Maternal & Child Practice Exam 3

EXPLANATION

✔Correct answer:

Imminent abortion. An imminent abortion, also known as an inevitable abortion, is indicated by moderate vaginal bleeding, abdominal cramping, and cervical dilation in early pregnancy. When the cervix is dilated and bleeding is present, it suggests that the pregnancy cannot continue, as the cervix is preparing to pass the contents of the uterus. In this case, the patient is 12 weeks pregnant with cervical dilation of 2 to 3 cm, which aligns with the findings of an imminent or inevitable abortion. This condition usually progresses to the expulsion of the fetus and placental tissue.

In contrast, other types of abortion (e.g., threatened, missed, complete) involve different clinical signs that do not include an open cervix with active bleeding.

Think of the cervix like a door. In an imminent abortion, the "door" (cervix) has started to open, making it almost certain that the pregnancy will end. In a threatened abortion, the "door" would remain closed, suggesting the pregnancy might still continue.

The nurse should document the findings and prioritize supportive care for the patient. Key considerations include:

• Provide emotional support and acknowledge the patient’s feelings, as this can be a distressing experience.
• Monitor vital signs, assess bleeding, and watch for signs of excessive blood loss.
• Prepare the patient for potential medical interventions or additional diagnostic testing as directed by the healthcare provider.
• Educate the patient about what to expect regarding the process of an imminent abortion and discuss follow-up care, including potential emotional support resources.
• Ensure that the healthcare provider is informed of the findings so that appropriate medical interventions, if needed, can be initiated promptly.

✘Incorrect answer options:

Threatened abortion. In a threatened abortion, the cervix remains closed, even though there may be vaginal bleeding and cramping. Since this patient has a dilated cervix, this is more consistent with an imminent abortion rather than a threatened abortion.

Complete abortion. A complete abortion means that all fetal tissue has been expelled from the uterus, and the cervix has closed after the expulsion. In this case, the cervix is open, and there is no indication that the pregnancy tissue has been fully expelled, so it does not meet the criteria for a complete abortion.

Missed abortion. A missed abortion refers to a situation where the fetus has died but remains in the uterus without any cramping, bleeding, or cervical dilation. This patient has active symptoms (bleeding, cramping, and cervical dilation), which do not align with a missed abortion.

EXPLANATION

✔Correct answer:

Checking for hemorrhage. In the first few hours after a circumcision, hemorrhage is the most immediate and critical risk. Newborns have a limited blood volume, and even a small amount of bleeding can lead to significant blood loss. Therefore, monitoring for bleeding at the circumcision site is Nurse Lisa’s top priority during the first 4 hours post-procedure. Assessing for hemorrhage includes checking the dressing (if used) and observing for active bleeding or oozing from the circumcision site. Prompt detection and intervention are essential to prevent complications.

Other concerns, such as infection and discomfort, are also important, but they are not as immediate as the risk of hemorrhage in the initial hours following circumcision.

Think of hemorrhage after circumcision like a small leak in a water tank with limited water. Even a small, steady leak can quickly lead to significant loss. Therefore, checking for bleeding immediately is like ensuring there’s no leak in the tank.

Nurse Lisa should closely monitor for signs of bleeding and take immediate action if any hemorrhage is noted. Key steps include:

• Inspect the circumcision site frequently within the first few hours for any active bleeding, oozing, or saturation of the dressing.
• If bleeding is observed, apply gentle pressure with a sterile gauze and notify the healthcare provider promptly.
• Reinforce to the parents that some mild redness and swelling are normal, but any active bleeding should be reported immediately.
• Document each assessment of the circumcision site, noting any findings and actions taken if bleeding is detected.
• After the initial hours, monitor for additional concerns like infection and pain, but prioritize hemorrhage checks during the early period post-procedure.

✘Incorrect answer options:

Signs of infection. Infection is an important concern, but it generally develops over time and is unlikely to occur within the first few hours post-procedure. The priority in the immediate period is to check for hemorrhage, which poses a more immediate risk.

Evaluating discomfort level. While managing discomfort is important, it is secondary to ensuring there is no bleeding. Pain can be addressed as needed, but hemorrhage requires immediate and consistent monitoring.

Monitoring for dehydration. Dehydration is not typically a primary concern following circumcision. It would be more relevant if the baby showed signs of poor feeding or illness but is not directly related to the procedure itself.

EXPLANATION

✔Correct answer:

The lochia. The patient’s symptoms—fever (101.4ºF), a tender and enlarged uterus, and a slower-than-expected descent—are suggestive of endometritis, a common postpartum infection of the uterine lining. Endometritis often occurs in the postpartum period, especially if there were risk factors such as prolonged labor, multiple vaginal exams, or cesarean delivery. Signs of endometritis include fever, uterine tenderness, and an enlarged or subinvoluted uterus (meaning it is not shrinking back to its pre-pregnancy size as expected).

Assessing the lochia is essential in this case, as foul-smelling, purulent, or abnormal-colored lochia (such as yellow or green) can indicate an infection in the uterus. By assessing the lochia, the nurse can gather additional clues to confirm the suspicion of endometritis. The presence of abnormal lochia would further support this diagnosis, prompting the need for medical intervention, such as antibiotics.

Think of lochia as a window into the uterus. Just as you might look through a window to check on the health of what’s inside, checking the lochia helps reveal signs of infection or abnormal healing in the uterus.

Nurse should continue assessing for signs of infection and prepare to notify the healthcare provider if endometritis is suspected. Key interventions include:

• Assess the lochia for color, amount, odor, and consistency. Foul-smelling or purulent lochia would indicate infection.
• Monitor the patient’s vital signs, especially temperature and heart rate, as elevated heart rate often accompanies infection.
• Check the uterine fundus for firmness and position, and document any tenderness, as this can confirm uterine subinvolution and infection.
• Notify the healthcare provider if signs of infection are present, as early intervention with antibiotics is essential to prevent complications.
• Educate the patient on signs of postpartum infection and the importance of reporting symptoms such as fever, foul-smelling lochia, or increasing abdominal pain.

✘Incorrect answer options:

The breasts. Although breast engorgement or mastitis can cause fever, it would not explain the uterine tenderness, enlargement, or delayed involution. Thus, assessing the breasts would not be the priority.

The incision. If the patient had a cesarean delivery, assessing the incision is important to rule out infection, but incision infection would not typically cause uterine tenderness or an enlarged uterus. Endometritis remains the primary concern with these symptoms.

The urine. A urinary tract infection (UTI) is possible postpartum and can cause fever, but it would not cause uterine tenderness, an enlarged uterus, or slow involution. UTIs typically cause symptoms like dysuria, frequency, and urgency, which are not present here.

EXPLANATION

✔Correct answer:

Suggest breastfeeding more frequently. Breastfeeding more frequently can help alleviate sore nipples by preventing the breasts from becoming overly full and engorged. When the breasts are too full, the baby may have difficulty latching deeply, which can lead to shallow latches and nipple soreness. Frequent breastfeeding sessions keep milk flowing, reduce engorgement, and encourage a more comfortable latch.

