Understanding True vs
. False Labor: Key Signs for Nurses
School
University of Maryland**We aren't endorsed by this school
Course
BIOL 103
Subject
Nursing
Date
Dec 11, 2024
Pages
298
Uploaded by LieutenantLark3558
Scheduled maintenance: July 2, 2024 from 05:00 PM to 07:00 PMfmlTerms in this set (783)1. A woman in her 40th week ofpregnancy calls the nurse at theclinic and says she is not surewhether she is in true or false labor.Which statement by the client wouldlead the nurse to suspect that thewoman is experiencing false labor?A. "I'm feeling contractions mostly inmy back."B. "My contractions are about 6minutes apart and regular."C. "The contractions slow downwhen I walk around."D. "If I try to talk to my partnerduring a contraction, I can't."CRationale: False labor is characterized by contractions that are irregularand weak, often slowing down with walking or a position change. Truelabor contractions begin in the back and radiate around toward thefront of the abdomen. They are regular and become stronger over time;the woman may find it extremely difficult if not impossible to have aconversation during a contraction.2. A client is in the third stage oflabor. Which finding would alert thenurse that the placenta isseparating?A. uterus becomes globularB. fetal head at vaginal openingC. umbilical cord shortensD. mucous plug is expelledARationale: Placental separation is indicated by the uterus changingshape to globular and upward rising of the uterus. Additional signsinclude a sudden trickle of blood from the vaginal opening, andlengthening (not shortening) of the umbilical cord. The fetal head at thevaginal opening is termed crowning and occurs before birth of thehead. Expulsion of the mucous plug is a premonitory sign of labor.3. When assessing cervicaleffacement of a client in labor, thenurse assesses which characteristic?A. extent of opening to its widestdiameterB. degree of thinningC. passage of the mucous plugD. fetal presenting partBRationale: Effacement refers to the degree of thinning of the cervix.Cervical dilation refers to the extent of opening at the widest diameter.Passage of the mucous plug occurs with bloody show as a premonitorysign of labor. The fetal presenting part is determined by vaginalexamination and is commonly the head (cephalic), pelvis (breech), orshoulder.fmlStudy
4. A woman calls the health carefacility stating that she is in labor.The nurse would urge the client tocome to the facility if the clientreports which symptom?A. increased energy level withalternating strong and weakcontractionsB. moderately strong contractionsevery 4 minutes, lasting about 1minuteC. contractions noted in the front ofabdomen that stop when she walksD. pink-tinged vaginal secretionsand irregular contractions lastingabout 30 secondsBRationale: Moderately strong regular contractions 60 seconds induration indicate that the client is probably in the active phase of thefirst stage of labor. Alternating strong and weak contractions,contractions in the front of the abdomen that change with activity, andpink-tinged secretions with irregular contractions suggest false labor.5. A woman is in the first stage oflabor. The nurse would encourageher to assume which position tofacilitate the progress of labor?A. supineB. lithotomyC. uprightD. knee-chestCRationale: The use of any upright position helps to reduce the length oflabor. Research shows that women who assumed the upright positionduring the first stage of labor experienced significant improvement inthe progress of labor, faster fetal head descent, significant reduction ofpain, and a good Apgar score. Additionally, studies show thatrecumbent positions result in supine hypotension, diminishing uterineactivity and reducing the dimensions of the pelvic outlet. The knee-chestposition would assist in rotating the fetus in a posterior position.fml
6. A client has not received anymedication during her labor. She ishaving frequent contractions aboutevery 1 to 2 minutes and hasbecome irritable with her coach andno longer will allow the nurse topalpate her fundus duringcontractions. Her cervix is 8 cmdilated and 90% effaced. The nurseinterprets these findings asindicating:A. latent phase of the first stage oflabor.B. perineal phase of the first stageof labor.C. late active phase of the first stageof labor.D. early phase of the third stage oflabor.CRationale: Late in the active phase of labor, contractions become morefrequent (every 2 to 5 minutes) and increase in duration (45 to 60seconds). The woman's discomfort intensifies (moderate to strong bypalpation). She becomes more intense and inwardly focused, absorbedin the serious work of her labor. She limits interactions with those in theroom. The latent phase is characterized by mild contractions every 5 to10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%,and excitement and frequent talking by the mother. The pelvic phase ofthe second stage of labor is characterized by complete cervical dilationand effacement, with strong contractions every 2 to 3 minutes; themother focuses on pushing. The perineal phase of the second stage isthe period of active pushing. The third stage, placental expulsion, startsafter the newborn is born and ends with the separation and birth of theplacenta7. The fetus of a nulliparous womanis in a shoulder presentation. Thenurse would prepare the client forwhich type of birth?A. cesareanB. vaginalC. forceps-assistedD. vacuum extractionARationale: The fetus is in a transverse lie with the shoulder as thepresenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.8. Assessment of a woman in laborreveals cervical dilation of 3 cm,cervical effacement of 30%, andcontractions occurring every 7 to 8minutes, lasting about 40 seconds.The nurse determines that this clientis in:A. latent phase of the first stage.B. active phase of the first stage.C. pelvic phase of the second stage.D. early phase of the third stage.ARationale: The latent phase of the first stage of labor involves cervicaldilation of 0 to 3 cm, cervical effacement of 0% to 40%, andcontractions every 5 to 10 minutes lasting 30 to 45 seconds. The activephase is characterized by cervical dilation of 4 to 7 cm, effacement of40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45to 60 seconds. The perineal phase of the second stage occurs withcomplete cervical dilation and effacement, contractions occurringevery 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendousurge to push by the mother. The third stage, placental expulsion, startsafter the newborn is born and ends with the separation and birth of theplacenta.fml
9. A client is admitted to the laborand birthing suite in early labor. Onreview of her prenatal history, thenurse determines that the client'spelvic shape as identified in theantepartal progress notes is themost favorable one for a vaginalbirth. Which pelvic shape would thenurse have noted?A. platypelloidB. gynecoidC. androidD. anthropoidBRationale: The most favorable pelvic shape for vaginal birth is thegynecoid shape. The anthropoid pelvis is favorable for vaginal birth, butit is not the most favorable shape. The android pelvis is not consideredfavorable for a vaginal birth because descent of the fetal head is slowand failure of the fetus to rotate is common. Women with a platypelloidpelvis usually require cesarean birth.10. A woman telephones the prenatalclinic and reports that her water justbroke. Which suggestion by thenurse would be most appropriate?A. "Call us back when you starthaving contractions."B. "Come to the clinic or emergencydepartment for an evaluation."C. "Drink 3 to 4 glasses of water andlie down."D. "Come in as soon as you feel theurge to push."BRationale: When the amniotic sac ruptures, the barrier to infection isgone, and there is the danger of cord prolapse if engagement has notoccurred. Therefore, the nurse should suggest that the woman come infor an evaluation. Calling back when contractions start, drinking water,and lying down are inappropriate because of the increased risk forinfection and cord prolapse. Telling the client to wait until she feels theurge to push is inappropriate because this occurs during the secondstage of labor.11. A nurse is conducting acontinuing education program for agroup of nurses working in theperinatal unit. After reviewinginformation about the maternalbony pelvis with the group, thenurse determines that the teachingwas successful based on whichstatement by the group?A. The bony pelvis plays a lesserrole during labor than soft tissue.B. The pelvic outlet is associatedwith the true pelvis.C. The false pelvis lies below theimaginary linea terminalis.D. The false pelvis is the passagewaythrough which the fetus travels.BRationale: The maternal bony pelvis consists of the true and falseportions. The true pelvis is made up of three planes—the inlet, the midpelvis, and the outlet. The bony pelvis is more important part of thepassageway because it is relatively unyielding. The false pelvis liesabove the imaginary linea terminalis. The true pelvis is the bonypassageway through which the fetus must travel.fml
