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A patient who was diagnosed prenatally as having epidural for pain management. What should the greater than 2,000 mL of amniotic fluid just deliv- nurse be prepared to do? Select all that apply. ered a 9 lb (4,082 g) baby girl. Her nurse is aware
- A. Assess maternal vital signs that she is now at risk for which condition?
- B. Assess FHR
- C. Infection
- D. Assist patient to the bathroom to void
Correct Answer: A
Rationale: A. Assess maternal vital signs: With the delivery of a baby with macrosomia (greater than 4,000 g), the mother is at risk for postpartum hemorrhage due to uterine atony, retained placental fragments, or lacerations. Therefore, assessing maternal vital signs is crucial in detecting any signs of hemorrhage promptly.
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A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Prepare the client for an immediate birth.
- C. Place the client in knee-chest position.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.
Correct Answer: D
Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to substances, such as methadone, while in the womb. Infants with NAS may exhibit excessive high-pitched crying as one of the manifestations. Other common symptoms of NAS include irritability, tremors, feeding difficulties, sweating, fever, vomiting, diarrhea, and poor weight gain. Therefore, in this case, the excessive high-pitched cry is a manifestation that the nurse should identify as an indication of neonatal abstinence syndrome.
The nurse is educating a client about preterm labor. What symptom should the client report immediately?
- A. Frequent urination.
- B. Lower back pain and cramping.
- C. Increased appetite.
- D. Braxton Hicks contractions.
Correct Answer: B
Rationale: Lower back pain and cramping may indicate preterm labor and should be reported promptly.
On admission to the nursery, a newborn is observed to be experiencing cold stress. The basis for the nursing intervention at this time would be to minimize:
- A. Shivering
- B. Hyperglycemia
- C. Oxygen consumption
- D. Metabolism of fat stores
Correct Answer: C
Rationale: Cold stress in a newborn can lead to an increase in oxygen consumption as the body works harder to maintain a normal body temperature. By minimizing oxygen consumption, the nursing intervention aims to prevent excessive oxygen demand and help the newborn cope with the cold stress more effectively. This can be achieved through methods such as swaddling, warming equipment, and ensuring the baby's environment is appropriately heated to maintain a stable body temperature. Minimizing oxygen consumption can help conserve energy and promote overall well-being in the newborn.
Which finding in a 36-week pregnant client is most concerning?
- A. Braxton Hicks contractions
- B. Frequent urination
- C. Proteinuria of +2
- D. Weight gain of 2 pounds in a week
Correct Answer: C
Rationale: Proteinuria is a sign of preeclampsia, requiring immediate assessment.