Frequent feeding also encourages the baby to latch when they are not overly hungry or frantic, which can help them latch more calmly and effectively. Additionally, this can prevent prolonged intervals where the baby may have a shallow latch, which often contributes to nipple soreness.

Imagine breastfeeding like filling a cup with water. If the cup (breast) becomes too full, it overflows, making it harder to drink from without spilling. Similarly, when the breast is overly full, it’s harder for the baby to latch deeply and effectively, leading to a shallow latch that can cause nipple soreness. By breastfeeding more frequently, the breast stays at a manageable level, making it easier for the baby to latch comfortably and reducing strain on the mother’s nipples.

Nurse Liz should provide additional guidance to help the mother manage sore nipples and promote comfortable breastfeeding. Key recommendations include:

• Encourage the mother to breastfeed frequently, ideally every 2-3 hours, to keep the breasts soft and manageable for the baby.
• Assess and educate on proper latch techniques, as a deep and comfortable latch reduces nipple soreness.
• Suggest expressing a small amount of milk manually if the breasts are overly full before latching the baby, which can make it easier for the baby to latch effectively.
• Advise against using soap on the nipples, as it can dry out the skin. Rinsing with plain water is sufficient.
• Recommend applying a small amount of breast milk to the nipples after feeding, as it has natural healing properties.

✘Incorrect answer options:

Offer a narcotic pain reliever before feeding. Narcotic pain relievers are generally not recommended for routine nipple soreness as they do not address the root cause and could pose risks to both mother and baby.

Advise wearing a supportive nursing bra. While a supportive nursing bra can help with general breast comfort, it does not specifically address nipple soreness. Ensuring a proper latch and frequent feeding is more effective in managing sore nipples.

Avoid using soap and water on the nipples. Avoiding soap is good advice to prevent dryness, but it does not directly address the cause of soreness. Frequent feeding to reduce engorgement and improve latch is more directly beneficial.

EXPLANATION

✔Correct answer:

"The enlargement is due to maternal hormones still present in his system." The best response Nurse Abby can give is to reassure the mother that her newborn son's enlarged breast tissue is a common and normal condition caused by maternal hormones. During pregnancy, maternal estrogen and progesterone pass through the placenta to the baby. These hormones can cause temporary breast enlargement and, in some cases, even a small amount of milky discharge, known as "witch’s milk," in both male and female newborns. This condition, called physiological breast engorgement, typically resolves on its own within a few weeks as the hormone levels decrease in the newborn's body.

This response is accurate, provides reassurance, and educates the mother about the temporary nature of the condition. It alleviates her concern without causing unnecessary worry.

Think of the enlarged breast tissue as a "leftover effect" from the mother’s hormones. Just as a fragrance can linger after someone leaves a room, maternal hormones linger in the baby’s body after birth, temporarily causing effects like breast enlargement.

Nurse Abby should provide reassurance to the mother and monitor the newborn for any unusual signs. Key points include:

• Reassure the mother that the breast enlargement is a normal and temporary condition caused by maternal hormones.
• Educate the mother that this swelling will generally resolve on its own within a few weeks without any intervention.
• Advise the mother to avoid squeezing or massaging the area, as this can lead to irritation or potential infection.
• Monitor for any signs of infection, such as redness, warmth, or discharge, which would require further evaluation.
• Encourage the mother to reach out if she notices any persistent swelling or signs of discomfort in the baby.

✘Incorrect answer options:

"The breast tissue is slightly swollen from the birth process." This response is incorrect because the breast enlargement is not due to the birth process itself but to the presence of maternal hormones in the newborn’s system.

"You might want to discuss this with the doctor; it could be something serious." This response may unnecessarily alarm the mother. Physiological breast enlargement is a common and benign condition that typically does not require a physician's intervention unless there are signs of infection or unusual symptoms.

"The tissue grew larger while he was developing in the uterus." This response is misleading. The breast enlargement occurs due to maternal hormones that the baby received in utero, but it is not related to tissue growth during fetal development.

EXPLANATION

✔Correct answer:

A total weight gain of 25 to 30 pounds. The general guideline for healthy weight gain during pregnancy is a total of 25 to 30 pounds for women with a normal pre-pregnancy weight. This range provides a basis for supporting fetal growth and development, as well as the maternal body’s needs. For pregnant teenagers, this guideline is particularly important, as they are often still growing themselves and need sufficient nutrients to support both their own development and that of the fetus. Weight gain recommendations may vary depending on the teen’s pre-pregnancy weight and individual health, but a 25- to 30-pound range is typical for those who start with a normal BMI.

Weight gain is usually distributed unevenly across the pregnancy. Generally, minimal weight gain occurs in the first trimester (about 1-4 pounds), with more gradual and steady weight gain in the second and third trimesters (approximately 1 pound per week). Nurse Emma should focus on educating the teen about healthy eating habits, regular monitoring of weight gain, and the importance of balanced nutrition for both her health and her baby’s.

Think of the weight gain in pregnancy like building a house. You need just the right amount of materials (weight gain) for the house to be strong and safe. If you add too little or too much, it can affect the stability. Similarly, gaining the right amount of weight in pregnancy helps support a healthy baby and mother.

Nurse Emma should provide educational guidance tailored to the teen’s concerns about weight gain and emphasize the importance of a healthy diet during pregnancy. Key points include:

• Educate the patient on the normal weight gain range of 25 to 30 pounds for a healthy pregnancy and explain how this supports both maternal and fetal health.
• Encourage balanced meals with a focus on nutrient-dense foods like fruits, vegetables, whole grains, lean proteins, and dairy.
• Explain that weight gain tends to be slow in the first trimester, with more steady gain in the second and third trimesters, aiming for around 1 pound per week after the first trimester.
• Reassure the teen that healthy weight gain is essential for her baby’s growth and should not be a source of worry if she follows a balanced diet.
• Discuss the importance of regular prenatal visits to monitor weight gain and overall health, addressing any concerns as they arise.

✘Incorrect answer options:

Gaining 10 pounds per trimester. This option would imply a total gain of about 30 pounds, but weight gain is not typically uniform across trimesters. Minimal gain is expected in the first trimester, with more consistent weekly gain in the second and third trimesters.

Gaining 1 pound per week for 40 weeks. Gaining 1 pound per week for 40 weeks would result in a 40-pound gain, which is higher than the recommended range of 25 to 30 pounds for a woman of normal pre-pregnancy weight. A 40-pound gain may be appropriate only for women who are underweight at the start of pregnancy.

Gaining ½ pound per week for 40 weeks. Gaining ½ pound per week for 40 weeks would result in a total of 20 pounds, which is lower than the recommended range. Insufficient weight gain can lead to risks for fetal growth restriction and other complications.

EXPLANATION

✔Correct answer:

Pain. Pain is the priority nursing diagnosis for a patient with an ectopic pregnancy, as this condition typically presents with significant, acute abdominal or pelvic pain. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, often in a fallopian tube. As the pregnancy grows, it can cause intense pain due to the stretching or rupture of the tube, which may lead to internal bleeding and other serious complications. Immediate management of pain is essential, as unmanaged pain can indicate worsening of the condition, including potential rupture, which requires emergency intervention.

