Exam 3 - Chapter 21 Flashcards
- A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of after birth hemorrhage in this woman is:
a. retained placental fragments.
b. unrepaired vaginal lacerations.
c. uterine atony.
d. puerperal infection.
ANS: C
This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause after birth hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.
- 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 nurse’s first action is to:
a. begin an intravenous (IV) infusion of Ringer’s lactate solution.
b. assess the woman’s vital signs.
c. call the woman’s primary health care provider.
d. massage the woman’s fundus.
ANS: D
The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. 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 impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.
- A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.
- The laboratory results for a after birth woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?
a. Rubella vaccine should be given.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of birth.
d. A Kleihauer-Betke test should be performed.
ANS: A
This patient’s rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the patient needs a blood transfusion. Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.
- A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:
a. running warm water on her breasts during a shower.
b. applying ice to the breasts for comfort.
c. expressing small amounts of milk from the breasts to relieve pressure.
d. wearing a loose-fitting bra to prevent nipple irritation.
ANS: B
Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.
- A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse’s most appropriate response is to ask the woman:
a. “Didn’t you like your lunch?”
b. “Does your doctor know that you are planning to eat that?”
c. “What is that anyway?”
d. “I’ll warm the soup in the microwave for you.”
ANS: D
“I’ll warm the soup in the microwave for you” shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. “What is that anyway?” does not show cultural sensitivity.
- In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice:
a. is inconsistent with the Baby-Friendly Hospital Initiative.
b. promotes longer periods of breastfeeding.
c. is perceived as supportive to both bottle-feeding and breastfeeding mothers.
d. is associated with earlier cessation of breastfeeding.
ANS: A
Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers
- A after birth woman overhears the nurse tell the obstetrics clinician that she has a positive Homans’ sign and asks what it means. The nurse’s best response is:
a. “You have pitting edema in your ankles.”
b. “You have deep tendon reflexes rated 2+.”
c. “You have calf pain when the nurse flexes your foot.”
d. “You have a ‘fleshy’ odor to your vaginal drainage.”
ANS: C
Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A “fleshy” odor, not a foul odor, is within normal limits.
- In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:
a. has recovered from epidural or spinal anesthesia.
b. has hidden bleeding underneath her.
c. has regained some flexibility.
d. is a candidate to go home after 6 hours.
ANS: A
If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.
- Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.
a. 24, 73
b. 24, 96
c. 48, 96
d. 48, 120
ANS: C
The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.
- In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:
a. the father of the infant.
b. her mother (the infant’s grandmother).
c. her eldest daughter (the infant’s sister).
d. the nurse.
ANS: D
In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care
- Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
a. formally initializing individualized care by confirming the woman’s and infant’s identification (ID) numbers on their respective wrist bands. (“This is your baby.”)
b. teaching the mother to check the identity of any person who comes to remove the baby from the room. (“It’s a dangerous world out there.”)
c. including other family members in the teaching of self-care and child care. (“We’re all in this together.”)
d. nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.
ANS: D
Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.
- Excessive blood loss after childbirth can have several causes; 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.
d. retained placental fragments.
ANS: C
Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
- A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
a. improve the accuracy of blood loss estimation, which usually is a subjective assessment.
b. determine which pad is best.
c. demonstrate that other nurses usually underestimate blood loss.
d. reveal to the nurse supervisor that one of them needs some time off.
ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.
- Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:
a. pouring water from a squeeze bottle over the woman’s perineum.
b. placing oil of peppermint in a bedpan under the woman.
c. asking the physician to prescribe analgesics.
d. inserting a sterile catheter
ANS: D
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.
