ATI Maternal Newborn Exam ( Latest New Versions) (Complete Solution Guides, Best document to secure Graded A)

ATI Maternal Newborn Proctored Exam (Latest New Versions-2020) (Complete Solution Guides, Best document to secure Graded A) ATI. MATERNAL-NEWBORN 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? InLochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. InNumerous clots are abnormal and should be reported to the physician. InSaturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. The color of the lochia changes from a bright red to white after four days Numerous large clots are normal for the next three to four days Saturation of the perineal pad with blood is expected when getting up from the bed Lochia should last for about 3 weeks, changing color every few days 2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? InA nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. InVariable decelerations (not late decelerations) are associated with cord compression. InLate decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress. The umbilical cord is wrapped tightly around the fetus' neck The fetal cord is being compressed due to rapid descent of the fetal head Maternal contractions are not adequate enough to deliver the fetus The fetus is not receiving adequate oxygen and is in distress 3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth? InMonitoring O2 saturations and administering pain medications are postoperative interventions. InTaking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made. InThe nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case. Monitor oxygen saturation and administer pain medication. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter. Perform a sterile vaginal examination and assess breath sounds. 4. Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge? InEngorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well. InApplying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms. In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied. InUsing soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs. The nipples should be covered with lotion when the baby is not nursing. The breasts should be pumped if the baby is not sucking adequately. The breasts should be washed with soap and water once per day. 5. A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering? Tocolytics are used to stop labor. One of the most commonly used tocolytic drugs is ritodrine (Yutopar). InAnticonvulsants are used for clients with pregnancy-induced hypertension who are likely to seize. InThe glucocorticoids (e.g., betamethasone and dexamethasone) are used for accelerating fetal lung maturation and production of surfactant. They are commonly used if the membranes are ruptured or labor cannot be stopped. InAnti-infective are used if there is infection. Preterm labor may or may not involve ruptured membranes with its accompanying risk of infection. Tocolytics Anticonvulsants Glucocorticoids Anti-infective 6. Which of the following are probable signs, strongly indicating pregnancy? InThe presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive Sign of pregnancy. InThese are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes. These are probable signs that strongly indicate pregnancy. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward. InThese are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes. Presence of fetal heart sounds and quickening Missed menstrual periods, nausea, and vomiting Hegar's sign, Chadwick's sign, and ballottement Increased urination and tenderness of the breasts 7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action? Bladder distention can lead to postpartum hemorrhage. A full bladder displaces the uterus causing it not to contract properly. Emptying the bladder allows the uterus to contract more firmly. InA distended bladder rises out of the abdomen, causing the uterus to be displaced and increasing the risk of hemorrhage. It does not affect the perineum. InBladder distention can lead to urinary stasis and infection. This, however, does not relate to the soft, boggy uterus or the potential for hemorrhage. InMassaging is uncomfortable regardless of whether the bladder is full or not. A full bladder displaces the uterus causing it not to contract properly, which may lead to postpartum hemorrhage. A full bladder prevents normal contractions of the uterus. An overdistended bladder may press against the episiotomy causing dehiscence. Distention of the bladder can cause urinary stasis and infection. It makes the client more comfortable when the fundus is massaged. 8. Which site is preferred for giving an IM injection to a newborn? InVentrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. The middle third of the vastus lateralis is the preferred site for injections. InVentrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. InNewborns do not receive injections in the dorsogluteal site (gluteus maximus) due to decreased muscle mass. Ventrogluteal Vastus lateralis Rectus femoris Dorsogluteal 9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding? InUrinary tract infections are common during pregnancy and in the postpartum period. Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of a UTI. InHigh output renal failure occurs with injury/trauma to the kidneys. There has been no damage to the kidneys. InMost women do receive some IV fluids during labor and delivery, however the IV rates are carefully calculated according to weight. During pregnancy, the circulating blood volume increases by about 50%. In order to get rid of the excess fluid volume after delivery, the woman experiences an increased amount of urine output during the first few hours. Urinary tract infection High output renal failure Excessive use of IV fluids during delivery Normal diuresis after delivery 10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive? InGlucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can cause damage to the fetus. They are not used in gestational diabetes for that reason. InGlucagon is a hormone used to raise blood sugar and manage severe hypoglycemia. Clients with gestational diabetes have hyperglycemia. Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's blood sugar without harming the fetus. InDiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta and can cause damage to the fetus. They are not used for gestational diabetes for that reason. Metformin (Glucophage) Glucagon Insulin Glyburide (DiaBeta) 11. Which assessment finding indicates that placental separation has occurred during the third stage of labor? InThere is usually an increase in bleeding (a sudden gush of blood) when the placenta separates. InContractions continue in an attempt to expel the placenta. The contractions may not be as intense, but they do not stop. Also, fundal massage helps contract the uterus preventing postpartum bleeding. InShaking and chills occur about 10-15 minutes after the delivery of the baby, but are not related to the placental detachment. They are a result of the release of pressure on pelvic nerves and the release of epinephrine during labor. As the placenta detaches, the cord that has been clamped becomes longer as it slides out of the vagina. Decreased vaginal bleeding Contractions stop Maternal shaking and chills Lengthening of the umbilical cord 12. The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are: InMost TORCH infections can cause mild flu-like symptoms for the mother. Death may or may not occur in the fetus. InTORCH is an abbreviation for Toxoplasmosis, Other (syphilis, HIV and Hepatitis B), Rubella, Cytomegalovirus, and Herpes simplex—not all of these are sexually transmitted. All TORCH infections have the capability of infecting the fetus or causing serious effects to the newborn. InA vector is a carrier of the disease such as a mosquito. Not all of the TORCH infections are carried by vector. benign to the woman but cause death to the fetus. sexually transmitted. capable of infecting the fetus. transmitted to the pregnant woman by a vector. 