While other nursing diagnoses, such as Risk for Infection, Knowledge Deficit, and Anticipatory Grieving, are relevant for the patient with an ectopic pregnancy, Pain takes priority because it is an acute, immediate concern that directly affects the patient’s physical status and can indicate potential complications that need prompt medical attention.

Think of pain as a fire alarm signaling an emergency. In ectopic pregnancy, pain is an alarm indicating possible rupture or worsening of the condition, making it the most immediate concern that requires prompt attention.

Nurse Sarah should focus on assessing and managing the patient’s pain, monitoring for signs of complications, and providing supportive care. Key interventions include:

• Monitor the patient’s pain level frequently and assess for any changes in pain location, intensity, or quality.
• Administer prescribed pain medications as appropriate, while keeping in mind that pain may indicate potential complications requiring further intervention.
• Monitor vital signs closely, as a drop in blood pressure or an increase in heart rate could indicate internal bleeding due to rupture.
• Prepare the patient for possible surgical intervention if rupture occurs, as this may be necessary to stop internal bleeding and prevent further complications.
• Provide emotional support, as an ectopic pregnancy is a distressing diagnosis, and discuss future fertility options with the patient if appropriate.

✘Incorrect answer options:

Risk for infection. Although infection is a concern, especially post-surgically if the ectopic pregnancy requires removal, it is not the primary issue during the acute phase. Pain related to the ectopic pregnancy and the risk of rupture take precedence.

Knowledge Deficit. While education is important, especially regarding ectopic pregnancy and treatment options, it is not an immediate concern in the acute phase. Pain management and monitoring for complications are more pressing.

Anticipatory Grieving. Grieving is relevant because the patient is likely experiencing an emotional loss due to the non-viable pregnancy. However, managing physical pain and preventing rupture are the primary priorities at this stage, with emotional support provided as needed.

EXPLANATION

✔Correct answer:

Condoms. Condoms are the most effective contraception method for reducing the risk of sexually transmitted infections (STIs). Unlike other contraceptive methods that primarily prevent pregnancy, condoms act as a barrier to protect against the transmission of STIs by preventing direct contact with bodily fluids that can carry infections, such as HIV, chlamydia, gonorrhea, and syphilis. Both male and female condoms offer protection, although male latex condoms are the most commonly used and widely recommended for STI prevention.

While condoms are highly effective at reducing STI risk, they are not 100% foolproof, as they may break or be used incorrectly. Nurse Maria should emphasize the correct and consistent use of condoms to maximize protection. Other contraceptive methods, such as diaphragms, spermicides, and permanent methods like vasectomy, do not provide protection against STIs.

Think of condoms like a raincoat. Just as a raincoat shields you from getting wet in the rain, condoms act as a protective barrier to prevent the "rain" of infections from reaching your body. Other contraceptives may prevent pregnancy, but only condoms protect you from infections.

Nurse Maria should provide comprehensive education on the correct use of condoms and the limitations of other contraceptive methods in STI prevention. Key points include:

• Emphasize the correct and consistent use of condoms for effective STI protection.
• Educate on the difference between methods that prevent pregnancy only (such as diaphragms, spermicides, and vasectomy) and those that also reduce STI risk (i.e., condoms).
• Instruct the client to check the expiration date and integrity of condoms before use, as expired or damaged condoms are less effective.
• Advise the client to use water-based lubricants with latex condoms to reduce the risk of breakage; oil-based lubricants can degrade latex and cause tearing.
• Provide resources or referrals for regular STI testing, as this is also important for sexual health.

✘Incorrect answer options:

Spermicides. Spermicides kill sperm to prevent pregnancy but offer no protection against STIs. In fact, frequent use of spermicides containing nonoxynol-9 may irritate the genital mucosa, potentially increasing susceptibility to infections.

Diaphragm. The diaphragm is a barrier method that covers the cervix to prevent sperm from entering the uterus, reducing the risk of pregnancy. However, it does not protect against STIs, as it does not prevent contact with bodily fluids that can carry infections.

Vasectomy. A vasectomy is a permanent form of male sterilization that prevents sperm from being released during ejaculation, making it effective for contraception. However, it does not protect against STIs, as it only impacts sperm transport, not fluid exchange during sexual activity.

EXPLANATION

✔Correct answer:

Bright red discharge in a client 5 days postpartum. Lochia, or postpartum vaginal discharge, typically progresses in stages as the uterus heals after delivery:

• Lochia rubra (dark red) occurs in the first 1-3 days postpartum and is primarily composed of blood, so a dark red discharge is expected during this time.
• Lochia serosa (pink to brownish) occurs from approximately day 4 to day 10 and contains less blood and more serous fluid, as well as tissue debris.
• Lochia alba (creamy or yellowish-white) occurs from about day 10 up to 4-6 weeks postpartum and contains mostly leukocytes and tissue fluid.

Bright red discharge after the initial 3 days postpartum may indicate abnormal bleeding or a possible complication such as secondary postpartum hemorrhage. By day 5, lochia should have transitioned to lochia serosa (pink or brownish in color), so bright red bleeding could suggest retained placental fragments, infection, or delayed healing of the uterine lining. Nurse Emily should notify the physician promptly to ensure appropriate intervention and assessment.

Think of lochia progression like a healing bruise. Initially, it's dark red (like fresh blood), then it fades to pink or brown, and finally, it becomes a light yellow or creamy color. If it suddenly returns to bright red, it's like a new injury, signaling something may be wrong.

Nurse Emily should monitor the client closely for additional signs of complications and provide supportive care as needed. Key interventions include:

• Assess the client for other signs of postpartum hemorrhage, such as increased bleeding, large clots, or signs of anemia (e.g., dizziness, weakness).
• Monitor vital signs for any signs of hemodynamic instability, including low blood pressure and elevated pulse.
• Check the fundus for firmness and positioning, as uterine atony or retained placental tissue can contribute to abnormal bleeding.
• Notify the physician promptly about the finding of bright red lochia on day 5 to facilitate further assessment and possible intervention.
• Provide education to the client on the normal progression of lochia, and advise her to report any return of bright red bleeding, heavy flow, or foul-smelling discharge.

✘Incorrect answer options:

Dark red discharge in a client 2 days postpartum. Dark red lochia (lochia rubra) is expected within the first 1-3 days postpartum, so this finding is normal.

Pink to brownish discharge in a client 5 days postpartum. Pink to brownish lochia (lochia serosa) is typical from days 4 to 10 postpartum, so this is an expected finding.

Almost colorless to creamy discharge in a client 2 weeks postpartum. Almost colorless or creamy discharge (lochia alba) is normal from about day 10 onward, so this finding is also expected.

EXPLANATION

✔Correct answer:

“Using alcohol helps it dry out and prevents infection.” The correct approach for umbilical cord care includes keeping the cord clean, dry, and exposed to air. Using alcohol (70% isopropyl alcohol) to clean around the base of the umbilical cord stump has been a traditional practice to help it dry out and prevent infection. However, practices may vary depending on institutional guidelines, and some recent guidelines advocate for "dry cord care," which involves keeping the cord clean and dry without the use of alcohol. That said, if Nurse Sarah instructed the mother to use alcohol, this statement would indicate that the mother understood the teaching correctly.

