Parents can facilitate the adjustment of their other children to a new baby by:
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Solution
Having the children choose or make a gift to give to the new baby upon its arrival home.
Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:
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Solution
Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.
Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.
When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:
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Solution
Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn.
One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in option C. This stage lasts for as long as 4 to 5 weeks after birth.
Options A and B are characteristic of the taking-in stage, which lasts for the first few days after birth.
Option D reflects the letting-go stage, which indicates that psychosocial recovery is complete.
Which measure would be least effective in preventing postpartum hemorrhage?
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Solution
Massage the fundus every hour for the first 24 hours following birth.
The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.
Options A, B, and D are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.
Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:
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Solution
Uses the peri bottle to rinse upward into her vagina.
The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.
The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be:
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Solution
Hypotension.
Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.
Option A: Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would be with a low spinal (saddle block) anesthesia;
Option B is an effect of epidural anesthesia but is not the most harmful.
Option C: Respiratory depression is a potentially serious complication.
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action would be to:
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Solution
Stop the Pitocin.
Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin which stimulates the uterus to contract.
Option A: The woman is already in an appropriate position for uteroplacental perfusion.
Option C: Elevation of her legs would be appropriate if hypotension were present.
Option D: Oxygen is appropriate but not the immediate action.
Which of the following findings meets the criteria of a reassuring FHR pattern?
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Solution
Variability averages between 6 – 10 BPM.
Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.
Option A: FHR should accelerate with fetal movement.
Option B: Baseline range for the FHR is 120 to 160 beats per minute.
Option C: Late deceleration patterns are never reassuring, though early and mild variable decelerations are expected, reassuring findings.
Upon completion of a vaginal examination on a laboring woman, the nurse records 50%, 6 cm, -1. Which of the following is a correct interpretation of the data?
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Solution
Fetal presenting part is 1 cm above the ischial spines.
Station of – 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged.
Options B and C: Progress of effacement is referred to by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10 cm indicating full dilation.
Option D: Passage through the ischial spines with internal rotation would be indicated by a plus station, such as + 1.
A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms?
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Solution
Uterine rupture.
Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. With placental abruption, the client typically complains of vaginal bleeding and constant abdominal pain.