13. During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of “pain related to perineal sutures.” Which nursing intervention is most appropriate during the first 24 hours following an episiotomy? InPetroleum jelly will harbor bacteria, which may hinder healing. InThe client should practice Kegel exercises to increase bladder tone, but these exercises would add to the client's discomfort during the first 24hours.InTaking a warm sitz bath is recommended after the first 24 hours. Ice packs will decrease edema and discomfort, and prevent formation of a hematoma. Instruct the client to use petroleum jelly on the episiotomy after voiding. Encourage the client to practice Kegel exercises. Advise the client to take a warm sitz bath every four hours. Apply ice packs to the perineum. 14. A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information? InBreastfeeding does not help speed up weight loss. The lactating mother requires more calories, but usually has an increased appetite to accommodate that need. InProtein amounts are greater in formula and cow's milk. Breast milk is easier to digest because of the type of fat and protein in the milk. InBreastfeeding does not prevent to woman from getting pregnant because it does not prevent ovulation. Most women ovulate within the first 6 weeks after delivery. Breastfeeding helps women lose weight faster. Breast milk contains a greater amount of protein. Breast milk is easier to digest than formula. Breastfeeding is a good method of contraception. 15. Which physiological change takes place during the puerperium? InThe puerperium is the first 6 weeks after delivery. The client will experience lochia for the first few weeks, and hormone levels will stabilize. Menstruation cannot occur until ovulation occurs. InThis occurs in stage three of labor. The uterine changes are called involution. The uterus should return to its pre-pregnancy state within 6 weeks after delivery. InThis describes the labor process, not the puerperium. The endometrium begins to undergo alterations necessary for menstruation. The placenta begins to separate from the uterine wall. The uterus returns to a pre-pregnant size and location. The uterus contracts at regular intervals with dilation of the cervix occurring. 16. A client delivered two days ago and is suspected of having postpartum "blues." Which symptoms confirm the diagnosis? These are signs of the postpartum blues, which typically diminishes within three-four days after delivery. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Other symptoms of the blues include: sadness, anxiety about the health of the baby, insomnia, anorexia, anger, feelings of anticlimax. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Depression and suicidal thoughts are signs of postpartum depression, not the blues and should be followed up with psychiatric treatment. Excess anxiety and the inability to care for the family are signs of postpartum depression, not the blues. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. InNausea and vomiting are psychosomatic symptoms of postpartum depression and require psychiatric treatment. Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts. Uncontrollable crying and insecurity Depression and suicidal thoughts Sense of the inability to care for the family and extreme anxiety Nausea and vomiting 17. Shortly after delivery, the nursery nurse gives the newborn an injection of phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got “a shot in his leg.” Which response by the nurse is most appropriate? InCalcium is needed for bone and muscle growth, not Vitamin K. InVitamin K is used to promote clotting, and does not affect digestion. InThe B vitamins are responsible for carbohydrate metabolism and the energy derived from glucose, not Vitamin K. Vitamin K is given to prevent bleeding until the intestinal bacteria can start to produce it. The intestines of a newborn are sterile until it starts to feed. Vitamin K helps with the clotting factors necessary to control bleeding. "Vitamin K promotes bone and muscle growth." "Vitamin K helps the baby digest milk." "Vitamin K helps stabilize the baby's blood sugar." "Vitamin K is used to prevent bleeding." 18. At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct? InWrinkles do not form until late in the pregnancy. Fat stores usually do not form until the third trimester. InThe eyelids are fused until about 26 weeks. The kidneys are making urine, which is excreted by the fetus into the amniotic fluid. InThe heart is already formed and beating at 8 weeks. "The skin is wrinkled and fat is being formed." "The eyelids are open and he can see." "The kidneys are making urine." "The heart is being developed." 19. A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs? InWhite vaginal discharge is a normal occurrence during pregnancy due to increased amounts of estrogen and increased blood supply to the cervix and vagina. It is not a “danger sign. “ InBackache is common in pregnancy due to the alteration of the woman's center of gravity; it is not a “danger sign.” Backaches become worse as the uterus enlarges. InFrequent, urgent urination is a common discomfort; it is not a danger sign. The pressure of the enlarging uterus causes frequency and urgency. Abdominal pain is a danger sign and can be indicative of an abruptio placenta. It is important for a physician to evaluate this symptom. It is one of several danger signs, including: headache, rupture of membranes, vaginal bleeding, edema, epigastric pain, elevated temperature, painful urination, prolonged vomiting, blurred vision, change in or absence of fetal movement. White vaginal discharge Dull backache Frequent, urgent urination Abdominal pain 20. An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism? InErythromycin (Ilotycin) is an antibiotic ointment used to prevent blindness related to gonorrhea. Antibiotics are effective against bacteria. Rubella is a virus. Ilotycin, an antibiotic, is used for the prophylaxis treatment of gonorrhea and chlamydia. If left untreated, it could result in blindness. InIlotycin, an antibiotic, is not effective in combating syphilis infections. InHIV is a virus. Antibiotics are effective against bacteria. Ilotycinis an antibiotic ointment and therefore not effective against HIV. Rubella Gonorrhea Syphilis Human immunodeficiency virus (HIV) 21. A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant? It will cause the infant's: InNarcotic analgesics cause respiratory depression and do not affect the infant's blood sugar. Narcotic analgesics can cause respiratory depression for the infant and also for the mother. This is evidenced by low Apgar scores (apnea and bradycardia) in the infant. If respiratory depression occurs, a narcotic antagonist (Narcan) is usually given. InNarcotic analgesics, if given too close to delivery, can cause bradycardia, not tachycardia. InNarcotics, such as Demerol, cause CNS depression, not hyperactivity. blood sugar to fall. respiratory rate to decrease. heart rate to increase. movements to be hyperactive. 