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New mother, postpartum period
Choose the sign or symptom that a new mother should be taught to report:
- A. Occasional uterine cramping when the infant nurses.
- B. Descent of the fundus one fingerbreadth each day.
- C. Reappearance of red lochia after it changes to serous.
- D. Oral temperature that is 37.2 C (99 F) in the morning.
Correct Answer: C
Rationale: Reappearance of red lochia after it becomes serous may indicate uterine atony or retained placental fragments, requiring immediate reporting.
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Pregnant woman educated about placental hormones
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
- A. Human placental lactogen (hPL).
- B. Estrogen (estriol).
- C. Progesterone (progestin).
- D. Human chorionic gonadotropin (hCG).
Correct Answer: D
Rationale: Human chorionic gonadotropin (hCG) is produced by the fertilized egg and detected in pregnancy tests, indicating fertilization and implantation.
Newborn reflex observation
Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?
- A. Tonic neck reflex.
- B. Moro reflex.
- C. Startled reflex.
- D. Babinski reflex.
Correct Answer: A
Rationale: The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side, causing the arm and leg on that side to stretch out and the opposite side to bend, matching the described reaction.
Woman receiving oxytocin stimulation
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because
- A. It produces a prolapsed cord.
- B. It increases maternal renal blood flow.
- C. It decreases maternal blood pressure.
- D. There is a reduction of placental blood flow.
Correct Answer: D
Rationale: Hypertonic contractions reduce placental blood flow by limiting the time for the placenta to refill with blood between contractions, risking fetal hypoxia. Note: The document incorrectly lists 'A' as the correct answer, but the explanation supports 'D' as the correct choice based on standard medical understanding.
Client receiving opioid epidural analgesia during labor
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
- A. Blood pressure 80/56 mm Hg.
- B. The client reports profuse itching.
- C. The client reports weakness of the lower extremities.
- D. Temperature 38.2°C (100.8 F).
Correct Answer: A
Rationale: Hypotension (80/56 mm Hg) is the priority as it can reduce placental blood flow, risking fetal distress, and requires immediate intervention.
Woman received epidural or intrathecal opioids
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
- A. delayed respiratory depression.
- B. inability to move lower extremities.
- C. pruritus.
- D. nausea and vomiting.
Correct Answer: A
Rationale: Delayed respiratory depression is not a primary concern with epidural or intrathecal opioids, which have limited systemic effects compared to systemic opioids.