12. A nurse is providing care to apregnant client in labor. Assessmentof a fetus identifies the buttocks asthe presenting part, with the legsextended upward. The nurseidentifies this as which type ofbreech presentation?A. frankB. fullC. completeD. footlingARationale: In a frank breech, the buttocks present first, with both legsextended up toward the face. In a full or complete breech, the fetus sitscross-legged above the cervix. In a footling breech, one or both legsare presenting13. A woman in her third trimestercomes to the clinic for a prenatalvisit. During assessment the womanreports that her breathing hasbecome much easier in the lastweek but she has noticed increasedpelvic pressure, cramping, andlower back pain. The nursedetermines that which event hasmost likely occurred?A. cervical dilationB. lighteningC. bloody showD. Braxton Hicks contractionsBRationale: Lightening occurs when the fetal presenting part begins todescend into the maternal pelvis. The uterus lowers and moves into thematernal pelvis. The shape of the abdomen changes as a result of thechange in the uterus. The woman usually notes that her breathing ismuch easier. However, she may complain of increased pelvic pressure,cramping, and lower back pain. Although cervical dilation also may beoccurring, it does not account for the woman's complaints. Bloody showrefers to passage of the mucous plug that fills the cervical canal duringpregnancy. It occurs with the onset of labor. Braxton Hicks contractionsincrease in strength and frequency and aid in moving the cervix from aposterior position to an anterior position. They also help in ripening andsoftening the cervix.14. A nurse is conducting an in-service program for a group ofnurses working in the labor and birthsuite of the facility. After teachingthe group about the factorsaffecting the labor process, thenurse determines that the teachingwas successful when the groupidentifies which component as partof the true pelvis? Select all thatapplyA. pelvic inletB. cervixC. mid pelvisD. pelvic outletE. vaginaF. pelvic floor musclesAnswer: A, C, DRationale: The true pelvis is made up of three planes: the pelvic inlet,mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floormuscles are the soft tissues of the passageway.fml
15. A nurse is providing care to awoman in labor. After assessment ofthe fetus, the nurse documents thefetal lie. Which term would the nurseuse?A. flexionB. extensionC. longitudinalD. cephalicCRationale: Fetal lie refers to the relationships of the long axis (spine) ofthe fetus to the long axis (spine) of the mother. There are three primarylies: longitudinal, oblique, and transverse. Flexion and extension areterms used to describe fetal attitude. Cephalic is a term used todescribe fetal presentation16. The nurse is reviewing themedical record of a woman in laborand notes that the fetal position isdocumented as LSA. The nurseinterprets this information asindicating which part as thepresenting part?A. occiputB. faceC. buttocksD. shoulderCRationale: The second letter denotes the presenting part which in thiscase is "S" or the sacrum or buttocks. The letter "O" would denote theocciput or vertex presentation. The letter "M" would denote the mentum(chin) or face presentation. The letter "A" would denote the acromion orshoulder presentation.17. A nurse is preparing a class forpregnant women about labor andbirth. When describing the typicalmovements that the fetus goesthrough as it travels through thepassageway, which movementswould the nurse include? Select allthat apply.A. internal rotationB. abductionC. descentD. pronationE. flexionAnswer: A, C, ERationale: The positional changes that occur as the fetus moves throughthe passageway are called the cardinal movements of labor and includeengagement, descent, flexion, internal rotation, extension, externalrotation, and expulsion. The fetus does not undergo abduction orpronation.fml
18. The nurse is reviewing themonitoring strip of a woman in laborwho is experiencing a contraction.The nurse notes the time thecontraction takes from its onset toreach its highest intensity. The nurseinterprets this time as which phase?A. incrementB. acmeC. peakD. decremenAnswer: ARationale: Each contraction has three phases: increment or the buildupof the contraction; acme or the peak or highest intensity; and thedecrement or relaxation of the uterine muscle fibers. The time from theonset to the highest intensity corresponds to the increment.19. A nurse is assessing a woman inlabor. Which finding would the nurseidentify as a cause for concernduring a contraction?A. heart rate increase from 76 bpmto 90 bpmB. blood pressure rise from 110/60mm Hg to 120/74C. white blood cell count of 12,000cells/mm3D. respiratory rate of 10breaths/minuteAnswer: DRationale: During labor, the mother experiences various physiologicresponses including an increase in heart rate by 10 to 20 bpm, a rise inblood pressure by up to 35 mm Hg during a contraction, an increase inwhite blood cell count to 25,000 to 30,000 cells/mm3, perhaps as aresult of tissue trauma, and an increase in respiratory rate with greateroxygen consumption due to the increase in metabolism. A drop inrespiratory rate would be a cause for concern.20. A nurse is caring for severalwomen in labor. The nursedetermines that which woman is thelatent phase of labor?A. contractions every 5 minutes,cervical dilation 3 cmB. contractions every 3 minutes,cervical dilation 6 cmC. contractions every 2 1/2 minutes,cervical dilation 8 cmD. contractions every 1 minute,cervical dilation 9 cmARationale: Contractions every 5 minutes with cervical dilation of 3 cm istypical of the latent phase. Contractions every 3 minutes with cervicaldilation of 6 cm, contractions every 2½minutes with cervical dilation of8 cm, and contractions every 1 minute with cervical dilation of 9 cmsuggest the active phase of labor.fml
21. A nurse is preparing apresentation for a group ofpregnant women about the laborexperience. Which factors would thenurse include when discussingmeasures to promote coping for apositive labor experience? Select allthat apply.A. presence of a support partner B.view of birth as a stressorC. low anxiety levelD. fear of loss of controlE. participation in a pregnancyexercise programAnswer: A, C, ERationale: Numerous factors can affect a woman's coping ability duringlabor and birth. Having the presence and support of a valued partnerduring labor, engaging in exercise during pregnancy, viewing thebirthing experience as a meaningful rather than stressful event, and alow anxiety level can promote a woman's ability to cope. Excessiveanxiety may interfere with the labor progress, and fear of labor and lossof control may enhance pain perception, increasing the fear.22. During a follow-up prenatal visit,a pregnant woman asks the nurse,"How long do you think I will be inlabor?" Which response by thenurse would be most appropriate?A. "It's difficult to predict how yourlabor will progress, but we'll bethere for you the entire time." B."Since this is your first pregnancy,you can estimate it will be about 10hours."C. "It will depend on how big thebaby is when you go into labor." D."Time isn't important; your healthand the baby's health are key."Answer: ARationale: It is difficult to predict how a labor will progress and thereforeequally difficult to determine how long a woman's labor will last. There isno way to estimate the likely strength and frequency of uterinecontractions, the extent to which the cervix will soften and dilate, andhow much the fetal head will mold to fit the birth canal. We cannot knowbeforehand whether the complex fetal rotations needed for an efficientlabor will take place properly. All of these factors are unknowns when awoman starts labor. Telling the woman an approximate time would beinappropriate because there is no way to determine the length of labor.It is highly individualized. Although fetal size and maternal and fetalhealth are important considerations, these responses do not address thewoman's concern.23. A nurse is describing how thefetus moves through the birth canal.Which component would the nurseidentify as being most important inallowing the fetal head to movethrough the pelvis?A. suturesB. fontanellesC. frontal bonesD. biparietal diameterARationale: Sutures are important because they allow the cranial bones tooverlap in order for the head to adjust in shape (elongate) whenpressure is exerted on it by uterine contractions or the maternal bonypelvis. Fontanelles are the intersections formed by the sutures. Thefrontal bones, along with the parietal and occipital bones are bones ofthe cranium that are soft and pliable. The biparietal diameter is animportant diameter that can affect the birth process.fml
