Chapter 26: Nursing Care of a Family with a High-Risk Newborn
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Course
Nursing Care of a Family with a High-Risk Newborn
Institution
Nursing Care Of A Family With A High-Risk Newborn
The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?
a. 20th
b. 9th
c. 5th
d. 95th
a. 20th
Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.
What ...
CHAPTER 25: NURSING CARE OF A FAMILY EXPERIENCING A POSTPARTUM COMPLICATION
A nurse is caring for a postpartum client with urinary tract infection. Which instruction would the nurse include in the teaching plan for the client to help prevent future infections?
a. "Empty your bladder frequently."
b. "Wear your elastic compression stockings."
c. "Avoid foods that are salty."
d. "Apply ice to the infected area." - correct answer a. "Empty your bladder frequently."
The nurse should instruct the client to empty her bladder frequently to prevent urinary stasis. In addition, the nurse would instruct the client to practice good perineal hygiene, and wipe from meatus to rectum to prevent bacterial contamination. Elastic compression stockings are helpful in preventing venous stasis, which is associated with venous thrombosis. Avoiding foods that are salty
have no effect on urinary tract infections. Applying ice packs to the infected area would be appropriate for a client with mastitis.
The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue?
a. Ibuprofen
b. Oxytocin
c. Penicillin
d. Digoxin - correct answer b. Oxytocin Oxytocin is the drug used first for uterine atony. Other medications which may be ordered include ergonovine, methylergonovine, carboprost, and misoprostol. Ibuprofen, penicillin, or digoxin would have no effect on uterine atony.
The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective?
a. "If the drainage changes from clear to bright red, I am to call the doctor."
b. "I will have large amount of vaginal drainage for at least several months."
c. "An elevated temperature is normal during the first few weeks after delivery."
d. "My drainage will fluctuate between bright red and dark red for several weeks." - correct answer a. "If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the client is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. The client will not have large amounts of drainage for several months. An elevated temperature indicates an infection. The drainage should not fluctuate between bright and dark red and could indicate retained placental fragments.
A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract?
a. history of hypertension
b. birth of a large newborn
c. excessive traction on umbilical cord
d. development of endometritis - correct answer b. birth of a large newborn
The nurse knows that lacerations of the genital tract may occur with the birth of a large infant. Other risk factors for lacerations include forceps or vacuum birth, precipitous second stage, and rapid expulsion. Scarring from prior gynecologic or birth events and vulvar, perineal, or vaginal varicosities increase the incidence of lacerations. When the client experiences excessive traction on the umbilical cord coupled with rapid expulsion of the uterine contents, it leads to uterine inversion and not lacerations of the genital tract. Endometritis is the primary cause of postpartum infections; it is not known to lead to lacerations of the genital tract.
Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?
a. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.
b. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart.
c. She says she is extremely thirsty.
d. Her perineum is obviously edematous on inspection. - correct answer a. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.
Postpartum women who void in small amounts may be experiencing bladder overflow from retention.
A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?
a. Bend her knee, and palpate her calf for pain.
b. Ask her to raise her foot and draw a circle.
c. Blanch a toe, and count the seconds it takes to color again.
d. Assess for pedal edema. - correct answer d. Assess for pedal edema.
Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.
The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client? a. weak and rapid pulse
b. warm and flushed skin
c. elevated blood pressure
d. decreased respiratory rate - correct answer a. weak and rapid pulse
If the loss of blood is extremely copious, a woman will quickly begin to exhibit symptoms of hypovolemic shock such as a weak and rapid pulse. The skin will be
pale and clammy, and the blood pressure will fall. Respiratory rate will be increased and shallow.
When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection?
a. in the milk ducts
b. in the reproductive tract
c. in the urinary bladder
d. within the blood stream - correct answer b. in the reproductive tract
The most common site for a postpartum infection is the reproductive tract. This is
important for teaching and education of clients.
A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?
a. Assess vital signs.
b. Assess the fundus.
c. Notify the health care provider.
d. Begin an IV infusion of Ringer's lactate solution. - correct answer b. Assess the
fundus.
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