/. Priority Actions for Late Decelerations - Answer--Place client in side-lying position
-Increase rate of IV fluid infusion
-D/c oxytocin
-O2 8-10 L nonrebreather
-Elevate legs
-Notify provider
/.Car Seat Safety - Answer-The nurse should educate the parents of a newborn that the
newborn must be placed in an approved rear-facing car seat in the back seat away from
air bags and side impact. Infants should be kept in a rear-facing car seat until 2 years
old (MN ATI, Chapter 26, Page 129)
/.Preventing Infant Abduction - Answer-Measures that the nurse can implement to
prevent infant abduction include teaching the client that all staff members are required
to wear photo identification badges and that the newborn should never be given to
anyone without a photo ID badge from the maternal-newborn unit, and that the mother
should bring the baby's bassinette into the bathroom with her to keep an eye on the
baby at all times (MN ATI, Chapter 24, Page 164).
/.Interventions for Mastitis - Answer--Allow nipples to air-dry
-Completely empty breasts with each feeding
-Use ice packs or warm packs
-Continue breastfeeding, especially on affected side
-Encourage rest, analgesics, and 3,000 mL/fluids/day
/.Breast Care - Answer--Completely empty breast with each feeding
-Massage breast to help express milk
-Apply warm packs before feedings and cool packs after feedings
-Sore nipples = put breast milk/ colostrum on nipples
-Apply breast creams
/.Assessing Client Risk for Rubella - Answer--Rubella (German measles) is contracted
through children who have rashes or neonates who are born to women who had rubella
during pregnancy.
-For rubella, immunization of women who are pregnant is contraindicated because
rubella infection can develop. These women should avoid crowds of young children.
Women who have low titers prior to pregnancy should receive immunizations.
/.Checking Fundal Height - Answer--Immediately after delivery, the fundus should be
firm, midline with the umbilicus, and approximately at the level of the umbilicus
-At 12 hr postpartum, the fundus may be palpated at 1 cm above the umbilicus