24. Assessment of a pregnantwoman reveals that the presentingpart of the fetus is at the level of thematernal ischial spines. The nursedocuments this as which station?A. -2B. -1C. 0D. +1CRationale: Station refers to the relationship of the presenting part to thelevel of the maternal pelvic ischial spines. Fetal station is measured incentimeters and is referred to as a minus or plus, depending on itslocation above or below the ischial spines. Zero (0) station is designatedwhen the presenting part is at the level of the maternal ischial spines.When the presenting part is above the ischial spines, the distance isrecorded as minus stations. When the presenting part is below theischial spines, the distance is recorded as plus stations.25. A nurse is providing care to apregnant woman in labor. Thewoman is in the first stage of labor.When describing this stage to theclient, which event would the nurseidentify as the major changeoccurring during this stage?A. regular contractionsB. cervical dilation (dilatation)C. fetal movement through the birthcanalD. placental separationBRationale: The primary change occurring during the first stage of laboris progressive cervical dilation (dilatation). Contractions occur during thefirst and second stages of labor. Fetal movement through the birth canalis the major change during the second stage of labor. Placentalseparation occurs during the third stage of labor.26. A nurse is providing care to awoman in labor. The nursedetermines that the client is in theactive phase based on whichassessment findings? Select all thatapply.A. cervical dilation of 6 cmB. contractions every 2 to 3 minutesC. cervical effacement of 30%D. contractions every 90 seconds E.strong desire to pushA, BRationale: During the active phase, the cervix usually dilates from 6 to 10cm, with 40% to 100% effacement taking place. Contractions becomemore frequent, occurring every 2-5 min and increase in duration (45 to60 seconds). Effacement of 30% reflects the latent phase. Contractionsoccurring every 90 seconds suggest the second stage of labor. Astrong urge to push reflects the later perineal phase of the secondstage of labor.fml
27. A pregnant woman comes to thelabor and birth unit in labor. Thewoman tells the nurse, "Yesterday, Ihad this burst of energy andcleaned everything in sight, but Idon't know why." Which response bythe nurse would be mostappropriate?A. "You had a burst of epinephrine,which is common before labor."B. "You were trying to get everythingready for your baby." C. "You feltyour mind telling you that you wereabout to go into labor."D. "You were looking forward to thebirth of your baby."ARationale: Some women report a sudden increase in energy beforelabor. This is sometimes referred to as nesting because many women willfocus this energy toward childbirth preparation by cleaning, cooking,preparing the nursery, and spending extra time with other children in thehousehold. The increased energy level usually occurs 24 to 48 hoursbefore the onset of labor. It is thought to be the result of an increase inepinephrine (adrenaline) release caused by a decrease in progesterone.The burst of energy is unrelated to getting everything ready, the mindtelling the woman that she will be going into labor, or looking forwardto the birth.28. A nurse is conducting a class fora group of nurses new to the laborand birth unit about labor and thepassage of the fetus through thebirth canal. As part of the class, thenurse explains that specificdiameters of the fetal skull canaffect the birth process. Whichdiameter would the nurse identify asbeing most important in affectingthe birth process? Select all thatapply.A. OccipitofrontalB. OccipitomentalC. SuboccipitobregmaticD. BiparietalE. Diagonal conjugateC, DRationale: The diameter of the fetal skull is an important considerationduring the labor and birth process. Fetal skull diameters are measuredbetween the various landmarks of the skull. Diameters includeoccipitofrontal, occipitomental, suboccipitobregmatic, and biparietal.The two most important diameters that can affect the birth process arethe suboccipitobregmatic (approximately 9.5 cm at term) and thebiparietal (approximately 9.25 cm at term) diameters. Diagonalconjugate is a measure of the pelvic inlet of the mother.fml
29. Assessment of a woman in laborreveals that the fetus is in a cephalicpresentation and engagement hasoccurred. The nurse interprets thisfinding to indicate that thepresenting part is at which station?A. -2B. -1C. 0D. +1CRationale: Fetal engagement signifies the entrance of the largestdiameter of the fetal presenting part (usually the fetal head) into thesmallest diameter of the maternal pelvis. The fetus is said to be engagedin the pelvis when the presenting part reaches 0 station.30. A nurse is providing care to aclient in labor. A pelvic exam revealsa vertex presentation with thepresenting part tilted toward the leftside of the mother's pelvis anddirected toward the anterior portionof the pelvis. When developing thisclient's plan of care, whichintervention would the nurseinclude?A. implementing measures for avaginal birthB. preparing the client for acesarean birthC. assisting with artificial rupture ofthe membranesD. instituting continuous internalfetal monitoringARationale: The fetal presentation and position is left occiput anteriorposition or LOA, which is the most common and most favorable fetalposition for birth. LOA along with right occiput anterior position areoptimal positions for vaginal birth. Therefore the nurse shouldimplement measures for a vaginal birth. This fetal presentation is not anindication for cesarean birth. Nor is there need for artificially rupturingthe membranes. Continuous internal fetal monitoring would bewarranted if the woman or fetus was considered to be high risk.A woman in labor who received anopioid for pain relief developsrespiratory depression. The nursewould expect which agent to beadministered?A. butorphanolB. fentanylC. naloxoneD. promethazineAnswer: CRationale: Naloxone is an opioid antagonist used to reverse the effectsof opioids such as respiratory depression. Butorphanol and fentanyl areopioids and would cause further respiratory depression. Promethazine isan ataractic used as an adjunct to potentiate the effectiveness of theopioid.fml
A client's membranes spontaneouslyruptured, as evidenced by a gush ofclear fluid with acontraction. What would the nursedo next?A. Check the fetal heart rate.B. Perform a vaginal exam.C. Notify the primary care providerimmediately.D. Change the linen saver pad.Answer: ARationale: When membranes rupture, the priority focus is on assessingfetal heart rate first to identify a deceleration, which might indicate cordcompression secondary to cord prolapse. A vaginal exam may be donelater to evaluate for continued progression of labor. The primary careprovider should be notified, but this is not a priority at this time.Changing the linen saver pad would be appropriate once the fetalstatus is determined and the primary care provider has beennotified.A woman is admitted to the laborand birthing suite. Vaginalexamination reveals that thepresenting part is approximately 2cm above the ischial spines. Thenurse documents this finding as:A. +2 station.B. 0 station.C. -2 station.D. crowning.Answer: CRationale: The ischial spines serve as landmarks and are designated aszero status. If the presenting part is palpated higher than the maternalischial spines, a negative number is assigned. Therefore, the nurse woulddocument the finding as -2 station. If the presenting part is below theischial spines, then the station would be +2. Crowning refers to theappearance of the fetal headat the vaginal opening.A client states, "I think my waterbroke! I felt this gush of fluidbetween my legs." The nursetests the fluid with nitrazine paperand confirms membrane rupture ifthe swab turns:A. yellow.B. olive green.C. pink.D. blue.Answer: DRationale: Amniotic fluid is alkaline and turns Nitrazine paper blue.Nitrazine swabs that remain yellow to olive green suggests that themembranes are most likely intact.fml
A woman in labor is to receivecontinuous internal electronic fetalmonitoring. The nurseprepares the client for thismonitoring based on theunderstanding that which criterionmust be present?A. intact membranesB. cervical dilation of 2 cm or moreC. floating presenting fetal partD. a neonatologist to insert theelectrodeAnswer: BRationale: For continuous internal electronic fetal monitoring, fourcriteria must be met: ruptured membranes, cervical dilation of at least 2cm, fetal presenting part low enough to allow placement of theelectrode, and a skilled practitioner available to insert the electrode.A woman in labor has chosen to usehydrotherapy as a method of painrelief. Which statement by thewoman would lead the nurse tosuspect that the woman needsadditional teaching?A. "The warmth and buoyancy of thewater has a nice relaxing effect."B. "I can stay in the bath for as longas I feel comfortable."C. "My cervix should be dilatedmore than 5 cm before I try usingthis method."D. "The temperature of the watershould be at least 105? (40.5?)."Answer: DRationale: Hydrotherapy is an effective pain relief method. The watertemperature should not exceed body temperature. Therefore, atemperature of 105? (40.5?) would be too warm. The warmth andbuoyancy have a relaxing effect, and women are encouraged to stay inthe bath as long as they feel comfortable. The woman should be inactive labor with cervical dilation greater than 5 cm.A woman in labor received anopioid close to the time of birth. Thenurse would assess thenewborn for which effect?A. respiratory depressionB. urinary retentionC. abdominal distentionD. hyperreflexiaAnswer: ARationale: Opioids given close to the time of birth can cause centralnervous system depression, including respiratory depression, in thenewborn, necessitating the administration of naloxone.Urinary retention may occur in the woman who received neuraxialopioids. Abdominaldistention is not associated with opioid administration. Hyporeflexiawould be more commonly associated with central nervous systemdepression due to opioids.fml
