The nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor has this
... [Show More] client reached?
First
Latent
Second
Transitional - ✔✔ First
Rationale
The first stage of labor lasts from the onset of contractions until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. There is no latent stage of labor. The second stage of labor lasts from complete dilation to birth. There is no transitional stage of labor; transition is the last phase of the first stage of labor.
When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings?
The neonate has bleeding in the subgaleal layer from labor.
The neonate's cranial nerve V was pressurized during labor.
The neonate's cranial nerve VII was pressurized during labor.
The neonate was exposed to vaginal gonorrheal infection during labor. - ✔✔ The neonate's cranial nerve VII was pressurized during labor
Rationale
Inability to close the eyes completely, drooping of the corner of mouth, and absence of wrinkling of the forehead and nasolabial fold indicate facial paralysis. When the facial nerve, or cranial nerve VII, is pressurized during labor, it can result in facial paralysis. Bleeding in the subgaleal layer indicates subgaleal hemorrhage in a neonate. Subgaleal hemorrhage is not characterized by inability to close the eyes, drooping of the corner of mouth, or absence of wrinkling of the forehead and nasolabial fold. Cranial nerve V does not innervate the face, so damage to cranial V does not result in facial paralysis. A neonate who is exposed to vaginal gonorrheal infections during labor may develop ophthalmia neonatorum, not facial paralysis.
The nurse is assessing a 12-hour-old newborn. Which clinical finding should be reported to the health care provider in a timely manner?
Jaundice
Cephalhematoma
Erythema toxicum
Edematous genitalia - ✔✔ Jaundice
Rationale
Jaundice occurring in the first 24 hours of life is pathological; it is associated with Rh or another blood incompatibility. Cephalhematoma is a collection of blood between the skull and periosteum that does not cross the suture line; it resolves within 6 weeks, and although it should be documented it does not require treatment. Erythema toxicum is newborn dermatitis, believed to be an inflammatory response. The rash is harmless, and although it should be documented it does not require treatment. Edematous genitalia, a response to maternal hormones, are common in newborns.
The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping due to afterbirth pains?
Multipara who has vaginally delivered three children
Primipara whose newborn weighed 7 lb
Multipara with effectively controlled diabetes
Multipara whose second child was small for gestational age - ✔✔ Multipara who has vaginally delivered three children
Rationale
A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.
The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues?
Frantic energy
Mild irritability
Hallucinations
Unwillingness to sleep - ✔✔ Mild irritability
Rationale
Postpartum blues are transient symptoms that a client may experience after childbirth. About 85% of women experience postpartum blues with symptoms of mild irritability, tearfulness, rapid mood fluctuations, and anxiety. About 0.1% to 0.2% of postpartum women experience postpartum psychosis. Frantic energy, hallucinations, and unwillingness to sleep are clinical manifestations of postpartum psychosis. [Show Less]