22. For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)? InA decrease in hemoglobin is indicative of anemia, while uterine tenderness may indicate abruptio placenta. InPolyuria and weight loss are signs of gestational diabetes. PIH is characterized by two components: elevated blood pressure and proteinuria. Vasospasm in the arterioles leads to increased blood pressure and a decrease in blood flow to the uterus and placenta. This results in a questionable outcome for the fetus due to placental insufficiency. Renal blood flow is affected, ultimately resulting in proteinuria. InElevated blood glucose is a sign of gestational diabetes. Hematuria may indicate a U.T.I. Hemoglobin 10.2 mg/dL and uterine tenderness Polyuria and weight loss of 3 pounds in the last month Blood pressure 168/110 and 3 proteinuria Hematuria and blood glucose of 160 mg/dL 23. A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery? A weak, ineffective suck could be a result of facial paralysis which is a major complication of forceps deliveries. Scalp edema is another complication and should subside within 2-3 days. Other complications of forceps deliveries include: cephalohematomas, intracranial hemorrhage (especially in premature infants) and excessive bruising, which increases the risk for hyperbilirubinemia. InMolding of the head is a common occurrence with vaginal deliveries. Jitteriness is a sign of low blood sugar, not forceps delivery. InA shrill, high-pitched cry and tachypnea are signs of drug withdrawal, not a complication of forceps delivery. InHypothermia is not a complication of forceps deliveries. The hemoglobin level is quite low (should be about 15-16 g/dL), but unless there is excessive bleeding, the hemoglobin level should be unaffected by the forceps delivery. Weak, ineffective suck, and scalp edema Molding of the head and jitteriness Shrill, high pitched cry, and tachypnea Hypothermia and hemoglobin of 12.5 g/dL 24. In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus? InThis position is contraindicated because the fetus creates pressure on the mother's vena cava. InSquatting widens the pelvic inlet, but does not improve contractions or fetal oxygenation. This prevents vena cava compression and, therefore, improves fetal oxygenation; at the same time, it provides a restful position between contractions. InHigh Fowler's (sitting upright) will assist with the intensity of the contractions because of gravity, but it will not help with fetal oxygenation. Supine with legs elevated Squatting Left side-lying High Fowler's 25. A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions? InPulse rates increase due to pain, not because of rupture of membranes. InThe woman is not reporting pain and ruptured membranes do not cause pain. Lack of fluid (ruptured membranes) has no influence on respiratory rates. InBlood pressure is not affected by prolonged rupture of membranes. The membranes are a protective barrier for the fetus. If the membranes are ruptured for a prolonged period of time, microorganisms from the vagina can ascend into the uterus. The longer the membranes have been ruptured, the greater the risk for infection. Pulse rates rise the longer the membranes are ruptured Respiratory rates decrease due to lack of fluid in the uterus Prolonged rupture of membranes can lead to transient hypertension Infection is a complication of prolonged rupture of membranes 26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a4-year-old and a set of 1-year-old twins. How should the nurse record the client's current gravida and para status? InGravida includes the number of times the woman has been pregnant. She has been pregnant 5 times. A parity of 3 would be obtained by incorrectly counting the 20-week spontaneous abortion as a viable infant. InThe woman has been pregnant 5 times, including the present pregnancy. The abortions count as pregnancies, but not in the parity. Gravida is the number of times a woman has been pregnant, including the present pregnancy. Para is the number of pregnancies carried past 20 weeks' gestation, regardless of the number of fetuses delivered. The woman has been pregnant five times, including this pregnancy, and has had two pregnancies that have exceeded 20 weeks. Even though she delivered two children as a result of one of those pregnancies, the para for her twin pregnancy remains at 1. The pregnancy after which she delivered her four-year-old child makes her a para 2. InA para of 4 would be obtained by incorrectly counting the 2 spontaneous abortions as viable at delivery. Gravida 2, para 3 Gravida 4, para 2 Gravida 5, para 2 Gravida 5, para 4 27. A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important? InAlthough this addresses the client's nausea and vomiting, it is not the most important diagnosis at this time. There are no data to indicate that the client actually has a nutritional deficit. Because nausea and vomiting place her at risk for nutritional deficit, a diagnosis of “risk for altered nutrition. . .” would be appropriate. The knowledge diagnosis is an actual problem and should be addressed at this contact with the client; the nutrition problem will be ongoing during the pregnancy. InThis diagnosis does not address the reason for the lack of client knowledge—she may be at risk for poor parenting, but this is not the priority because there will be time to address that issue as the pregnancy progresses. InThere is no clear evidence of the denial of pregnancy nor of the lack of coping skills. This client clearly has a knowledge deficit about the causes of pregnancy and the physiological changes associated with it. It is important for teaching to begin immediately because her understandings essential to her compliance with suggestions for a healthy pregnancy. Altered nutrition: less than body requirements related to nausea and vomiting Risk for altered family processes related to the client's age Ineffective individual coping related to denial of pregnancy Knowledge deficit related to the client's developmental stage and age 28. A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction? InThese are contraindications for labor induction. Induction of labor is the stimulation of contractions (usually by the use of Pitocin) before they begin on their own. Maternal indications for induction of labor include: pregnancy