When applying the ultrasoundtransducer for continuous externalelectronic fetal monitoring, thenurse would place the transducer atwhich location on the client's bodyto record the FHR?A. over the uterine fundus wherecontractions are most intenseB. above the umbilicus toward theright side of the diaphragmC. between the umbilicus and thesymphysis pubisD. between the xiphoid process andumbilicusAnswer: CRationale: The ultrasound transducer is positioned on the maternalabdomen in the midline between the umbilicus and the symphysis pubis.The tocotransducer is placed over the uterine fundus in the area ofgreatest contractility.After describing continuous internalelectronic fetal monitoring to alaboring woman and her partner,which statement by the womanwould indicate the need foradditional teaching?A. "This type of monitoring is themost accurate method for our baby."B. "Unfortunately, I'm going to haveto stay quite still in bed while it is inplace."C. "This type of monitoring can onlybe used after my membranesrupture."D. "You'll be inserting a specialelectrode into my baby's scalp."Answer: BRationale: With continuous internal electronic monitoring, maternalposition changes andmovement do not interfere with the quality of the tracing. Continuousinternal monitoring is considered the most accurate method, but it canbe used only if certain criteria are met, such as rupture of membranes. Aspiral electrode is inserted into the fetal presenting part, usually thehead.Which action is a priority whencaring for a woman during thefourth stage of labor?A. assessing the uterine fundusB. offering fluids as indicatedC. encouraging the woman to voidD. assisting with perineal careAnswer: ARationale: During the fourth stage of labor, a priority is to assess thewoman's fundus to prevent postpartum hemorrhage. Offering fluids,encouraging voiding, and assisting with perineal careare important but not an immediate priority.fml
When palpating the fundus during acontraction, the nurse notes that itfeels like a chin. The nurse interpretsthis finding as indicating which typeof contraction?A. intenseB. strongC. moderateD. mildAnswer: CRationale: A contraction that feels like the chin typically represents amoderate contraction. A contraction described as feeling like the tip ofthe nose indicates a mild contraction. A strong orintense contraction feels like the forehead.When planning the care of a womanin the latent phase of labor, thenurse would anticipate assessing thefetal heart rate at which interval?A. every 30 to 60 minutesB. every 60 to 90 minutesC. every 15 to 30 minutesD. every 10 to 15 minutesAnswer: ARationale: FHR is assessed every 30 to 60 minutes during the latentphase of labor and every 15 to 30 minutes during the active phase. Thewoman's temperature is typically assessed every 4 hours during the firststage of labor and every 2 hours after ruptured membranes. Bloodpressure,pulse, and respirations are assessed every hour during the latent phaseand every 30 minutes during the active and transition phases.Contractions are assessed every 30 to 60 minutes during the latentphase and every 15 to 30 minutes during the active phase, and every 15minutes during transition.A nurse palpates a woman's fundusto determine contraction intensity.What would be most appropriate forthe nurse to use for palpation?A. finger padsB. palm of the handC. finger tipsD. back of the handAnswer: ARationale: To palpate the fundus for contraction intensity, the nursewould place the pads of the fingers on the fundus and describe how itfeels. Using the finger tips, palm, or back of the handwould be inappropriate.A woman's amniotic fluid is noted tobe cloudy. The nurse interprets thisfinding as:A. normal.B. a possible infection.C. meconium passage.D. transient fetal hypoxia.Answer: BRationale: Amniotic fluid should be clear when the membranes rupture,either spontaneously or artificially through an amniotomy (a disposableplastic hook [Amnihook] is used to perforate the amniotic sac). Cloudyor foul-smelling amniotic fluid indicates infection. Green fluid mayindicate that the fetus has passed meconium secondary to transienthypoxia, prolonged pregnancy, cord compression, intrauterine growthrestriction, maternal hypertension, diabetes, orchorioamnionitis; however, it is considered a normal occurrence if thefetus is in a breech presentation.fml
A nurse is conducting a class for agroup of nurses who are newly hiredfor the labor andbirth unit. After teaching the groupabout fetal heart rate patterns, thenurse determines the need foradditional teaching when the groupidentifies which finding as indicatingnormal fetal acid- base status?Select all that apply.A. sinusoidal patternB. recurrent variable decelerationsC. fetal bradycardiaD. absence of late decelerationsE. moderate baseline variabilityAnswer: A, B, CRationale: Predictors of normal fetal acid-base status include a baselinerate between 110 and160 bpm, moderate baseline variability, and absences of later or variabledecelerations.Sinusoidal pattern, recurrent variable decelerations, and fetalbradycardia are predictive of abnormal fetal acid-base status.A nurse is reviewing the fetal heartrate pattern and observes abruptdecreases in FHR below thebaseline, appearing as a U-shape.The nurse interprets these changesas reflecting which type ofdeceleration?A. early decelerationsB. variable decelerationsC. prolonged decelerationsD. late decelerationsAnswer: BRationale: Variable decelerations present as visually apparent abruptdecreases in FHR belowbaseline and have an unpredictable shape on the FHR baseline,possibly demonstrating no consistent relationship to uterinecontractions. The shape of variable decelerations may be U, V, or W, orthey may not resemble other patterns. Early decelerations are visuallyapparent, usually symmetrical and characterized by a gradual decreasein the FHR in which the nadir (lowest point) occurs at the peak of thecontraction. They are thought to be a result of fetal head compressionthat results in a reflex vagal response with a resultant slowing of the FHRduringuterine contractions. Late decelerations are visually apparent, usuallysymmetrical, transitory decreases in FHR that occur after the peak of thecontraction. The FHR does not return to baseline levels until well afterthe contraction has ended. Delayed timing of the deceleration occurs,with the nadir of the uterine contraction. Late decelerations areassociated with uteroplacental insufficiency. Prolonged decelerationsare abrupt FHR declines of at least 15 bpm that last longer than 2minutes but less than 10 minutes.fml
A nurse is explaining the use ofeffleurage as a pain relief measureduring labor. Whichstatement would the nurse mostlikely use when explaining thismeasure?A. "This technique focuses onmanipulating body tissues."B. "The technique requires focusingon a specific stimulus."C. "This technique redirects energyfields that lead to pain."D. "The technique involves lightstroking of the abdomen withbreathing."Answer: DRationale: Effleurage involves light stroking of the abdomen in rhythmwith breathing.Therapeutic touch is an energy therapy and is based on the premise thatthe body contains energy fields that lead to either good or ill health andthat the hands can be used to redirect the energy fields that lead topain. Attention focusing and imagery involve focusing on a specificstimulus. Massage focuses on manipulating body tissues.A nurse is reading a journal articleabout the various medications usedfor pain relief duringlabor. Which drug would the nursenote as producing amnesia but noanalgesia?A. midazolamB. prochlorperazineC. fentanylD. meperidineAnswer: ARationale: Midazolam is given intravenously and produces goodamnesia but no analgesia. It is most commonly used as an adjunct foranesthesia. Prochlorperazine is typically given with an opioid such asmorphine to counteract the nausea of the opioid. Fentanyl andmeperidine are opioids that produce analgesia.fml