Regardless of specific practices, the primary goal is to ensure the cord stump dries out naturally and falls off within 1-2 weeks without infection. Nurse Sarah should reinforce the importance of keeping the area clean and dry, and avoiding unnecessary manipulation or applying other substances unless instructed.

Think of the umbilical cord stump like a small tree branch that needs time to dry out and fall naturally. Alcohol helps to keep it clean and dry, like a gentle breeze drying out a branch in the open air.

Nurse Sarah should educate the mother on proper umbilical cord care to prevent infection and promote natural drying and detachment. Key points include:

• Clean the cord area as directed, using alcohol if instructed, or dry cord care if that is the protocol.
• Keep the cord stump dry by folding the diaper down, allowing the area to be exposed to air.
• Avoid tub baths until the cord stump has fallen off to reduce the risk of infection. Use sponge baths instead.
• Instruct the mother to monitor for signs of infection, such as redness, swelling, foul odor, or discharge, and to contact a healthcare provider if these occur.
• Reassure the mother that the cord should naturally detach within 1-2 weeks and that minimal handling is ideal.

✘Incorrect answer options:

“Cleaning it daily with soap and water is the best method.” Soap and water are not recommended for cleaning the cord stump, as moisture can delay drying and increase the risk of infection. Keeping it dry is essential.

“Applying antibiotic ointment each day keeps it from getting infected.” Routine use of antibiotic ointment is not recommended, as it may delay the drying process. Unless prescribed for specific concerns, ointments should not be applied to the cord.

“It’s okay for him to have a daily tub bath.” Tub baths should be avoided until the cord stump falls off to keep the area dry and prevent infection. Sponge baths are recommended until then.

EXPLANATION

✔Correct answer:

Positioning the crib near the nursery window for family viewing. Positioning the crib near a nursery window is least effective for maintaining a neutral thermal environment. Windows can be a source of cold drafts and radiant heat loss, which can lead to cooling of the infant’s environment and increase the risk of heat loss. Newborns are particularly susceptible to cold stress, which can lead to complications such as hypoglycemia and respiratory distress. To maintain a neutral thermal environment, it’s essential to keep the newborn away from cold or drafty areas, such as windows or exterior walls.

The other actions—using a radiant warmer, lining the scale with a warmed blanket, and covering the newborn’s head with a knit hat—are all effective strategies to prevent heat loss by convection, conduction, and radiation.

Think of a newborn like a small candle flame. A slight draft near a window can easily cool or extinguish the flame. Similarly, positioning a newborn near a window can cause them to lose heat, which is why keeping them away from drafts is essential for temperature stability.

Nurse Ellen should ensure that all efforts are directed toward maintaining a neutral thermal environment for the newborn. Key actions include:

• Position the crib away from windows, doors, and other potential sources of drafts to reduce the risk of heat loss.
• Use a radiant warmer when the newborn is exposed (e.g., during a bath or assessment) to prevent rapid heat loss.
• Place a warmed blanket on surfaces like scales or exam tables to prevent heat loss through conduction.
• Ensure the newborn’s head is covered with a hat, as a significant amount of body heat can be lost through the head.
• Educate family members about the importance of these precautions to help protect the newborn from cold stress.

✘Incorrect answer options:

Placing the infant under a radiant warmer after giving a bath. This is an effective measure to prevent heat loss after a bath. Newborns lose heat quickly when wet, so a radiant warmer helps maintain their body temperature.

Lining the scale with a warmed blanket before weighing the infant. This is also an effective method, as it prevents heat loss by conduction when the newborn’s body comes in contact with a cold surface.

Covering the newborn’s head with a knit hat. Covering the head helps to prevent heat loss by convection and radiation, as the head is a primary area of heat loss in newborns.

EXPLANATION

✔Correct answer:

G4 T1 P1 A1 L2. In obstetrical history, the GTPAL system is used to document a client’s pregnancy history, where:

• G (Gravida): Total number of pregnancies, regardless of outcome.
• T (Term): Number of term deliveries (37 weeks or more).
• P (Preterm): Number of preterm deliveries (20 to 36 weeks).
• A (Abortions): Number of pregnancies ending before 20 weeks, either by miscarriage or elective abortion.
• L (Living): Number of living children.

Based on the client’s reported history:

1. G (Gravida): She has been pregnant 4 times — a term birth, a preterm birth, an early loss at 8 weeks, and her current pregnancy. So, G = 4.
2. T (Term): She has had 1 term delivery (her son born at 38 weeks). So, T = 1.
3. P (Preterm): She has had 1 preterm delivery (her daughter born at 30 weeks). So, P = 1.
4. A (Abortions): She experienced 1 miscarriage at 8 weeks (prior to 20 weeks gestation). So, A = 1.
5. L (Living): She has 2 living children (her son and daughter). So, L = 2.

Therefore, her obstetrical history should be documented as G4 T1 P1 A1 L2.

Nurse Jane should accurately record the client’s obstetrical history, as it guides pregnancy management and helps identify any special care needs. Key considerations include:

• Explain the GTPAL system to the client if needed, ensuring she understands how her pregnancy history is documented.
• Discuss any potential risk factors based on her history of preterm birth and miscarriage.
• Provide education on the importance of regular prenatal care, particularly with a history of preterm birth.
• Document the obstetrical history in the client’s medical record to inform future care and monitoring needs.

✘Incorrect answer options:

G2 T2 P0 A0 L2. This answer incorrectly states that the client has been pregnant twice and had two term deliveries, which does not align with her history.

G3 T1 P1 A0 L2. This answer does not include the miscarriage at 8 weeks, so it incorrectly states A = 0 and G = 3.

G3 T2 P0 A0 L2. This answer incorrectly states that the client has had two term deliveries and no preterm deliveries, which does not reflect her history.

EXPLANATION

✔Correct answer:

Instructions for regular glucose monitoring. Regular glucose monitoring is a critical component in managing gestational diabetes because it helps Sarah understand how her body is responding to different foods, physical activity, and any medications she may need. By monitoring her blood glucose levels consistently, Sarah can identify patterns and adjust her lifestyle accordingly to keep her blood sugar levels within the target range. This daily monitoring allows for immediate feedback, enabling timely adjustments to diet, activity, and possibly medication if necessary.

Proper glucose control is essential in preventing complications for both mother and baby, such as macrosomia (large baby size), preterm birth, and the risk of cesarean delivery. Nurse Amanda should teach Sarah how to use a glucose meter, when and how often to check her blood sugar, and what her target blood glucose levels should be.

Think of glucose monitoring like using a GPS while driving. By regularly checking her blood sugar, Sarah can "navigate" her diet and activity to stay on the right path, adjusting as needed to avoid blood sugar "detours" that could lead to complications.

Nurse Amanda should ensure that Sarah understands how to monitor her blood glucose and provide comprehensive education on other aspects of managing gestational diabetes. Key considerations include:

• Teach Sarah how to properly use a glucose meter, including techniques for obtaining a blood sample and interpreting the readings.
• Discuss the timing of blood glucose checks, typically fasting and 1-2 hours after meals, as directed by her healthcare provider.
• Provide guidance on the target blood glucose levels for gestational diabetes to help Sarah understand when her readings are within the desired range.
• Emphasize the importance of logging her blood glucose readings to share with her healthcare provider for ongoing management.
• In addition to glucose monitoring, offer information on dietary recommendations, exercise, and medication if prescribed, as all contribute to effective glucose control.