induced hypertension, chorioamnionitis, gestational diabetes, chronic hypertension and premature rupture of membranes. Fetal indications include intrauterine growth retardation, post-term dates and fetal demise. InThese are contraindications for labor induction. InThese are contraindications for labor induction. They are indications for a C-section. Placenta previa and twins Pregnancy-induced hypertension and postterm fetus Breech position and prematurity Cephalopelvic disproportion and fetal distress 29. A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics? InThis choice describes general anesthesia. Regional anesthetics provide numbness and loss of pain sensation to an area. The most common regional blocks are: local, pudendal, epidural, and spinal. InPain sensations travel to the central nervous system not away from it. InThis choice describes the action for narcotic medications, not regional anesthetics. To relieve pain by decreasing the client's level of consciousness To provide general loss of sensation by blocking sensory nerves to an area To provide pain relief by blocking descending impulses from the central nervous system To relieve pain by decreasing the perception of pain leading to the pain centers in the brain 30. The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant: InUsually babies that only need suctioning of the mouth and nose have Apgars that are 8 or 9. InIf intubation is required, it means that the baby's heart and respiratory rates are not stable, and Apgars would be lower than 5. InApgar scores are used to quickly assess the well-being of the baby. Apgar scores range from 0-10. A score of 0 indicates that the baby is dead. An Apgar score of 5 indicates that the baby needs assistance. Apgar scores of 5 and 7 indicate that the heart rate was below 100, the respiratory effort was irregular, there was little muscle tone, the baby was pink with blue extremities, and there was a grimace. These scores indicate that the baby needed stimulation in order to breathe, and oxygen to increase its oxygen saturation. needed brief oral and nasal suctioning. required endotracheal intubation and bagging with a hand-held resuscitator. was stillborn and required CPR. required physical stimulation and supplemental oxygen. 31. With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy? Insulin is given to gestational diabetic clients because their insulin requirements cannot keep up with the metabolic needs of the fetus in the last trimester. Insulin decreases the blood sugar. InOral hypoglycemic agents are not given to clients with gestational diabetes because they cross the placenta and are harmful to the fetus. InThe client will need frequent follow-up after delivery and into the postpartum period, but she should not need insulin after delivery because in gestational diabetes, blood glucose usually returns to normal after delivery. InClients with gestational diabetes need to eat three balanced meals and three snacks daily. The glucose load is best when maintained at a steady level throughout the day to avoid periodic overproduction of insulin. The last snack of the day should contain protein to stabilize the energy production during the night. "Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby." "You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar." "There is a good possibility you will be taking insulin for the rest of your life." "You should eat three large meals per day to maintain steady glucose load." 32. A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains? InInfection of the suture line can cause pain and discomfort, but is not the cause of afterpains. Afterpains are postpartum uterine contractions. InConstipation and bloating do occur in the postpartum period as peristalsis resumes, but constipation does not cause afterpains, which are uterine contractions. Afterpains are caused by uterine contractions that occur for the first 2-3 days postpartum. Breast-feeding mothers have more afterpains due to the release of oxytocin stimulated by the nursing baby. Oxytocin strengthens uterine contractions and compresses blood vessels, preventing blood loss. InTrauma is not the cause of afterpains. Afterpains are postpartum uterine contractions. Infection of the suture line Constipation and bloating Contractions of the uterus Trauma during delivery 33. A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun? InThese signs describe Braxton-Hicks contractions, which occur throughout pregnancy and increase in intensity and frequency as labor grows closer. InTrue labor pains start in the lower back and sweep to the front in waves. InThese signs occur with lightening, usually 10-14 days before labor begins. These are true signs of labor, along with the rupturing of the membranes and cervical dilatation. Contractions that are irregular and decrease in intensity when walking Abdominal pain that starts at the fundus and progresses to the lower back Increased pressure on the bladder and urinary frequency Expulsion of pink-tinged mucous and contractions that start in the lower back 34. A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care afterbirth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will: InThis expected outcome does not address the client's knowledge deficit. Instead, this is an expected outcome for the nursing diagnosis of ineffective individual coping. InThis choice does not address the client's knowledge deficit, but instead addresses a problem with interrupted bonding. Goals/outcomes should reflect resolution of the stated nursing diagnosis—in this case, knowledge deficit. Verbalization of reasons for the surgery would indicate resolution of the knowledge deficit. If interventions for knowledge deficit are effective, other problems (e.g., anxiety, ineffective coping) may be prevented. InThis choice addresses the anxiety that will occur because of the unknown, but does not address the stated problem, knowledge deficit. demonstrate appropriate coping mechanisms needed to get through the surgery. accept that the type of delivery will not affect the bonding with the baby. verbalize understanding about the reason for the unplanned surgery. demonstrate decreased anxiety and fear of the unknown. 35. The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure? InMaternal oxygenation is not affected by an amniotomy. InMaternal pulse and blood pressure are not affected by an amniotomy. InAssessing the perineum should be done after an episiotomy, not after amniotomy. An amniotomy, or artificial rupture of membranes (AROM), is used to speed up labor. The nurse must document the color, amount, character and odor of the fluid, and assess for fetal well being. Check the client's capillary refill and oxygenation. Monitor the maternal pulse and blood pressure. Inspect the perineum for lacerations, bleeding, and hematoma. Assess the fluid for color, odor, and amount. 