A nurse is describing the differenttypes of regional analgesia andanesthesia for labor to a group ofpregnant women. Which statementby the group indicates that theteaching wassuccessful?A. "We can get up and walk aroundafter receiving combined spinal-epidural analgesia."B. "Higher anesthetic doses areneeded for patient-controlledepidural analgesia."C. "A pudendal nerve block is highlyeffective for pain relief in the firststage of labor."D. "Local infiltration using lidocaineis an appropriate method forcontrolling contraction pain."Answer: ARationale: When compared with traditional epidural or spinal analgesia,which often keeps the woman lying in bed, combined spinal-epiduralanalgesia allows the woman to ambulate ("walking epidural"). Patient-controlled epidural analgesia provides equivalent analgesia with loweranesthetic use, lower rates of supplementation, and higher clientsatisfaction. Pudendalnerve blocks are used for the second stage of labor, an episiotomy, oran operative vaginal birth with outlet forceps or vacuum extractor. Localinfiltration using lidocaine does not alter the pain of uterinecontractions, but it does numb the immediate area of the episiotomy orlaceration.A nurse is completing theassessment of a woman admitted tothe labor and birth suite.Which information would the nurseexpect to include as part of thephysical assessment? Select all thatapply.A. current pregnancy historyB. fundal height measurementC. support systemD. estimated date of birthE. membrane statusF. contraction patternAnswer: B, E, FRationale: As part of the admission physical assessment, the nurse wouldassess fundal height, membrane status, and contractions. Currentpregnancy history, support systems, and estimateddate of birth would be obtained when collecting the maternal healthhistory.fml
A pregnant woman admitted to thelabor and birth suite undergoesrapid HIV testing and isfound to be HIV-positive. Whichaction would the nurse expect toinclude when developing a plan ofcare for this woman? Select all thatapply.A. administrating of penicillin G atthe onset of laborB. avoiding scalp electrodes for fetalmonitoringC. refraining from obtaining fetalscalp blood for pH testingD. administering antiretrovial therapyat the onset of laborE. electing for the use of forceps-assisted birthAnswer: B, C, DRationale: To reduce perinatal transmission, HIV-positive women aregiven a combination of antiretroviral drugs. To further reduce the risk ofperinatal transmission, ACOG and the U.S. Public Health Servicerecommend that HIV-infected women with plasma viral loads of morethan 1,000 copies per milliliter be counseled regarding the benefits ofelective cesarean birth. Additional interventions to reduce thetransmission risk would include avoiding use of scalp electrode for fetalmonitoring or doing a scalp blood sampling for fetal pH, delayingamniotomy,encouraging formula feeding after birth, and avoiding invasiveprocedures such as forceps or vacuum-assisted devices.Which positions would be mostappropriate for the nurse to suggestas a comfort measure to a womanwho is in the first stage of labor?Select all that apply.A. walking with partner supportB. straddling with forward leaningover a chairC. closed knee-chest positionD. rocking back and forth with footon chairE. supine with legs raised at a 90-degree angleAnswer: A, B, DRationale: Positioning during the first stage of labor includes walkingwith support from thepartner, side-lying with pillows between the knees, leaning forward bystraddling a chair, table, or bed or kneeling over a birthing ball, lungingby rocking weight back and forth with a foot up on a chair or birthingball, or an open knee-chest position.fml
Which suggestion by the nurseabout pushing would be mostappropriate to a woman in thesecond stage of labor?A. "Lying flat with your headelevated on two pillows makespushing easier."B. "Choose whatever method youfeel most comfortable with forpushing."C. "Let me help you decide when itis time to start pushing."D. "Bear down like you're having abowel movement with everycontraction."Answer: BRationale: The role of the nurse should be to support the woman in herchoice of pushing method and to encourage confidence in her maternalinstinct of when and how to push. In the absence ofany complications, nurses should not be controlling this stage of labor,but empowering womento achieve a satisfying experience. Common practice in many labor unitsis still to coach women to use closed glottis pushing with everycontraction, starting at 10 cm of dilation, a practice thatis not supported by research. Research suggests that directed pushingduring the second stage may be accompanied by a significant declinein fetal pH and may cause maternal muscle andnerve damage if done too early. Effective pushing can be achieved byassisting the woman to assume a more upright or squatting position.Supporting spontaneous pushing and encouragingwomen to choose their own method of pushing should be accepted asbest clinical practice.A nurse is assessing a woman afterbirth and notes a second-degreelaceration. The nurseinterprets this as indicating that thetear extends through which area?A. skinB. muscles of perineal bodyC. anal sphincterD. anterior rectal wallAnswer: BRationale: The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second-degree lacerationextends through the muscles of the perineal body; athird-degree laceration continues through the anal sphincter muscle;and a fourth-degree laceration also involves the anterior rectal wall.A nurse is assisting with the birth ofa newborn. The fetal head has justemerged. Which action would beperformed next?A. suctioning of the mouth and noseB. clamping of the umbilical cordC. checking for the cord around theneckD. drying of the newbornAnswer: CRationale: Once the fetal head has emerged, the primary care providerexplores the fetal neck to see if the umbilical cord is wrapped around it.If it is, the cord is slipped over the head to facilitate delivery. Then thehealth care provider suctions the newborn's mouth first (because thenewborn is an obligate nose breather) and then the nares with a bulbsyringe to prevent aspirationof mucus, amniotic fluid, or meconium. Finally the umbilical cord isdouble-clamped and cut between the clamps. The newborn is placedunder the radiant warmer, dried, assessed, wrapped in warm blankets,and placed on the woman's abdomen for warmth and closeness.fml
A nurse is providing care to awoman during the third stage oflabor. Which finding wouldalert the nurse that the placenta isseparating?A. boggy, soft uterusB. uterus becoming discoid shapedC. sudden gush of dark blood fromthe vaginaD. shortening of the umbilical cordAnswer: CRationale: Signs that the placenta is separating include a firmlycontracting uterus; a change in uterine shape from discoid to globularovoid; a sudden gush of dark blood from the vaginal opening; andlengthening of the umbilical cord protruding from the vagina.A nurse is preparing to auscultatethe fetal heart rate of a pregnantwoman at term admitted to thelabor and birth suite. Assessmentreveals that the fetus is in a cephalicpresentation. At which area on thewoman's body would the nurse besthear the sounds?A. At the level of the woman'sumbilicusB. In the area above the woman'sumbilicusC. In the woman's lower abdominalquadrantD. At the upper outer quadrant ofthe woman's abdomenAnswer: CRationale: The fetal heart rate is heard most clearly at the fetal back. In acephalic presentation, the fetal heart rate is best heard in the lowerquadrant of the maternal abdomen. In a breech presentation, it is heardat or above the level of the maternal umbilicus.fml
A pregnant woman is discussingnonpharmacologic pain controlmeasures with the nurse inanticipation of labor. Afterdiscussing the various breathingpatterns that can be used, thewoman decides to use slow-pacedbreathing. Which instruction wouldthe nurse provide to the womanabout this technique?A. "Inhale through your nose andexhale through pursed lips."B. "Inhale and exhale through yourmouth about 4 times in 5 seconds."C. "Forcefully exhale every so oftenafter inhaling and exhaling throughyour mouth."D. "Take a cleansing breath beforebut not after each contraction."Answer: ARationale: Many couples learn patterned-paced breathing during theirchildbirth education classes. Three levels may be taught, each beginningand ending with a cleansing breath or sigh after each contraction. In thefirst pattern, also known as slow-paced breathing, the womaninhales slowly through her nose and exhales through pursed lips. Thebreathing rate is typically 6 to 9 breaths/min. In the second pattern, thewoman inhales and exhales through her mouth at arate of 4 breaths every 5 seconds. The rate can be accelerated to 2breaths/sec to assist her to relax. The third pattern is similar to thesecond pattern except that the breathing is punctuatedevery few breaths by a forceful exhalation through pursed lips. Allbreaths are kept equal andrhythmic and can increase as contractions increase in intensity.A nurse is performing Leopoldmaneuvers on a pregnant woman.The nurse determineswhich information with the firstmaneuver?A. Fetal presentationB. Fetal positionC. Fetal attitudeD. Fetal flexionAnswer: ARationale: Leopold maneuvers are a method for determining thepresentation, position, and lie of the fetus through the use of fourspecific steps. The first maneuver determines presentation; the secondmaneuver determines position; the third maneuver confirmspresentation by feeling forthe presenting part; the fourth maneuver determines attitude based onwhether the fetal head is flexed and engaged in the pelvis.A pregnant woman with a fetus inthe cephalic presentation is in thelatent phase of the firststage of labor. Her membranesrupture spontaneously. The fluid isgreen in color. Which action by thenurse would be appropriate?A. Check the pH to ensure the fluidis amniotic fluid.B. Prepare to administer anantiobiotic.C. Notify the health care providerabout possible meconium.D. Check the maternal heart rate.Answer: CRationale: Amniotic fluid should be clear when the membranes rupture.Green fluid may indicate that the fetus has passed meconium secondaryto transient hypoxia, prolonged pregnancy, cordcompression, intrauterine growth restriction, maternal hypertension,diabetes, orchorioamnionitis. Therefore, the nurse would notify the health careprovider. Antibiotic therapy would be indicated if the fluid was cloudy orfoul-smelling, suggesting an infection. Color of the fluid has nothing todo with the pH of the fluid. Spontaneous rupture of membranes canlead tocord compression, so checking fetal heart rate, not maternal heart rate,would be appropriate.fml
