,
perinatally by maternal blood and secretions, and by breast milk.
Inborn errors of metabolism (IEMs) constitute a large number of inherited diseases caused by
the absence or deficiency of a substance essential to cellular metabolism, usually an enzyme.
Newborn screening for IEMs varies from state to state; but all states test for at least seven core
disorders, CH, galactosemia, sickle cell disease, thalassemia, congenital adrenal hyperplasia,
and cystic fibrosis.
Congenital anomalies are the leading cause of death in the first year of life.
The curative and rehabilitative problems of a child with a congenital anomaly are often
complex, requiring a multidisciplinary approach to care.
Parents often need special instruction (e.g., cardiopulmonary resuscitation, oxygen therapy, or
nutritional requirements) before they take a high risk infant home.

The supportive care given to the parents of infants with a congenital anomaly or IEM must
begin at birth or at the time of diagnosis and continue for years.
Ch.25 Evolve Questions
1. Which laboratory test result would be a cause for concern if exhibited by an Rh-positive
newborn 12 hours after birth?
A.

Direct Coombs: negative

B.

Hematocrit (Hct): 58% and hemoglobin (Hgb): 18 g/dL

C.

Blood glucose level: 55 mg/dL

D.

Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories


(VDRL): reactive Correct

The negative Coombs indicates absence of antibodies against Rh-positive blood. Hgb is between
15 and 20 g/dL, and Hct is between 43% and 61%. The blood glucose level should be 45 mg/dL
or higher. A reactive RPR/VDRL indicates exposure to syphilis while in utero.
.
2. The nurse is caring for an infant who is suspected to have neonatal sepsis. Which
neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to
observe?
A.

Large for gestational age (LGA) and an infant of a diabetic mother

B.

Small for gestational age (SGA) and intrauterine growth restriction

C.

Singleton gestation and female

D.

Multiple gestation and low birth weight Correct

LGA and infant of a diabetic mother are not neonatal risk factors. SGA and intrauterine growth
restriction are not neonatal risk factors. Singleton and female are not neonatal risk factors.
Neonatal risk factors include multiple gestation and low birth weight.

3. With regard to hemolytic diseases of the newborn, nurses should be aware that:
A.

Rh incompatibility matters only when an Rh-negative offspring is born to an


Rh-positive mother.

B.

ABO incompatibility is more likely than Rh incompatibility to precipitate


significant anemia.

C.

exchange transfusions frequently are required in the treatment of hemolytic


disorders.

D.

he indirect Coombs test is performed on the mother before birth; the direct
Coombs test is performed on the cord blood after birth. Correct

Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more
common than Rh incompatibility but causes less severe problems; significant anemia, for
instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease
in the incidence of severe hemolytic disease in newborns from Rh incompatibility. An indirect
Coombs test may be performed on the mother a few times during pregnancy

4. Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present
at birth, although they may not be diagnosed immediately. The most common type of
CHD is:
A.

tetralogy of Fallot.

B.

ventricular septal defect (VSD). Correct

C.

pulmonary stenosis.

D.

transposition of the great vessels.

Tetralogy of Fallot has an incidence of 4.7 per 10,000 births and is the most common cardiac
defect with decreased blood flow. VSD with increased pulmonary blood flow is the most
common type of heart defect with a prevalence of 27 per 10,000 births and accounts for about
30% to 35% of all congenital heart defects. Pulmonary stenosis is less common and is a defect
that causes obstruction to blood flow out of the heart. Transposition of the great vessels is a
complex cardiac anomaly that involves a flow of mixed saturated and desaturated blood in the
heart or great vessels.
5. Concerning congenital abnormalities involving the central nervous system, nurses should
be aware that:
A.

although the death rate from most congenital anomalies has decreased over
the past several decades, neural tube defects (NTDs) have gone up in the last few
years.

B.

spina bifida cystica usually is asymptomatic and may not be diagnosed unless
associated problems are present.

C.

a major preoperative nursing intervention for a neonate with


myelomeningocele is to protect the protruding sac from injury. Correct

D.

microcephaly can be corrected with timely surgery.

Most congenital anomalies have had a stable neonatal death rate since the 1930s; NTDs are
declining because of mandatory food fortification with folic acid. Spina bifida occulta often is
asymptomatic; spina bifida cystica has a visible sac. The nurse protects the infant by laying the
baby on his or her side. Microcephaly is a tiny head; there is no treatment.

6. A male infant at 26 weeks of gestation arrives from the delivery room intubated. The
nurse weighs the infant, places him under the radiant warmer, and attaches him to the
ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are
placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed
saturations are 92%. The nurses most appropriate action is to:
A.

listen to breath sounds and ensure the patency of the endotracheal tube,
increase oxygen, and notify a physician. Correct

B.

continue to observe and make no changes until the saturations are 75%.

C.

continue with the admission process to ensure that a thorough assessment is


completed.

D.

notify the parents that their infant is not doing well.

These are appropriate nursing interventions to assist in optimal O2 saturation of the infant.
Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%.
Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the
infant. This is not appropriate. Further assessment and intervention are warranted before
determination of fetal status.

7. Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal


mucosa. The signs of NEC are nonspecific. Some generalized signs include:
A.

hypertonia, tachycardia, and metabolic alkalosis.

B.

abdominal distention, temperature instability, and grossly bloody stools.


Correct

C.

hypertension, absence of apnea, and ruddy skin color.

D.

scaphoid abdomen, no residual with feedings, and increased urinary output.

The infant may display hypotonia, bradycardia, and metabolic acidosis. Some generalized signs
of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased
oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension,
decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric
aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal
wall. Hypotension, apnea, and pallor are signs of NEC. Abdominal distention, residual gastric
aspirates, and oliguria are signs of NEC.

8. With regard to the classification of neonatal bacterial infection, nurses should be aware
that:
A.

congenital infection progresses slower than health careassociated infection.

B.

health careassociated infection can be prevented by effective handwashing;


early onset cannot. Correct

C.

infections occur with about the same frequency in boy and girl infants,
although female mortality is higher.

D.

the clinical sign of a rapid, high fever makes infection easier to diagnose.

Congenital (early onset) infections progress more rapidly than health careassociated (late onset)
infections.Handwashing is an effective preventative measure for late onset (health care
associated) infections because these infections come from the environment around the infant.
Early onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract.
Congenital (early onset) infections progress more rapidly than health careassociated (late onset)
infections. Infection occurs about twice as often in boys and results in higher mortality.
Congenital (early onset) infections progress more rapidly than health careassociated (late onset)
infections. Clinical signs of neonatal infection are nonspecific and similar to noninfectious

problems, making diagnosis difficult. Congenital (early onset) infections progress more rapidly
than health careassociated (late onset) infections.

9. Which TORCH infection could be contracted by the infant because the mother owned a
cat?
A.

Toxoplasmosis Correct

B.

Varicella-zoster

C.

Parvovirus B19

D.

Rubella

Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts.
Humans (including pregnant women) can become infected if they fail to wash their hands after
cleaning the litter box. The infection is passed through the placenta. The varicella-zoster virus is
responsible for chickenpox and shingles. Approximately 90% of childbearing women are
immune. This virus cannot be contracted from a cat. During pregnancy infection with parvovirus
can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and
stillbirth. This virus is spread by vertical transmission, not by felines. Since vaccination for
rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly.
Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in
periodic outbreaks of rubella (German measles).

10. In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses
should be aware that:
A.

the pattern of growth restriction of the fetus begun in prenatal life is halted
after birth, and normal growth takes over.

B.

two thirds of newborns with fetal alcohol syndrome (FAS) are boys.

C.

alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet


FAS criteria (learning disabilities, speech and language problems) are often not
detected until the child goes to school. Correct

D.

both the distinctive facial features of the FAS infant and the diminished
mental capacities tend toward normal over time.

The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls.
Some learning problems do not become evident until the child is in school. Although the
distinctive facial features of the FAS infant tend to become less evident, the mental capacities
never become normal.
11. Antidepressant medication is the mainstay treatment for maternal depression, with
selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy.
Reports of cardiac defects have been associated with the use of which SSRI?
A.

Citalopram

B.

Fluoxetine

C.

Sertraline

D.

Paroxetine Correct

The absolute risk of any congenital abnormality associated with citalopram use is small. The
absolute risk of any congenital abnormality associated with fluoxetine use is small. The absolute
risk of any congenital abnormality associated with sertraline use is small. The American College
of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be
avoided both during pregnancy and in women considering pregnancy. There have also been
reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and
anencephaly.

12. An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant
appears chubby with a flushed complexion and is very tremulous. The tremors are most
likely the result of:
A.

birth injury.

B.

hypocalcemia.

C.

hypoglycemia. Correct

D.

seizures.

This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a
macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. This infant
is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic
infant. The tremors are jitteriness that is associated with hypoglycemia. Hypoglycemia is
common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea,
and cyanosis. This infant is macrosomic and at risk for hypoglycemia. The description is
indicative of a macrocosmic infant. The tremors are jitteriness that is associated with
hypoglycemia.
.
13. The nurse is caring for an infant born at 28 weeks of gestation. Which complication could
the nurse expect to observe during the course of the neonates hospitalization? (Select all
that apply.)
A.

Polycythemia

B.

Respiratory distress syndrome Correct

C.

Meconium aspiration syndrome

D.

Periventricular hemorrhage Correct

E.

Persistent pulmonary hypertension

F.

Patent ductus arteriosus Correct

Respiratory distress syndrome, periventricular hemorrhage, and a patent ductus arteriosus are
common complications with preterm infants. Polycythemia, meconium aspiration syndrome, and
persistent pulmonary hypertension are complications of postmaturity.
14. The nurse is caring for a preterm infant who needs to have gavage feedings started and
requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for
insertion of a nasogastric tube in a preterm infant.
A.

Lubricate the tip of the tube with sterile water. Correct

B.

Place infant in supine position. Correct

C.

Measure the length of the NG tube from the tip of the nose to the lobe of the
ear to midpoint between the xyphoid process and the umbilicus. Correct

D.

Check placement of the NG tube by aspirating gastric contents. Correct

E.

Gently insert the NG tube through the mouth or nose. Correct