✘Incorrect answer options:

Guidance on dietary intake. Although dietary management is an essential aspect of controlling gestational diabetes, it is not the top priority. Sarah must monitor her glucose levels first to assess how her dietary choices affect her blood sugar and make informed adjustments.

Information on prescribed medications. While medication may be necessary if blood sugar levels cannot be controlled through diet and exercise alone, medication is not always required for gestational diabetes. Glucose monitoring will inform whether or not medication adjustments are needed.

Recommendations for safe exercise routines. Exercise is beneficial for managing blood glucose levels, but it should be approached cautiously based on Sarah’s glucose monitoring results. Monitoring her glucose first allows her to determine the most appropriate times to exercise and avoid hypoglycemia or hyperglycemia during physical activity.

EXPLANATION

✔Correct answer:

Promiscuous young adult. An intrauterine device (IUD) may not be recommended for a client who has multiple sexual partners or is at high risk for sexually transmitted infections (STIs), as this can increase the risk of pelvic inflammatory disease (PID). PID is a serious infection that can occur when bacteria enter the upper reproductive tract, potentially causing infertility, chronic pelvic pain, and other complications. The IUD string, which extends through the cervix, may facilitate the ascent of bacteria from the vagina into the uterus, especially in clients with high-risk sexual behaviors.

In such cases, Nurse Amy should discuss other contraceptive options that do not involve devices in the uterus, such as condoms, which also offer STI protection, or hormonal contraceptives if STI prevention is managed separately. IUDs are generally safe for most women, but careful consideration of the client's lifestyle and risk factors is essential for safe contraceptive counseling.

Think of an IUD like a fence protecting a garden, but with an open gate. If there’s a high risk of pests (STIs) getting through, the garden (uterus) is at risk of infection. For those at higher risk of STIs, a more protective barrier (like condoms) might be a better choice to avoid contamination.

Nurse Amy should provide education on alternative contraceptive methods and stress the importance of STI prevention for clients at higher risk. Key considerations include:

• Discuss the increased risk of PID with IUD use for clients with multiple sexual partners or inconsistent STI prevention measures.
• Encourage the use of condoms as a reliable form of protection against STIs, especially for clients at high risk.
• Provide information on other contraceptive options, such as birth control pills, implants, or injectables, which do not increase the risk of upper reproductive tract infections.
• Explain that IUDs are safe for most other clients, including women over age 35, nulliparous women, and postpartum clients, as long as they have low STI risk.
• Educate clients about routine STI testing and safe sexual practices as part of comprehensive reproductive health care.

✘Incorrect answer options:

Woman over age 35. Age alone is not a contraindication for IUD use. In fact, IUDs are often recommended for older women as a safe and effective long-term contraceptive method, especially if they are in monogamous relationships with low STI risk.

Nulliparous woman. Historically, IUDs were sometimes discouraged for nulliparous women (those who have not given birth), but current guidelines support their use. IUDs are considered safe and effective for nulliparous women as long as they have low STI risk.

Postpartum client. IUDs can be safely inserted postpartum, although timing may vary. Some providers prefer to wait a few weeks postpartum to ensure proper placement and reduce infection risk. However, postpartum clients with low STI risk are generally good candidates for IUDs.

EXPLANATION

✔Correct answer:

Ensuring safe and effective care for both mother and newborn. The primary focus of discharge teaching for a new mother being discharged early should be ensuring safe and effective care for both the mother and newborn. Early discharge means that Maria will need to be prepared to manage both her own recovery and her newborn’s basic needs at home. This includes understanding signs of potential complications for herself (e.g., excessive bleeding, signs of infection) and her baby (e.g., feeding difficulties, jaundice, signs of dehydration). Nurse Carla should provide clear instructions on essential topics such as newborn care (e.g., feeding, diapering, and bathing), maternal self-care, signs of postpartum complications, and when to seek medical assistance.

While supporting comfort, assessing emotional well-being, and discussing family planning are all important aspects of postpartum care, safe and effective care for mother and newborn takes priority, especially when discharge is occurring earlier than usual. Safety and health are the foundation upon which all other aspects of postpartum recovery and adjustment are built.

Think of the discharge process like a pilot preparing a plane for takeoff. Before considering passenger comfort or in-flight services, the pilot’s top priority is ensuring that all essential safety protocols are in place. Similarly, Nurse Carla’s primary focus should be on ensuring Maria’s and her baby’s safety and well-being at home.

Nurse Carla should prioritize essential information that supports Maria’s and her newborn’s safety at home. Key considerations include:

• Educate on recognizing signs of postpartum complications in the mother, such as heavy bleeding, severe pain, or fever.
• Provide instructions on newborn care, including safe feeding practices, diapering, and recognizing signs of newborn distress (e.g., poor feeding, jaundice).
• Discuss the importance of follow-up appointments for both mother and newborn and ensure Maria understands the timing and purpose of these visits.
• Emphasize hand hygiene and other infection prevention practices to protect both mother and baby.
• Encourage Maria to ask questions and clarify any concerns she may have about managing her care and the newborn’s care at home.

✘Incorrect answer options:

Supporting comfort and recovery for the mother. Although comfort and recovery are important, they are not the primary focus in early discharge education. The priority is safety and effective care for both mother and newborn, which includes understanding potential complications.

Assessing the emotional well-being of the family. Assessing emotional well-being is valuable, particularly for identifying risk factors for postpartum depression. However, the immediate priority is ensuring that Maria understands the basics of safe and effective care for herself and her baby at home.

Providing guidance on the significance of family planning. Family planning is important in postpartum care but is not an immediate focus for early discharge teaching. Safe care and understanding when to seek help take precedence in discharge education.

EXPLANATION

✔Correct answer:

Increased fiber intake. Constipation is a common complaint during pregnancy, especially in the third trimester, due to factors like hormonal changes, reduced physical activity, and the pressure of the growing uterus on the intestines. Increasing dietary fiber intake is one of the safest and most effective ways to alleviate constipation in pregnant women. Fiber adds bulk to the stool, which can help stimulate bowel movements and make stools easier to pass. Foods rich in fiber include fruits, vegetables, whole grains, and legumes.

In addition to increasing fiber intake, Nurse Sarah should advise the client to drink plenty of water to help soften stools and aid digestion. Regular, gentle physical activity, such as walking, can also promote bowel regularity.

Think of fiber like a sponge in the digestive system. Just as a sponge soaks up water to expand, fiber absorbs fluid, adding bulk to the stool and making it easier to pass through the intestines.

Nurse Sarah should provide additional guidance on managing constipation naturally and safely during pregnancy. Key recommendations include:

• Encourage the client to increase fiber intake through natural sources like fruits, vegetables, and whole grains.
• Advise the client to drink plenty of water (at least 8-10 glasses per day) to help fiber work effectively and soften stools.
• Suggest gentle physical activity, such as walking, to stimulate bowel function and promote regularity.
• Educate the client to avoid using laxatives or enemas without medical guidance, as these can lead to dehydration or electrolyte imbalances.
• Reassure the client that constipation is a common experience in pregnancy and can often be managed with dietary and lifestyle changes.