After teaching a woman who hashad an evacuation for a hydatidiformmole (molar pregnancy) about hercondition, which of the followingstatements indicates that the nurse'steaching was successful?A) "I will be sure to avoid gettingpregnant for at least 1 year."B) "My intake of iron will have to beclosely monitored for 6 months."C) "My blood pressure will continueto be increased for about 6 moremonths."D) "I won't use my birth control pillsfor at least a year or two."Ans: AAfter evacuation of a hydatidiform mole, long-term follow-up isnecessary to make sure any remaining trophoblastic tissue does notbecome malignant. Serial hCG levels are monitored closely for 1 yearand the client is urged to avoid pregnancy for 1 year because it caninterfere with the monitoring of hCG levels. Iron intake and bloodpressure are not important aspects of follow-up after evacuation of ahydatidiform mole. Use of a reliable contraceptive is stronglyrecommended so that pregnancy is avoided.Which of the following findings on aprenatal visit at 10 weeks might leadthe nurse to suspect a hydatidiformmole?A) Complaint of frequent mildnauseaB) Blood pressure of 120/84 mm HgC) History of bright red spotting 6weeks agoD) Fundal height measurement of 18cmAns: DFindings with a hydatidiform mole may include uterine size larger thanexpected. Mild nausea would be a normal finding at 10 weeks' gestation.Blood pressure of 120/84 would not be associated with hydatidiformmole and depending on the woman's baseline blood pressure may bewithin acceptable parameters for her. Bright red spotting might suggesta spontaneous abortion.A client is diagnosed withgestational hypertension and isreceiving magnesium sulfate. Whichfinding would the nurse interpret asindicating a therapeutic level ofmedication?A) Urinary output of 20 mL per hourB) Respiratory rate of 10breaths/minuteC) Deep tendons reflexes 2+D) Difficulty in arousingAns: CWith magnesium sulfate, deep tendon reflexes of 2+ would beconsidered normal and therefore a therapeutic level of the drug. Urinaryoutput of less than 30 mL, a respiratory rate of less than 12breaths/minute, and a diminished level of consciousness would indicatemagnesium toxicity.fml
Upon entering the room of a clientwho has had a spontaneousabortion, the nurse observes theclient crying. Which of the followingresponses by the nurse would bemost appropriate?A) "Why are you crying?"B) "Will a pill help your pain?"C) "I'm sorry you lost your baby."D) "A baby still wasn't formed in youruterus."Ans: CTelling the client that the nurse is sorry for the loss acknowledges theloss to the woman, validates her feelings, and brings the loss into reality.Asking why the client is crying is ineffective at this time. Offering a pillfor the pain ignores the client's feelings. Telling the client that the babywasn't formed is inappropriate and discounts any feelings or beliefs thatthe client has.A nurse is reviewing a client's historyand physical examination findings.Which information would the nurseidentify as contributing to theclient's risk for an ectopicpregnancy?A. use of oral contraceptives for 5yearsB. ovarian cyst 2 years agoC. recurrent pelvic infectionsD. heavy, irregular mensesAnswer: CRationale: In the general population, most cases of ectopic pregnancyare the result of tubal scarring secondary to pelvic inflammatorydisease. Oral contraceptives, ovarian cysts, and heavy, irregular mensesare not considered risk factors for ectopic pregnancy.Which of the following data on aclient's health history would thenurse identify as contributing to theclient's risk for an ectopicpregnancy?A) Use of oral contraceptives for 5yearsB) Ovarian cyst 2 years agoC) Recurrent pelvic infectionsD) Heavy, irregular mensesAns: CIn the general population, most cases of ectopic pregnancy are theresult of tubal scarring secondary to pelvic inflammatory disease. Oralcontraceptives, ovarian cysts, and heavy, irregular menses are notconsidered risk factors for ectopic pregnancy.In a woman who is suspected ofhaving a ruptured ectopicpregnancy, the nurse would expectto assess for which of the followingas a priority?A) HemorrhageB) JaundiceC) EdemaD) InfectionAns: AWith a ruptured ectopic pregnancy, the woman is at high risk forhemorrhage. Jaundice, edema, and infection are not associated with aruptured ectopic pregnancy.fml
Which of the following findingswould the nurse interpret assuggesting a diagnosis ofgestational trophoblastic disease?A) Elevated hCG levels, enlargedabdomen, quickeningB) Vaginal bleeding, absence ofFHR, decreased hPL levelsC) Visible fetal skeleton onultrasound, absence of quickening,enlarged abdomenD) Gestational hypertension,hyperemesis gravidarum, absenceof FHRAns: DGestational trophoblastic disease may be manifested by earlydevelopment of preeclampsia (gestational hypertension), severemorning sickness due to high hCG levels, and absence of fetal heartrate or activity. There is no fetus, so quickening and evidence of a fetalskeleton would not be seen. The abdominal enlargement is greater thanexpected for pregnancy dates, but hCG, not hPL, levels are increased.It is determined that a client's bloodRh is negative and her partner's ispositive. To help prevent Rhisoimmunization, the nurseanticipates that the client willreceive RhoGAM at which time?A) At 34 weeks' gestation andimmediately before dischargeB) 24 hours before delivery and 24hours after deliveryC) In the first trimester and within 2hours of deliveryD) At 28 weeks' gestation and againwithin 72 hours after deliveryAns: DTo prevent isoimmunization, the woman should receive RhoGAM at 28to 32 weeks gestation and again within 72 hours after delivery.A woman pregnant with twins comesto the clinic for an evaluation. Whileassessing the client, the nurse wouldbe especially alert for signs andsymptoms for which potentialproblem?A) OligohydramniosB) PreeclampsiaC) Post-term laborD) ChorioamnionitisAns: BWomen with multiple gestations are at high risk for preeclampsia,preterm labor, hydramnios, hyperemesis gravidarum, anemia, andantepartal hemorrhage. There is no association between multiplegestations and the development of chorioamnionitis.fml
A woman hospitalized with severepreeclampsia is being treated withhydralazine to control bloodpressure. Which of the followingwould the lead the nurse to suspectthat the client is having an adverseeffect associated with this drug?A) Gastrointestinal bleedingB) Blurred visionC) TachycardiaD) SweatingAns: CHydralazine reduces blood pressure but is associated with adverseeffects such as palpitation, tachycardia, headache, anorexia, nausea,vomiting, and diarrhea. It does not cause gastrointestinal bleeding,blurred vision, or sweating. Magnesium sulfate may cause sweating.A client comes to the clinic for anevaluation. The client is at 22 weeks'gestation. After reviewing a client'shistory, which factor would the nurseidentify as placing her at risk forpreeclampsia?A. Her mother had preeclampsiaduring pregnancy.B. Client has a twin sister.C. Her sister-in-law had gestationalhypertension.D. This is the client's secondpregnancyAnswer: ARationale: A family history of preeclampsia, such as a mother or sister, isconsidered a risk factor for the client. Having a twin sister or having asister-in-law with gestational hypertension would not increase theclient's risk. If the client had a history of preeclampsia in her firstpregnancy, then she would be at risk in her second pregnancy.After reviewing a client's history,which factor would the nurseidentify as placing her at risk forgestational hypertension?A) Mother had gestationalhypertension during pregnancy.B) Client has a twin sister.C) Sister-in-law had gestationalhypertension.D) This is the client's secondpregnancy.Ans: AA family history of gestational hypertension, such as a mother or sister, isconsidered a risk factor for the client. Having a twin sister or having asister-in-law with gestational hypertension would not increase theclient's risk. If the client had a history of preeclampsia in her firstpregnancy, then she would be at risk in her second pregnancy.A client with hyperemesisgravidarum is admitted to the facilityafter being cared for at homewithout success. Which of thefollowing would the nurse expect toinclude in the client's plan of care?A) Clear liquid dietB) Total parenteral nutritionC) Nothing by mouthD) Administration of labetalolAns: CTypically, on admission, the woman with hyperemesis has oral food andfluids withheld for the first 24 to 36 hours to rest the gut and receivesparenteral fluids to rehydrate and reduce the symptoms. Once thecondition stabilizes, oral intake is gradually increased. Total parenteralnutrition may be used if the client's condition does not improve withseveral days of bed rest, gut rest, IV fluids, and antiemetics. Labetalol isan antihypertensive agent that may be used to treat gestationalhypertension, not hyperemesis.fml
