Sie sind auf Seite 1von 2

45. D.

Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding,
blurred vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness,
and nasal stuffiness are common discomforts associated with pregnancy.

46. B
A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant,
indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white
blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal

52. A. The newborns ability to regulate body temperature is poor. Therefore, placing the
newborn under a radiant warmer aids in maintaining his or her body temperature. Suctioning
with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the
newborns immediate adjustment to extra uterine life. Inspecting the umbilical cord aids in
detecting cord anomalies.

53. D. Immediately before expulsion or birth of the rest of the body, the cardinal movement
of external rotation occurs. Descent flexion, internal rotation, extension, and restitution
(in this order) occur before external rotation.
66. D No rationale

67. 2, When cord prolapse occurs, prompt actions are taken to relieve cord compression and
increase fetal oxygenation. The mother should be positioned with her hips higher than her head
to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to
summon help, and other staff members should call the health care provider and notify the
delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it
because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face
mask is administered to the mother to increase fetal oxygenation.

69. C. Because of early postpartum discharge and limited time for teaching, the nurses priority
is to facilitate the safe and effective care of the client and newborn. Although promoting comfort
and restoration of health, exploring the familys emotional status, and teaching about family
planning are important in postpartum/newborn nursing care, they are not the priority focus in the
limited time presented by early post-partum discharge.

70. Answer: c. adverse reactions of oxytocin are hyperstimulation of uterine contractions and
nonreassuring fetal heart rate patterns.
71. 2. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually
decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually
indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or
increase ambulation is not an accurate nursing intervention.

74. The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An
episiotomy was performed, and the woman has developed a wound infection at the episiotomy
site. The nurse provides instructions to the client regarding care related to the infection. Which
statement by the client indicates a need for further teaching?
"I need to isolate my infant for 48 hours after the starting the antibiotics."

79. A. The diaphragm must be fitted individually to ensure effectiveness. Because of the changes
to the reproductive structures during pregnancy and following delivery, the diaphragm must be
refitted, usually at the 6 weeks examination following childbirth or after a weight loss of 15 lbs
or more. In addition, for maximum effectiveness, spermicidal jelly should be placed in the dome
and around the rim. However, spermicidal jelly should not be inserted into the vagina until
involution is completed at approximately 6 weeks. Use of a female condom protects the
reproductive system from the introduction of semen or spermicides into the vagina and may be
used after childbirth. Oral contraceptives may be started within the first postpartum week to
ensure suppression of ovulation. For the couple who has determined the females fertile period,
using the rhythm method, avoidance of intercourse during this period, is safe and effective.

85. 3. If the uterus is not contracted firmly, the first intervention is to massage the fundus
until it is firm and to express clots that may have accumulated in the uterus. Pushing on
an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the
clients legs and encouraging the client to void will not assist in managing uterine atony.
If the uterus does not remain contracted as a result of the uterine massage, the problem
may be distended bladder and the nurse should assist the mother to urinate, but this would
not be the initial action.