36. For a pregnant adolescent who is anemic, which foods should the nurse include In the client's dietary plan to increase iron levels? InMilk does not contain iron and it interferes with iron absorption. Orange juice enhances the absorption of iron. Apricots are a good source of iron. InChicken does contain iron, but cottage cheese, a dairy product, does not. InPickles contain large amounts of salt, not iron. Peanut butter sandwiches do not contain much iron. Milk and fish Orange juice and apricots Chicken and cottage cheese Pickles and peanut butter sandwiches 37. Which condition must occur in order for identical (monozygotic) twins to develop? InUsually only one ovum is released per month; one sperm cannot fertilize two ova. InThis is the case in fraternal (dizygotic) twins. There are two placentas, two chorions, and two amnions. The twins may be the same or different sex. One sperm fertilizes one ovum, and then the zygote divides into two individuals with one placenta, one chorion, two amnion and two umbilical cords. These twins are always the same sex. InThe enzyme on the head of the sperm dissolves the coating of the ovum so eventually only one sperm penetrates one egg. One sperm fertilizes two ova Two sperm fertilize two ova One sperm fertilizes one ovum Two sperm fertilize one ovum 38. Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus? InThe ductus arteriosus is a shunt that connects the lungs to the aorta, allowing the blood to bypass the lungs. InExcept in the case of fetal circulation, arteries do carry oxygenated blood; but during pregnancy, the two umbilical arteries carry unoxygenated blood from the fetus to the placenta, where preoxygenation occurs. InThe portal vein carries blood from the intestine to the liver. The umbilical vein carries oxygenated blood from the placenta to the fetus. The direction of blood flow is toward the fetal heart. Ductus arteriosus Umbilical artery Portal vein Umbilical vein 39. A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor in the client's history supports this diagnosis? The client states that she: InDrinking alcohol is not usually associated with abruptio placenta. InClients with abruptio placenta do not have contractions that can be relieved by walking. Usually the pain is quite intense. InIntercourse should not cause an abruptio placenta, although it is contraindicated in clients with placenta previa. The use of crack cocaine is associated with the separation of the placenta and the bleeding/ hemorrhage that results. Cocaine use is not usually an isolated incident, so the nurse should ask the client about the frequency/amount of the drug usage. drinks two glasses of wine before dinner every night. has intermittent contractions that are relieved by walking. had intercourse with her partner last night. used crack an hour before the symptoms began. 40. Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn? InPathological jaundice, not physiological jaundice, occurs within the first 24 hours and is a result of an ABO incompatibility or Rh incompatibility. Physiological jaundice is the result of the breakdown of excessive amounts of red blood cells that are not needed after birth. Physiological jaundice is also related to the inability of the immature liver to rid the body of bilirubin, which occurs as the red blood cells are broken down. The bilirubin accumulates in the blood causing it to be yellow. InJaundice related to breast milk occurs after the first 7 days, not within the first three. It is not the cause of physiological jaundice. InHepatitis B may have been acquired during delivery and may cause jaundice, but it is not the cause of physiological jaundice, which this case represents. "The baby has a minor incompatibility of the blood." “The baby is breaking down the extra red blood cells that were present at birth.” “The baby is getting too much breast milk, but this is not dangerous.” “The baby may have gotten exposed to hepatitis B during the delivery.” 41. A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery? InCephalopelvic disproportion is seen in large-for-gestational age infants, not postterm infants. Hypothermia occurs in premature and small-for-gestational age infants. Asphyxia is a result of chronic hypoxia in utero because of the progressive degeneration of the placenta. Meconium stained amniotic fluid is a result of the relaxation of the anal sphincter and the passage of meconium into the fluid related to hypoxia. If the meconium stained fluid is aspirated into the infant's lungs at delivery, pneumonia (and possibly death) will result. If there is meconium stained fluid, the infant's mouth and throat are suctioned as soon as the head is delivered. InIntraventricular hemorrhage occurs as a major complication in premature infants, not postterm infants. Dry, cracked skin is a normal finding of postterm infants and is not considered a complication. InHyperbilirubinemia is not a complication of postterm infants at birth. Hypocalcemia is a complication in small-for gestational age infants Cephalopelvic disproportion and hypothermia Asphyxia and meconium aspiration Intraventricular hemorrhage and dry, cracked skin Hyperbilirubinemia and hypocalcemia 42. Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant? InThe baby should be wrapped snuggly with a warm blanket in order to preserve heat loss. InIt helps to cover the feet, of course. However, because the scalp is so vascular (and the blood is close to the surface) and because the head makes up a large portion of the baby's surface area, most heat loss occurs via the head initially. Peripheral circulation is sluggish at first, so not much blood would be cooled by circulating through cold feet. Newly delivered infants lose a great deal of heat as the amniotic fluid evaporates from the surface of the skin. To prevent rapid heat loss, the baby's face and head should be dried and a hat placed on the baby's head. InInfants should NEVER be placed on a heating pad because of risk for burns. Wrap the baby loosely with a blanket. Be sure the baby's feet are covered. Cover the baby's head with a hat. Position the baby on a heating pad. 43. The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers? InSterile vaginal exams are used to assess the dilation of the cervix. InLeopold's maneuvers are not used to assess contraction frequency or intensity. However, some nurses do place their hands on the abdomen to palpate the intensity and frequency of the contractions. InLeopold's maneuvers are not used to assess membrane rupture. Sterile vaginal exams may assess this if membranes are intact. Leopold's maneuvers are a method of determining fetal position by abdominal palpation. It assesses the position, presentation and engagement of the fetus. It also assists in the location of fetal heart sounds. To determine whether the client's cervix has dilated To assess the frequency and intensity of the contractions To assess whether membranes have been ruptured To determine the presentation and position of the fetus 44. Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action? Temperature regulation is the priority for the newborn. Infants who are cold stressed are at risk for respiratory complications or death. InPlacing the infant in the warmer does assist the nurse with easier access, but temperature regulation is the main priority. InMost infants are not connected to the cardiac monitor unless the Apgar scores are low. InThe warmer does provide easy access for the family, but this is not the main reason for its use. To facilitate an efficient means of thermoregulation To facilitate initial assessment by the nurse To permit the use of the cardiac monitor To permit close observation by the family members 45. A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client? InSince this is the client's first baby, there will be concerns/anxiety because of the unknown expectations. This response is appropriate, and will help decrease anxiety by allowing identification and ventilation of fears. InThis response will encourage the client to talk and will foster good communication. This is an example of meaningless reassurance and will block therapeutic communication because the needs of the client are not being met. InThis response will facilitate communication, not block it. "What concerns are you having now?" "Tell me how you are feeling." "Everything is going just fine." "You seem a little nervous." 46. A nurse prepares to teach a class regarding postpartum care and includes infections in the teaching plan. Which is the main cause of mastitis in the postpartum client? Poor breast-feeding technique and improper positioning of the baby are the main reasons for mastitis. Improper release of the baby's suction can lead to sore, cracked nipples, creating a portal of entry for pathogens. InPoor hand washing is not the main reason that a woman gets mastitis but can be a contributing cause. For example, if the woman touches her perineal pad and then the breast, the bacteria on the hands can cause an infection. InSystemic infections such as flu or cold are not the cause of mastitis, which is a localized infection. InProlonged nursing by itself does not cause mastitis. Often babies engage in nonnutritive sucking. Poor breast feeding technique Inadequate hand washing Systemic maternal infection Prolonged nursing 47. A postterm infant is delivered by cesarean section because of fetal distress and meconium-stained amniotic fluid. The nursery nurse frequently monitors the baby's respiratory rate, observing for tachypnea. Which is the reason for the nurse's actions? The infant may: InRespiratory depression does not result in tachypnea but in apnea. This infant is a risk for meconium aspiration pneumonia related to post maturity, meconium staining, fetal distress and being delivered by c-section. InInfants with respiratory distress (tachypneic) are usually cold stressed and hypothermic, not hyperthermic. InA pneumothorax usually is seen in premature infants who lack surfactant. experience respiratory depression from the medications used during delivery. develop meconium aspiration pneumonia. have an elevated temperature. have a pneumothorax related to delivery. 48. The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate? InHyperventilation is not the cause of the variable decelerations. InHypertonic uterine contractions refer to a labor with very painful but not necessarily effective contractions. The uterus does not relax between contractions. This leads to fetal distress and results in late decelerations, not variable decelerations. Variable decelerations are a result of cord compression. Turning the client onto her left side may improve fetal oxygenation by relieving pressure on the cord. InVariable decelerations are a result of fetal cord compression. Decreasing the fluids will not relieve cord compression. Instruct the mother to breathe slowly because this is a sign of hyperventilation. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions. Turn the woman onto her left side to relieve pressure on the umbilical cord. Reduce the oral and IV fluids to decrease circulatory overload. 49. The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has: InOne method of increasing an infant's low blood sugar is by feeding him. Bottle feeding of an infant who is tachypneic (resp. rate > 60) is contraindicated due to risk of aspiration. InAcrocyanosis (blue hands and feet) is a normal finding for the first 24 hours. InIt is not unusual for the nurse to hear a heart murmur shortly after birth. a blood glucose of 45 gm/dL. a respiratory rate above 60. blue hands and feet. a heart murmur. 50. During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate? With a sterile gloved hand, the nurse should push the presenting part away from the cord, thus preventing cord compression. The cord supplies the fetus with oxygen and nutrients. The fetus is already showing signs of distress because of the slowing of the heart rate. In addition, the nurse should prepare for immediate delivery. InSince the head is not engaged (which is why the cord prolapsed), it will be very difficult to insert a scalp electrode. InTrendelenburg position places the client with her head lower than her feet. Reverse Trendelenburg places the client with the head higher than the feet. Due to gravity, this will place additional pressure on the cord. InCovering the cord with a dry gauze will not help the situation. The gauze will get wet in a matter of seconds. There is a risk that the gauze will be lost internally. Hold the presenting part away from the cord. Insert a scalp electrode for an internal fetal monitor. Place the client in reverse Trendelenburg position. Cover the cord with a dry, sterile gauze. 51. A client is in the latent stage of labor. Which nursing intervention is most appropriate? Latent stage is an early stage of labor, which begins with the onset of contractions and ends when the cervix is dilated to 4 cm. Walking adds gravity to the force of the contractions, promotes fetal descent, and relieves backache. Once the membranes rupture, bed rest may be indicated, for example if the fetal head is not engaged. InPushing is not indicated until full cervical dilation. InThis type of breathing pattern is used late in labor when pushing begins. InOnce labor begins fluids and ice chips are preferred. Nausea and vomiting are common as labor progresses. During labor, peristalsis stops. Therefore, having food in the stomach is not advisable. Encourage the client to walk in the hall until membranes rupture. Instruct the client to place her head on her chest and push with the contraction. Teach the client to use the “pant-blow” method of breathing. Advise the client to eat a light meal consisting of carbohydrates. 