The nurse is reviewing thelaboratory test results of a pregnantclient. Which one of the followingfindings would alert the nurse to thedevelopment of HELLP syndrome?A) HyperglycemiaB) Elevated platelet countC) LeukocytosisD) Elevated liver enzymesAns: DHELLP is an acronym for hemolysis, elevated liver enzymes, and lowplatelets. Hyperglycemia or leukocytosis is not a part of this syndrome.A client with severe preeclampsia isreceiving magnesium sulfate as partof the treatment plan. To ensure theclient's safety, which compoundwould the nurse have readilyavailable?A) Calcium gluconateB) Potassium chlorideC) Ferrous sulfateD) Calcium carbonateAnswer: ARationale: The woman is at risk for magnesium toxicity. The antidote formagnesium sulfate is calcium gluconate, and this should be readilyavailable in case the woman has signs and symptoms of magnesiumtoxicity.A nurse is conducting an assessmentof a woman who has experiencedPROM. Which amniotic fluid findingwould lead the nurse to suspectinfection as the cause of a client'sPROM?A) Yellow-green fluidB) Blue color on Nitrazine testingC) FerningD) Foul odorAns: DA foul odor of the amniotic fluid indicates infection. Yellow-green fluidwould suggest meconium. A blue color on Nitrazine testing and ferningindicate the presence of amniotic fluid.While assessing a pregnant woman,the nurse suspects that the clientmay be at risk for hydramnios basedon which of the following? (Selectall that apply.)A) History of diabetesB) Complaints of shortness of breathC) Identifiable fetal parts onabdominal palpationD) Difficulty obtaining fetal heartrateE) Fundal height below that forexpected gestational ageAns: A, B, DFactors such as maternal diabetes or multiple gestations place thewoman at risk for hydramnios. In addition, there is a discrepancybetween fundal height and gestational age, such that a rapid growth ofthe uterus is noted. Shortness of breath may result from overstretchingof the uterus due to the increased amount of amniotic fluid. Often, fetalparts are difficult to palpate and fetal heart rate is difficult to obtainbecause of the excess fluid present.fml
A nurse is conducting an in-serviceprogram for a group of nursesworking at the women's healthfacility about the causes ofspontaneous abortion. The nursedetermines that the teaching wassuccessful when the group identifieswhich condition as the mostcommon cause of first trimesterabortions?A) Maternal diseaseB) Cervical insufficiencyC) Fetal genetic abnormalitiesD) Uterine fibroidsAns: CThe causes of spontaneous abortion are varied and often unknown. Themost common cause for first-trimester abortions is fetal geneticabnormalities, usually unrelated to the mother. Chromosomalabnormalities are more likely causes in first trimester and maternaldisease is more likely in the second trimester. Those occurring duringthe second trimester are more likely related to maternal conditions,such as cervical insufficiency, congenital or acquired anomaly of theuterine cavity (uterine septum or fibroids), hypothyroidism, diabetesmellitus, chronic nephritis, use of crack cocaine, inherited and acquiredthrombophilias, lupus, polycystic ovary syndrome, severe hypertensionand acute infection such as rubella virus, cytomegalovirus, herpessimplex virus, bacterial vaginosis, and toxoplasmosis.A pregnant woman is admitted withpremature rupture of themembranes. The nurse is assessingthe woman closely for possibleinfection. Which of the followingwould lead the nurse to suspect thatthe woman is developing aninfection? (Select all that apply.)A) Fetal bradycardiaB) Abdominal tendernessC) Elevated maternal pulse rateD) Decreased C-reactive proteinlevelsE) Cloudy malodorous fluidAns: B, C, EPossible signs of infection associated with premature rupture ofmembranes include elevation of maternal temperature and pulse rate,abdominal/uterine tenderness, fetal tachycardia over 160 bpm, elevatedwhite blood cell count and C-reactive protein levels, and cloudy, foul-smelling amniotic fluid.A nurse is teaching a pregnantwoman with preterm prematurerupture of membranes who is aboutto be discharged home aboutcaring for herself. Which statementby the woman indicates a need foradditional teaching?A) "I need to keep a close eye onhow active my baby is each day."B) "I need to call my doctor if mytemperature increases."C) "It's okay for my husband and meto have sexual intercourse."D) "I can shower but I shouldn't takea tub bath."Ans: CFeedback:The woman with preterm premature rupture of membranes shouldmonitor her baby's activity by performing fetal kick counts daily, checkher temperature and report any increases to the health care provider,not insert anything into her vagina or vaginal area, such as tampons orvaginal intercourse, and avoid sitting in a tub bath.fml
A nurse is assessing a pregnantwoman with gestationalhypertension. Which of thefollowing would lead the nurse tosuspect that the client hasdeveloped severe preeclampsia?A) Urine protein 300 mg/24 hoursB) Blood pressure 150/96 mm HgC) Mild facial edemaD) HyperreflexiaAns: DSevere preeclampsia is characterized by blood pressure over 160/110mm Hg, urine protein levels greater than 500 mg/24 hours andhyperreflexia. Mild facial edema is associated with mild preeclampsia.A nurse suspects that a pregnantclient may be experiencingabruption placenta based onassessment of which of thefollowing? (Select all that apply.)A) Dark red vaginal bleedingB) Insidious onsetC) Absence of painD) Rigid uterusE) Absent fetal heart tonesAns: A, D, EFeedback:Assessment findings associated with abruption placenta include asudden onset, with concealed or visible bleeding, dark red bleeding,constant pain or uterine tenderness on palpation, firm to rigid uterinetone, and fetal distress or absent fetal heart tones.The health care provider ordersPGE2 for a woman to help evacuatethe uterus following a spontaneousabortion. Which of the followingwould be most important for thenurse to do?A) Use clean technique toadminister the drug.B) Keep the gel cool until ready touse.C) Maintain the client for 1/2 hourafter administration.D) Administer intramuscularly intothe deltoid area.Ans: CWhen PGE2 is ordered, the gel should come to room temperaturebefore administering it. Sterile technique should be used and the clientshould remain supine for 30 minutes after administration. RhoGAM isadministered intramuscularly into the deltoid area.fml
A nurse is reviewing an article aboutpreterm prelabor rupture ofmembranes. Which factors wouldthe nurse expect to find placing awoman at high risk for thiscondition? Select all that apply.A) High body mass indexB) Urinary tract infectionC) Low socioeconomic statusD) Single gestationsE) SmokingAns: B, C, EHigh-risk factors associated with preterm PROM include lowsocioeconomic status, multiple gestation, low body mass index,tobacco use, preterm labor history, placenta previa, abruptio placenta,urinary tract infection, vaginal bleeding at any time in pregnancy,cerclage, and amniocentesis.A woman with placenta previa isbeing treated with expectantmanagement. The woman and fetusare stable. The nurse is assessing thewoman for possible dischargehome. Which statement by thewoman would suggest to the nursethat home care might beinappropriate?A) "My mother lives next door andcan drive me here if necessary."B) "I have a toddler and preschoolerat home who need my attention."C) "I know to call my health careprovider right away if I start to bleedagain."D) "I realize the importance offollowing the instructions for mycare."Ans: BHaving a toddler and preschooler at home needing attention suggestthat the woman would have difficulty maintaining bed rest at home.Therefore, expectant management at home may not be appropriate.Expectant management is appropriate if the mother and fetus are bothstable, there is no active bleeding, the client has readily available accessto reliable transportation, and can comprehend instructions.A woman with hyperemesisgravidarum asks the nurse aboutsuggestions to minimize nausea andvomiting. Which suggestion wouldbe most appropriate for the nurse tomake?A) "Make sure that anything aroundyour waist is quite snug."B) "Try to eat three large meals aday with less snacking."C) "Drink fluids in between mealsrather than with meals."D) "Lie down for about an hour afteryou eat"Ans: CSuggestions to minimize nausea and vomiting include avoiding tightwaistbands to minimize pressure on the abdomen, eating small frequentmeals throughout the day, separating fluids from solids by consumingfluids in between meals; and avoiding lying down or reclining for atleast 2 hours after eating.fml