✘Incorrect answer options:

Daily enemas. Enemas are not recommended for routine management of constipation in pregnancy, as they can irritate the intestines, cause dehydration, and potentially stimulate uterine contractions. They should only be used under medical supervision.

Laxatives. While some mild laxatives may be safe during pregnancy, they should generally be avoided unless recommended by a healthcare provider. Overuse of laxatives can lead to dehydration, electrolyte imbalances, and dependency.

Decreased fluid intake. Decreasing fluid intake would likely worsen constipation, as adequate hydration is essential for softening stool and promoting regular bowel movements. Pregnant women should be encouraged to increase, not decrease, their fluid intake to help relieve constipation.

EXPLANATION

✔Correct answer:

Administer supplemental oxygen and notify the pediatrician. The findings noted by Nurse Kim—rapid respirations (78 breaths per minute), an elevated heart rate (160 BPM), flaring nostrils, mild intercostal retractions, and grunting at the end of expiration—are classic signs of respiratory distress in a newborn. These symptoms suggest that the newborn is struggling to breathe and may not be receiving adequate oxygen. Grunting, in particular, is an indication that the newborn is attempting to keep the alveoli open by creating positive end-expiratory pressure. This can be a sign of respiratory distress syndrome or transient tachypnea of the newborn, both of which require prompt intervention.

Nurse Kim should take immediate action by administering supplemental oxygen to help increase the newborn’s oxygen saturation and notifying the pediatrician for further evaluation and management. Early intervention is crucial in newborns with respiratory distress, as their condition can deteriorate rapidly if left untreated.

Think of the newborn’s respiratory system like a small engine that’s struggling to run smoothly. Just as you’d give immediate support to avoid further strain on the engine, providing oxygen can help the newborn’s respiratory system function more effectively until further assessment is done.

Nurse Kim should take the following steps to ensure that the newborn receives appropriate care for respiratory distress:

• Administer supplemental oxygen as per protocol to support adequate oxygenation.
• Notify the pediatrician or neonatal care team immediately so they can assess the newborn and determine the need for additional interventions.
• Monitor the newborn’s respiratory rate, heart rate, and oxygen saturation continuously to detect any changes in condition.
• Ensure the newborn is kept warm, as cold stress can exacerbate respiratory distress in newborns.
• Educate the parents about the situation and reassure them that the medical team is providing the necessary support for their baby.

✘Incorrect answer options:

Document the findings as normal for a newborn. These findings are not normal for a newborn. Normal respiratory rates for a newborn are between 30-60 breaths per minute, and signs such as nasal flaring, retractions, and grunting indicate respiratory distress that requires intervention.

Perform gentle suctioning to clear the airway. Although suctioning is sometimes necessary to clear amniotic fluid or mucus, the symptoms here suggest a problem with oxygenation and respiratory effort, not an airway blockage. Suctioning alone would not alleviate the respiratory distress.

Swaddle the newborn to reduce respiratory rate. Swaddling would not address the underlying respiratory distress. The newborn’s rapid respiratory rate and signs of distress require oxygen support and further evaluation by a healthcare provider, not swaddling.

EXPLANATION

✔Correct answer:

Combined oral contraceptives. Combined oral contraceptives contain both estrogen and progestin and are generally avoided in the immediate postpartum period, especially within the first 3 to 6 weeks. The presence of estrogen in these contraceptives increases the risk of thromboembolism (blood clots), which is a heightened concern after childbirth due to the natural increase in blood clotting factors postpartum. This risk is particularly significant for women who are not fully mobile or who have additional risk factors for clotting. Additionally, for breastfeeding mothers, estrogen can potentially reduce milk supply, which makes combined oral contraceptives less ideal during the early postpartum period.

In contrast, progestin-only contraceptives (such as the "mini-pill") and non-hormonal options, such as condoms, are safer choices for immediate postpartum use. An intrauterine device (IUD) may also be appropriate postpartum, though some providers may recommend waiting a few weeks to ensure proper placement and reduce infection risk.

Think of estrogen in combined contraceptives like a heavy coat during a time when your body is already warm after childbirth. It adds unnecessary strain, increasing the risk of clotting. The body needs time to cool down and return to a lower clotting risk before it can safely handle the "extra layer" of estrogen.

Nurse Laura should provide information on safe contraceptive options during the postpartum period and explain why combined oral contraceptives should be delayed. Key points include:

• Educate the patient on the increased risk of blood clots with estrogen-containing contraceptives in the immediate postpartum period.
• Inform breastfeeding mothers that estrogen can decrease milk supply, making progestin-only methods or non-hormonal options preferable if contraception is desired early on.
• Discuss safe contraceptive alternatives, such as progestin-only pills, condoms, and possibly IUDs (as advised by the healthcare provider).
• Encourage a follow-up appointment at the 6-week postpartum visit to reassess contraceptive needs and options.
• Provide resources on family planning, and discuss the importance of consistent and reliable contraception to prevent unintended pregnancies.

✘Incorrect answer options:

Progestin-only pills. Progestin-only pills are generally considered safe for postpartum use and do not carry the same risk of blood clots as combined oral contraceptives. They are also suitable for breastfeeding mothers, as they do not affect milk supply.

Condoms. Condoms are a non-hormonal, barrier method of contraception, making them safe for use immediately postpartum without any impact on clotting risk or breastfeeding.

Intrauterine device (IUD). An IUD can be used postpartum, although some providers prefer to wait a few weeks before insertion to reduce the risk of infection and ensure proper placement. IUDs are safe and effective long-term options that do not interfere with breastfeeding.

EXPLANATION

✔Correct answer:

A Doppler device placed at the midline in the suprapubic region. At 12 weeks of pregnancy, the fetus is still relatively low in the pelvis, making the suprapubic region the most appropriate location to detect the fetal heart rate. A Doppler device is the best tool for this stage of pregnancy, as it uses ultrasound technology to detect the fetal heartbeat. Typically, the fetal heart rate becomes detectable by Doppler around 10 to 12 weeks gestation. The Doppler allows the nurse to pick up the fetal heartbeat earlier than a stethoscope or fetoscope, which generally cannot detect the fetal heart rate until later in the pregnancy (usually around 18 to 20 weeks).

Positioning the Doppler at the midline in the suprapubic area increases the chances of picking up the fetal heartbeat, as the uterus at 12 weeks is still located relatively low, just above the pubic symphysis.

Think of the fetus as a small radio playing a song from inside a box located low in the abdomen. Using the Doppler near the suprapubic area is like putting a microphone close to the box to better pick up the sound of the heartbeat.

Nurse Kelly should take the following actions to optimize the fetal heart rate assessment at this stage of pregnancy:

• Position the Doppler device at the midline in the suprapubic area to maximize the chance of detecting the fetal heartbeat.
• Explain to the patient that it may take a few moments to locate the fetal heartbeat at this early stage, as the fetus is still small.
• Reassure the patient that a Doppler device is effective for early fetal heart rate detection, usually from 10 to 12 weeks of pregnancy.
• Document the fetal heart rate and the location where it was detected, as well as any difficulties encountered during the assessment.
• If the fetal heart rate is not detectable, advise the patient that this can occasionally happen at 12 weeks and offer a follow-up appointment for reassurance if necessary.