52. Which conditions create a risk for uterine atony in the immediate postpartum period? InBreastfeeding causes uterine contractions due to the release of oxytocin. Uterine atony is not related to the delivery of a child with chromosomal defect. InUterine atony is not a result of postterm pregnancy or amniotomy. InGestational diabetes in and of itself does not cause uterine atony. However, clients with gestational diabetes do have babies that are large for gestational age (> 4000 grams). Pregnancy-induced hypertension is associated with vasospasm, which does not result in uterine atony. Uterine atony is the inability of the uterus to contract, which leads to hemorrhage. Clients who have had more than one delivery have decreased muscle tone in the uterus. Clients with twins or triplets are at risk for overdistention of the uterus, which may lead to uterine atony and hemorrhage. Breast feeding and delivery of an infant with chromosome defects Postterm birth and an amniotomy during labor Gestational diabetes and pregnancy-induced hypertension Multiparity and multiple gestation 53. A client at ten weeks gestation tells the nurse that she has been having “morning sickness.” The nurse advises the client to eat foods that are easy to digest and low in fat. Which is the rationale for the nurse's instruction? InLow fat diets do not stimulate peristalsis. On the contrary, high fat foods can lead to bloating, increased peristalsis and diarrhea. Foods containing a high fat content stay in the digestive system longer. Decreasing the amount of fat causes faster gastric emptying, which leaves less in the stomach to be vomited. InFluid and electrolyte imbalance is not a cause of nausea and vomiting related to pregnancy. InRelaxation of the cardiac sphincter, causing heartburn, is a result of increased progesterone. It causes heartburn, not nausea and vomiting. A low-fat diet increases peristalsis, which reduces the food volume in the stomach A low-fat diet is digested faster and leaves less in the stomach that can be vomited Easily digested foods provide a better balance of fluids and electrolytes, resulting in less nausea and vomiting Easily digested foods are less likely to cause relaxation of the cardiac sphincter, which causes regurgitation and vomiting 54. Which information is most important for the nurse to gather when a client is admitted to the unit in labor? InThis is useful information, but the priority information is that regarding medical conditions which may create serious risks to the fetus and mother. Asking the client about any medical problems should be the priority because it provides a quick assessment for risks to the fetus and mother. InFluids are given in the latent phases of labor, but gathering this information at the initial admission interview is not as important as obtaining information about medical conditions which may create serious risks to the fetus and mother. InThis is not important unless the client has PIH or a cardiac condition. Even then, the initial assessment would be to find out if the client actually has PIH or cardiac condition (e.g., by checking the history), not to diagnose it. Name of the support person Medical problems or complications Fluid preferences Amount of weight gained during the pregnancy 55. The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should this assessment finding be documented? InBruising usually does not involve the scrotum, and is not usually gray. Mongolian spots are the result of increased pigmentation over parts of the baby. They are most commonly found in infants of Asian, Indian, African-American or Mediterranean descent. They are harmless and fade during the first two years of life. InNevus flammeus is a dark red lesion called a port wine stain. It does not blanch when touched, and does not fade with age. This type of hemangioma usually is seen on the face or thigh rather than the back. InAcrocyanosis, a normal finding, is a bluish discoloration of the hands and feet (not the back or buttocks), and is related to sluggishness of the peripheral circulation. Extensive bruising Mongolian spots Nevus flammeus Acrocyanosis 56. A small-for-gestational-age infant is irritable and jittery, and has hyperreflexia and clonus. He is jaundiced, has temperature instability, and spitty after feedings. The nurse suspects the infant is displaying signs of passive addiction during pregnancy. When planning for the infant's care at home, which nursing assessment is most important for the infant experiencing neonatal abstinence syndrome? In cases of maternal drug addiction, it is very important that the home situation be assessed because infant abuse and neglect are common in homes where there is drug/alcohol abuse. InWhile this may be important information to know, it does not address the infant or its care. InAssessing whether or not the mother has money enough to afford treatment for her addiction is not as important as the infant's safety. InDrug withdrawal is not measured in degree of severity. The baby is withdrawing, and that is all that is important. The mother's ability to provide a safe environment The extent of addiction of the mother The mother's ability to obtain treatment The severity of the infant' s withdrawal 57. A woman in active labor is admitted to the labor and delivery unit, accompanied by her partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in the corner, looking out the window. How may the nurse understand the man's actions? InOther factors such as culture, personality, and language should be considered before assessing the inability to cope due to overwhelming concern for the woman. At this point there are no data to indicate overwhelming concern. These factors must first be considered along with ability to speak the language. Keeping in mind that there are individual and cultural differences in expressing concern will enable the nurse to make unbiased assessments. InEmbarrassment may be a reason for the man's actions, but is not the first consideration. It is important to first consider that there individual and cultural differences in expressing concern. This will enable the nurse to make unbiased assessments. InIf a man's religious beliefs prohibited him from viewing a birth, he is not likely to be in the room during the active phase of labor. He is likely to be very concerned about the woman's health to the point that his ability to cope with the situation is compromised. His actions reflect personality or cultural differences, which do not necessarily indicate a lack of concern. Due to his embarrassment and discomfort regarding the woman's expressions of pain, he withdraws from the situation. His religious beliefs regarding participation in the birth experience affect his interactivity and communication in this situation. 58. A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug? Because hypertension is a sign of PIH, the client's BP must be monitored. The client's respiratory rate should be monitored because one sign of magnesium sulfate toxicity is a respiratory rate under 12/min. InAssessing blood glucose levels does not pertain to PIH but to gestational diabetes. InA side effect of magnesium sulfate is a decrease in blood pressure, which might cause orthostatic hypotension; however, the client with severe PIH will be on strict bed rest and not allowed to walk. InMagnesium sulfate may be used for preterm labor to slow contractions, but this does not pertain to PIH. Assess blood pressure and respiratory rate every fifteen minutes. Monitor blood glucose levels every eight hours. Evaluate for orthostatic hypotension when getting the client up to walk. Observe for premature labor every shift. 