Free Nclex Review Questions 10

Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus should be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.

During the first 24 hours after delivery, the mother's temperature may increase to 100° F (38° C) as a result of the dehydrating effects of labor. Therefore the initial nursing action is to encourage fluid intake. The nurse would document the temperature, but this is not the initial action.

The fetus is at risk in this situation. The greatest danger of a prolapsed cord is fetal cord compression, which will be indicated by changes in the fetal monitor pattern. Fetal heart rate and variability are the primary measures to determine fetal well-being and are thus the most vital indicators of the effectiveness of interventions. If interventions are ineffective, the fetal heart monitor will show a pattern of increasing early decelerations and a decreasing baseline as the situation deteriorates

Signs of hypothermia include a decrease in skin temperature; increased activity; pallor or mottling; cool skin, hands, and feet; and a flexed position. The newborn attempts to maintain temperature by vasoconstriction, increased muscle activity, metabolizing brown fat, and increased metabolism. A flexed position decreases body surface through which heat can be lost.

Jaundice is a complication of the term SGA infant and occurs as a result of an increased hematocrit. Jaundice in the 4-day-old infant should be reported to the physician, because determination of the bilirubin level and treatment for the jaundice may be appropriate. Four-day-old SGA infants should be fed at least every 3 hours because they require more calories per kilogram because of increased metabolic activity and oxygen consumption. The newborn should be fed small feedings of high-calorie formula because of decreased stomach capacity. Feedings should be done even through the night. Newborns usually wet at least six to eight diapers per day. Urine output less than normal indicates dehydration.

The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.

The mother needs to be taught to feed the newborn soon after delivery, and often, as a prophylactic measure to decrease the possibility of hypoglycemia. Newborns of diabetic mothers may become hypoglycemic within 15 minutes of delivery, as exhibited by lethargy and poor feeding in the first hour after delivery. Hypoglycemia is a result of hyperinsulinism and loss of maternal glucose. Cold stress increases the metabolism of glucose. Jitteriness is one of the classic symptoms of hypoglycemia. A risk of a newborn of a diabetic mother is immature lungs.

Use of condoms is a primary method to prevent sexually transmitted diseases (STDs).

An increase in calories is needed with pregnancy, but concentrated sugars should be avoided because they may cause hyperglycemia. The fat intake should remain at 30% of the total calories. The fetus of a diabetic mother is prone to macrosomia. The diabetic client needs about 40% to 50% of the diet from carbohydrates and about 20% to 25% of the diet from protein. High-fiber foods will cause blood glucose levels to increase more slowly by delaying gastrointestinal absorption.

When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.

Signs of a fetal or maternal compromise include a persistent nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate a fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.