✘Incorrect answer options:

A stethoscope positioned at the midline of the umbilicus. A regular stethoscope is not sensitive enough to detect the fetal heart rate at 12 weeks. Additionally, at this stage, the fetal heart would be located lower in the pelvis, near the suprapubic area, not at the umbilicus.

A fetoscope positioned midway between the umbilicus and the xiphoid process. A fetoscope is generally used to detect the fetal heart rate later in pregnancy, usually around 18 to 20 weeks or later. Also, at 12 weeks, the fetal heart would be located lower, closer to the suprapubic area, rather than higher up between the umbilicus and xiphoid process.

An external electronic fetal monitor set at the umbilicus. External electronic fetal monitors are typically used in the third trimester during labor to continuously monitor the fetal heart rate. At 12 weeks, the fetal heart rate would not be detectable in the umbilical area but rather lower down, in the suprapubic region.

EXPLANATION

✔Correct answer:

Observing for edema in the hands and face. A sudden or excessive weight gain, such as 6 pounds in 4 weeks, can be an indicator of fluid retention rather than an increase in body fat, which could be a warning sign of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure, protein in the urine, and signs of organ damage. It often presents with edema in the hands and face, which is different from the mild swelling that might occur in the legs and feet during pregnancy. Edema in these areas, especially when accompanied by excessive weight gain, is a potential red flag for preeclampsia, which can have serious implications for both mother and baby if left untreated.

Nurse Elena should prioritize checking for edema in the patient’s hands and face, as identifying this sign early can lead to timely intervention and management of preeclampsia if it is present. Following this assessment, she may also need to monitor the patient’s blood pressure and check for proteinuria as part of a comprehensive assessment for preeclampsia.

Think of preeclampsia as a warning light on a car's dashboard. If there is sudden weight gain and edema, it’s like the light blinking, signaling that something needs immediate attention to prevent potential complications.

Nurse Elena should proceed with a thorough assessment for preeclampsia signs and provide the patient with information on what to monitor. Key considerations include:

• Check for edema in the hands and face, as well as generalized swelling, which may indicate fluid retention associated with preeclampsia.
• Monitor the patient’s blood pressure, as hypertension is a hallmark of preeclampsia.
• Request a urine sample to check for proteinuria, another key indicator of preeclampsia.
• Educate the patient on symptoms of preeclampsia, including severe headaches, visual disturbances, and abdominal pain, and advise her to report these symptoms immediately if they occur.
• Document the findings and inform the healthcare provider of any abnormal results to facilitate timely intervention if needed.

✘Incorrect answer options:

Checking for glucosuria. While glucosuria (glucose in the urine) is relevant for screening for gestational diabetes, it is not a priority in response to sudden weight gain. Excessive weight gain alone does not indicate diabetes, and the primary concern with sudden weight gain at this stage is preeclampsia.

Screening for signs of depression. While assessing mental health is important, it is not the immediate priority for sudden weight gain. Nurse Elena should focus on physical signs that may indicate preeclampsia, which poses an acute risk if present.

Reviewing recent dietary intake. Although reviewing dietary habits can provide insight into weight gain, a sudden increase in weight due to diet is less likely than fluid retention at 24 weeks. The immediate concern is to assess for signs of preeclampsia, such as edema.

EXPLANATION

✔Correct answer:

October 21. To calculate the estimated due date (EDD) using Naegele’s rule, Nurse Jane should take the first day of the client’s last menstrual period (LMP), add 7 days, and then subtract 3 months. This rule is a standard method used to estimate the due date for a pregnancy based on a regular 28-day menstrual cycle.

The client’s last menstrual period (LMP) began on January 14.

1. Add 7 days to January 14, which results in January 21.
2. Subtract 3 months from January, which brings us to October.

Therefore, the EDD is October 21.

Think of calculating the due date like adjusting the calendar. You start from the LMP, add a week to move forward, and then step back three months to pinpoint the due date.

Nurse Jane should confirm that the client has a regular menstrual cycle, as Naegele’s rule is most accurate for clients with regular 28-day cycles. Key considerations include:

• Explain to the client how the due date is estimated and that this is an approximation.
• Inform the client that the due date might be adjusted based on early ultrasound findings, which can provide a more accurate EDD.
• Encourage the client to attend regular prenatal visits to monitor her progress and adjust care as needed.
• Provide educational resources on pregnancy milestones to help the client understand her pregnancy journey.
• Reassure the client that labor may occur within a range of about two weeks before or after the EDD.

✘Incorrect answer options:

September 27. This date does not follow Naegele’s rule for calculating an EDD based on the provided LMP.

November 7. This date is too late according to Naegele’s rule; it does not correctly apply the “add 7 days, subtract 3 months” calculation.

December 27. This date is also incorrect and is too far from the expected due date using Naegele’s rule.

EXPLANATION

✔Correct answer:

To keep hormone levels steady. The primary reason Nurse Amanda instructs the client to take oral contraceptives at the same time each day is to keep hormone levels steady. Oral contraceptives contain hormones (estrogen and/or progestin) that work by suppressing ovulation, thickening cervical mucus, and altering the uterine lining to prevent pregnancy. Maintaining a consistent level of these hormones in the bloodstream is essential for the pill's effectiveness. Taking the pill at the same time each day helps prevent fluctuations in hormone levels, reducing the risk of ovulation and potential contraceptive failure.

Inconsistent timing, especially with progestin-only pills (often called the "mini-pill"), can lead to decreased efficacy, as even a slight delay in taking these pills can increase the chances of ovulation. With combination pills (estrogen and progestin), a small delay is less critical but still recommended for optimal effectiveness.

Think of taking the pill like watering a plant every day. If you skip a day or change the time, the plant might not get the consistent hydration it needs to stay healthy. Similarly, taking the pill at the same time each day provides a steady dose of hormones, keeping its effectiveness at preventing pregnancy.

Nurse Amanda should educate the patient on the importance of adherence to daily timing and discuss strategies to ensure consistency. Key points include:

• Advise the patient to set a daily reminder or alarm to take the pill at the same time each day.
• Educate the patient about the importance of timing, especially if they are using a progestin-only pill, which has a stricter timing requirement.
• Discuss what to do if a dose is missed, including when to use backup contraception if needed.
• Encourage the patient to keep an extra pack of pills on hand and to carry their pill pack if traveling.
• Review potential side effects and reassure the patient that consistent timing can help maintain steady hormone levels, which may reduce certain side effects.

✘Incorrect answer options:

To reduce the chances of experiencing nausea. Although taking the pill with food or at bedtime may help reduce nausea, timing consistency is primarily to maintain hormone levels, not specifically to prevent nausea.

To minimize potential side effects. Consistent timing may help in maintaining steady hormone levels, which could influence side effects. However, minimizing side effects is not the primary reason for taking the pill at the same time each day; the primary reason is to ensure effectiveness by maintaining stable hormone levels.