59. A 27-week gestation infant is taken to a newborn intensive care unit 150 miles away. Initially, which emotion should the nurse expect the mother to display after the transfer? InUsually denial is seen when the mother fails to recognize the severity of the situation. Denial would probably have occurred before the transfer, when the mother first learned about the baby's critical status. InThe mother may display frustration but it is aimed at not being able to follow the baby to the intensive care unit, and lack of knowledge about the child's condition. The mother feels a great deal of guilt for not having a perfect baby and perhaps for causing the baby pain and discomfort. The mother may also feel that she could have done something to prevent the early delivery. This is the primary emotion to expect. InAnger is not usually seen initially. It occurs later in the grieving process. Denial Frustration Guilt Anger 60. A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby? InNormally infants who are withdrawing from drugs are hyperactive and jittery, not lethargic and limp. These symptoms indicate a large-for-gestational-age (LGA) infant. LGA infants typically have diabetic mothers and have respiratory problems and difficulty with stabilization of blood sugar. InThe baby's signs and symptoms are reflective of large-for-gestational age, not a heart defect. InRespiratory depression may cause the infant to be limp, but this does not account for the baby's elevated weight. Neonatal abstinence symptoms Large for gestational age Congenital cardiac defect Respiratory depression 61. Which assessment finding suggests thrombophlebitis in a postpartum client? InThese signs and symptoms are indications of pulmonary embolism. InThese are signs and symptoms of a pulmonary embolism. Pulmonary emboli may occur as a result of clot formation in the calf. These signs and symptoms are common for clients with thrombophlebitis. Thrombophlebitis occurs because of changes in the blood volume and coagulation factors that result after delivery. Although eliciting a Homan's sign could dislodge a thrombus, it is considered a positive sign. InThese signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension Chills, hypotension, and abdominal tenderness Positive Homan's sign, calf warmth, and pain Dizziness, loss of consciousness, and chest pain 62. A client comes to the clinic to confirm that she is pregnant. Her last menstrual period was January 31st. According to Naegele's rule, when should the client expect to deliver? InSeven days have not been added. InOnly two months have been subtracted. When using Nagele's rule to estimate delivery dates, the nurse takes the client's last menstrual period (LMP), adds 7days, and then subtracts 3 months. Adding 7 days to the LMP of January 31st makes it February 7th. Subtracting 3 months then makes the due date November 7th.InSeven days have been subtracted instead of added to the LMP. November 31 December 7 November 7 December 24 63. Which procedure should be avoided for the client known to have a placenta previa? InNon-stress tests are necessary to monitor the well-being of the fetus. Non-stress tests are usually performed if the client returns home after a bleeding episode. InPerforming a catheterization has nothing to do with placenta previa. In placenta previa, the placenta covers all or part of the cervical opening. Therefore, vaginal exams are contraindicated because of risk of bleeding or infection. Hemorrhage is the main complication of placenta previa. InAbdominal ultrasounds are non-invasive and are commonly performed upon admission to the hospital to locate the position of the placenta. A non-stress test A urinary catheterization A sterile vaginal exam An abdominal ultrasound 64. A woman in the first trimester comes to the clinic with vaginal bleeding. The physician determines that the fetus has died and that the placenta, fetus, and tissues still remain in the uterus. How should the findings be documented? InA complete abortion occurs when all products of conception are expelled. InStillborn is a lay term that means the baby has died. This does not address the products of conception such as the placenta or tissues. Prolonged retention of the products of conception (placenta/tissues) after the fetus has died is known as a missed abortion. Infection and coagulation defects are common complications. InAn incomplete abortion occurs when some, but not all, of the products of conception have been expelled. Complete abortion Stillborn abortion Missed abortion Incomplete abortion 65. A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms? InAnoxia/hypoxia results in restlessness, nasal flaring, and cyanosis of the lips and nailbeds. The signs and symptoms listed in the question are not related to anoxia. These signs and symptoms are a result of hyperventilation. The nurse should have the client breathe slower and into a paper bag to counteract the signs and symptoms. InAnxiety usually causes rapid heart rate and muscle tenseness, not the symptoms listed in the question. InWhile hypertension often affects vision, it is not the reason for this cluster of signs and symptoms. Anoxia Hyperventilation Anxiety Hypertension 66. Which data support a diagnosis of abruptio placenta in a pregnant woman? These are classic signs of an abruptio placenta. Other signs and symptoms include: dark, red vaginal bleeding, fetal distress, signs of hypovolemic shock. InThese are signs of placenta previa, not abruptio placenta. InThese have nothing to do with abruptio placenta. InBright red blood loss is a sign of placenta previa. Hypertension may occur in abruptio placenta, however. Uterine rigidity and abdominal pain Painless bleeding with soft abdomen Premature rupture of membranes and uterine contractions Bright red blood loss and elevated blood pressure 67. A women in her first trimester contracts rubella. How is the fetus likely to be affected? InRubella is usually associated with hearing, vision and cardiac defects. The rubella virus usually causes mild illness in the mother, but has devastating effects on the fetus, including cataracts, heart defects (patent ductus arteriosus and pulmonary stenosis are the most common), deafness, mental and motor retardation, growth retardation and clotting disorders. InSpinal cord defects are a result of the inability of the vertebrae to fuse—it is a congenital problem and not related to rubella. InPolydactyly, the presence of extra digits (fingers or toes), and club feet are not usually seen in fetuses with rubella. Reproductive and urinary defects Heart defects and cataracts Spinal cord and skeletal defects Polydactyly and club feet 68. An hour after delivery, a 4000 gram infant exhibits pallor, jitteriness, a blood sugar level of 40 gm/dL, irritability and periodic apnea. Which maternal condition could be the cause of the newborn's symptoms? InJitteriness and irritability may indicate a drug withdrawal problem, but the large birth weight and the low glucose levels indicate an infant of a diabetic mother. InJitteriness, irritability, and pallor are classic signs of hypoglycemia in the infant with a history of gestational diabetes. Infants born to mothers with pregnancy induced hypertension may be small for gestational age due to uteroplacental insufficiency. InTORCH infections do affect the baby, but the symptoms described do not indicate a TORCH infection. These signs and symptoms are cla