To avoid interactions with other medications. Timing the pill does not prevent interactions with other medications. Patients should be aware of potential interactions, but the time of day the pill is taken does not change its interaction with other drugs.

EXPLANATION

✔Correct answer:

A possible fractured clavicle. An asymmetrical Moro reflex (also known as the startle reflex) in a newborn can indicate an injury or condition affecting one side of the upper body, such as a fractured clavicle. During the Moro reflex, a healthy newborn will typically extend and abduct both arms symmetrically. If there is asymmetry in the response—where only one arm moves while the other remains still—it may suggest an injury to the affected side, most commonly a fractured clavicle. Fractured clavicles can occur during a difficult delivery, especially in larger babies or after shoulder dystocia, and may lead to restricted movement on the injured side.

Nurse Dana should assess for other signs of a fractured clavicle, such as tenderness, swelling, or crepitus along the clavicle, as well as decreased movement of the affected arm.

Imagine a baby extending both arms in a startle reaction. If one arm responds and the other doesn’t, it’s like clapping with one hand—there’s an imbalance. This can indicate an injury, like a broken clavicle, which prevents full movement on one side.

Nurse Dana should perform a thorough assessment of the newborn’s upper body and provide appropriate interventions. Key steps include:

• Gently palpate the clavicles for any swelling, tenderness, or crepitus, which could indicate a fracture.
• Assess for restricted or painful movement in the affected arm and shoulder area.
• Inform the healthcare provider of the findings, as further evaluation or imaging may be needed to confirm the diagnosis.
• Educate the parents on gentle handling techniques to avoid putting pressure on the newborn’s shoulder area until healing occurs.
• Provide reassurance to the parents, explaining that fractured clavicles generally heal well in newborns with minimal long-term impact.

✘Incorrect answer options:

Clubfoot (talipes equinovarus). Clubfoot affects the foot and ankle, not the upper body or arm movement. It would not impact the Moro reflex, so it is not related to an asymmetrical Moro response.

Signs of congenital hypothyroidism. Congenital hypothyroidism can lead to general lethargy, poor muscle tone, and delayed reflexes, but it does not specifically cause an asymmetrical Moro reflex. This option is unrelated to the observed asymmetry in the Moro reflex.

Indicators of increased intracranial pressure. Increased intracranial pressure may cause changes in the newborn’s neurological status, such as altered level of consciousness or bulging fontanelles, but it does not typically cause an asymmetrical Moro reflex.

EXPLANATION

✔Correct answer:

Check the amount of lochia present. The patient’s vital signs indicate hypotension (BP 90/60), elevated pulse (100, weak and thready), and a mild fever (100.4ºF). These signs, especially the low blood pressure and elevated, weak pulse, suggest the possibility of postpartum hemorrhage, a common but serious complication in the immediate postpartum period. Lochia, or postpartum vaginal discharge, is an important indicator of bleeding status. Assessing the amount and characteristics of lochia can provide immediate insight into whether the patient is experiencing excessive bleeding, which may be contributing to her low blood pressure and elevated heart rate.

Checking for excessive lochia (e.g., heavy flow, large clots) will help Nurse Dana determine if there is active bleeding that requires urgent intervention, such as uterine massage or medical management to control hemorrhage. This assessment should be prioritized over the elevated temperature, rechecking blood pressure, or assessing the uterus, as active bleeding is the most immediate and life-threatening concern.

Imagine you see a puddle forming near a leaking pipe. Before checking the temperature of the room or the pressure in the pipe, you’d first inspect the leak itself to see how severe it is. In this case, the lochia is like the “leak,” and assessing it gives the most immediate clue about active bleeding.

Nurse Dana should act quickly to assess for signs of postpartum hemorrhage and address any findings. Key steps include:

• Check the amount and characteristics of lochia to determine if there is excessive bleeding. Note color, consistency, and presence of clots.
• If lochia is heavy or excessive, perform a fundal assessment to evaluate uterine firmness and position, as a boggy or displaced uterus may indicate uterine atony (a common cause of postpartum hemorrhage).
• Prepare to administer uterotonic medications (e.g., oxytocin) if ordered, to promote uterine contractions and control bleeding.
• Monitor the patient’s vital signs closely for any worsening signs of shock, such as further drops in blood pressure or increased pulse rate.
• Notify the healthcare provider promptly if hemorrhage is suspected, as rapid intervention is critical for patient safety.

✘Incorrect answer options:

Report the elevated temperature to the physician. While the temperature is mildly elevated, a temperature of 100.4°F within the first 24 hours postpartum is not unusual and may be due to exertion or dehydration. The priority is to address the signs of potential hemorrhage, given the low blood pressure and elevated pulse.

Recheck the blood pressure using a different cuff. While verifying blood pressure can be helpful, the priority is to assess for active bleeding, which could explain the low blood pressure. Addressing potential hemorrhage is more urgent than verifying BP accuracy in this scenario.

Assess the uterus for firmness and position. Although assessing the uterus is important, it is secondary to checking the lochia, as excessive lochia will provide the most immediate indication of active bleeding. If lochia is excessive, Nurse Dana should then assess the uterus for atony or displacement.

EXPLANATION

✔Correct answer:

Assist her to empty her bladder. Before assessing the uterus of a postpartum patient, it is important for Nurse Julia to assist the patient in emptying her bladder. A full bladder can displace the uterus, often pushing it up and to the side. This can lead to inaccurate assessment findings and may affect uterine tone, potentially contributing to inadequate contraction of the uterus (uterine atony) and increasing the risk of postpartum hemorrhage. By ensuring the bladder is empty, Nurse Julia can get a more accurate assessment of the uterine position and firmness, as it should be located at or slightly below the umbilicus and midline if it is properly contracted.

Imagine trying to check the position of a balloon inside a box while a small water balloon sits beside it. The water balloon (full bladder) would shift the main balloon (uterus), making it harder to assess its true position. Emptying the bladder removes this interference.

Nurse Julia should provide clear guidance to the patient on the importance of emptying her bladder before the uterine assessment. Key interventions include:

• Explain to the patient that emptying her bladder will allow for a more accurate assessment of the uterus’s position and firmness.
• Assist the patient to the bathroom or provide a bedpan if she is unable to ambulate safely on her own.
• After the patient empties her bladder, position her comfortably in a supine position to perform the uterine assessment.
• Gently palpate the uterus to assess its firmness, height relative to the umbilicus, and position in relation to the midline.
• Document findings and monitor for any signs of uterine atony or displacement that may indicate a need for further interventions.

✘Incorrect answer options:

Check the patient’s vital signs. Although checking vital signs is important, it is not necessary immediately before assessing the uterus for firmness and position. Ensuring an empty bladder takes precedence to obtain an accurate uterine assessment.

Administer pain medication. Pain management is essential, but administering pain medication is not required before assessing uterine firmness and position. Palpating the uterus may cause mild discomfort, but it is generally tolerable for most patients.

Walk with her in the hallway. While ambulation is encouraged for postpartum recovery, walking with the patient is not necessary before assessing uterine firmness and position. Ensuring an empty bladder is more relevant to an accurate assessment.