A woman with gestationalhypertension experiences a seizure.Which of the following would be thepriority?A) Fluid replacementB) OxygenationC) Control of hypertensionD) Delivery of the fetusAns: BAs with any seizure, the priority is to clear the airway and maintainadequate oxygenation both to the mother and the fetus. Fluids andcontrol of hypertension are addressed once the airway andoxygenation are maintained. Delivery of fetus is determined once theseizures are controlled and the woman is stable.A woman is receiving magnesiumsulfate as part of her treatment forsevere preeclampsia. The nurse ismonitoring the woman's serummagnesium levels. Which levelwould the nurse identify astherapeutic?A) 3.3 mEq/LB) 6.1 mEq/LC) 8.4 mEq/LD) 10.8 mEq/LAns: BAlthough exact levels may vary among agencies, serum magnesiumlevels ranging from 4 to 7 mEq/L are considered therapeutic, whereaslevels more than 8 mEq/dL are generally considered toxic.A nurse is teaching a woman withmild preeclampsia about importantareas that she needs to monitor athome. The nurse determines that theteaching was successful based onwhich statements by the woman?Select all that apply.A. "I should check my bloodpressure twice a day."B. "I will weigh myself once a week."C. "I should complete a fetal kickcount each day."D. "I will check my urine for proteinfour times a day."E. "I'll call my health care provider ifI have burning when I urinate."Answer: A, C, ERationale: The client should take her blood pressure twice daily, checkand record weight daily, perform urine dipstick checks for protein twicedaily, record the number of fetal kicks daily, and notify her health careprovider if she experiences burning on urination.fml
A client comes to the emergencydepartment with moderate vaginalbleeding. She says, "I have had tochange my pad about every 2 hoursand it looks like I may have passedsome tissue and clots." The womanreports that she is 9 weeks'pregnant. Further assessmentreveals the following:-Cervical dilation-Strong abdominal cramping-Low human chorionicgonadotropin (hCG) levels-Ultrasound positive for products ofconceptionThe nurse suspects that the womanis experiencing which type ofspontaneous abortion?A. ThreatenedB. InevitableC. IncompleteD. CompleteAnswer: BRationale: Based on the assessment findings, the woman is likelyexperiencing an inevitable abortion characterized by vaginal bleeding,rupture of membranes, cervical dilation, strong abdominal cramping,possible passage of products of conception, and ultrasound and hCGlevels indicating pregnancy loss. A threatened abortion is characterizedby slight vaginal bleeding, no cervical dilation or cange in cervicalconsistency, mild abdominal cramping, close cervical os, and nopassage of fetal tissue. An incomplete abortion is characterized byintense abdominal cramping, heavy vaginal bleeding and cervicaldilation with passage of some products of conception. A completeabortion is characterized by a history of vaginal bleeding andabdominal pain along with passage of tissue and subsequent decreasein pain and decrease in bleeding.A pregnant client with preeclampsiais being treated with intravenousmagnesium sulfate. The nurseassesses the client's deep tendonreflexes and grades them as 4+. Thenurse notifies the health careprovider about this finding,describing them using which term toensure accurate communication?A. AbsentB. AverageC. BriskD. ClonusAnswer: DRationale: The National Institute of Neurological Disorders and Stroke, adivision of the National Institutes of Health, published a scale in theearly 1990s that, though subjective, is used widely today. It gradesreflexes from 0 to 4+. Grades 2+ and 3+ are considered normal, andgrades 0 which indicates an absent reflex and 4 which indicates clonusmay indicate pathology. Because these are subjective assessments, toimprove communication of reflex results, condensed descriptorcategories such as absent, average, brisk, or clonus should be usedrather than numeric codes. A 4+ grade indicates clonus which is thepresence of rhythmic involuntary contractions, most often at the foot orankle. Sustained clonus confirms central nervous system involvement.fml
A client who has experienced anincomplete abortion is prescribedmifepristone to assist in removingthe retained products ofconception. Which medicationwould the nurse expect to adminsterif prescribed before administeringmifepristone?A. Opioid analgesic for relief ofcrampingB. Antiemetic to minimize nauseaC. VItamin K to reduce bleedingD. Diuretic to promote fluid lossAnswer: BRationale: For the client receiving mifepristone, the nurse wouldanticipate administering an antiemetic beforehand to reduce nauseaand vomiting. Acetaminophen would be useful for pain relief, not anopioid. VItamin K or a diuretic would not be appropriate whenadministering mifepristone. Vitamin K would be used to counteractbleeding such as that associated with heparin administration. A diureticwould be appropriate to promote fluid excretion with fluid overload.A client at 33 weeks' gestationcomes to the emergencydepartment with vaginal bleeding.Assessment reveals the following:-Onset of slight vaginal bleeding at29 weeks with spontaneouscessation-Recent onset of bright red vaginalbleeding, more than with previousepisode-No uterine contractions at present-Fetal heart rate within normal range-Uterus soft and nontenderBased on the assessment findings,which condition would the nurselikely suspect?A. Placental abruptionB. Placenta previaC. Ruptured ectopic pregnancyD. PolyhydramniosAnswer: BRationale: The assessment findings suggest placenta previa, a bleedingcondition that occurs during the last two trimesters of pregnancy. It ischaracterized by slight birght red vaginal bleeding initially that stopsspontaneously and then recurs later in amounts greater than the initialepisode; absence of pain/contractions; soft, relaxed uterine tone; and afetal heart rate within normal parameters. Placental abruption ischaracterized by a sudden onset with concealed or visible dark vaginalbleeding, utuerie tenderness and pain, with a firm or rigid uterus andfetal distress. The hallmark of ectopic pregnancy is abdominal pain withspotting within 6 to 8 weeks after a missed menstrual period. If ectopicrupture or hemorrhage occurs before treatment begins, symptoms mayworsen and include severe, sharp, and sudden pain in the lowerabdomen as the tube tears open and the embryo is expelled into thepelvic cavity; feelings of faintness; referred pain to the shoulder area,indicating bleeding into the abdomen caused by phrenic nerveirritation; hypotension; marked abdominal tenderness with distention;and hypovolemic shock. Polyhydramnios is initially suspected whenuterine enlargement, maternal abdominal girth, and fundal height arelarger than expected for the fetus's gestational age. Withpolyhydramnios, there is a discrepancy between fundal height andgestational age, or a rapid growth of the uterus is noted. Shortness ofbreath and uterine contractions from overstretching may occur. Oftenthe fetal parts and heart rate are difficult to obtain because of theexcess fluid present.fml
Which woman should receiveRhoGAM postpartum?a. Nonsensitized Rh-negativemother with an Rh-negativenewbornb. Nonsensitized Rh-negativemother with an Rh-positive newbornc. Sensitized Rh-negative motherwith an Rh-positive newbornd. Sensitized Rh-negative motherwith an Rh-negative newbornBA woman is suspected of havingplacental abruption. Which findingwould the nurse expect to assess asa classic symptom?a. Painless, bright red bleedingb. "Knife-like" abdominal painc. Excessive nausea and vomitingd. Hypertension and headacheBRhoGAM is given to Rh-negativewomen to prevent maternalsensitization. In addition topregnancy, Rh-negative womenwould also receive this medicationafter which occurrence?a. Therapeutic or spontaneousabortionb. Head injury from a car accidentc. Blood transfusion after ahemorrhaged. Unsuccessful artificialinsemination procedureafml
After teaching a woman abouthyperemesis gravidarum and how itdiffers from the typical nausea andvomiting of pregnancy, whichstatement by the woman indicatesthat the teaching was successful?a."I can expect the nausea to lastthrough my second trimester."b. "I should drink fluids with mymeals instead of in between them."c. "I need to avoid strong odors,perfumes, or flavors."d. "I should lie down after I eat forabout 2 hours."CA pregnant woman who is atapproximately 12 weeks' gestationcomes to the emergencydepartment after calling her healthcare provider's office and reportingmoderate vaginal bleeding.Assessment reveals cervical dilationand moderately strong abdominalcramps. She reports that she haspassed some tissue with thebleeding. The nurse interprets thesefindings to suggest which of thefollowing?a. Threatened abortionb. Inevitable abortionc. Incomplete abortiond. Missed abortionCWhen administering magnesiumsulfate to a client with preeclampsia,the nurse explains to her that thisdrug is given toa. reduce blood pressure.b. increase the progress of labor.c. prevent seizures.d. lower blood glucose levels.Cfml
A woman is being discharged afterreceiving treatment for ahydatidiform molar pregnancy. Thenurse should include whichinformation in the dischargeteaching?a. Do not become pregnant for atleast a year; use contraceptives toprevent it.b. Have your blood pressurechecked weekly in the clinic.c. RhoGAM must be given within thenext month at the clinic.d. An amniocentesis can detect arecurrence of this disorder in thefuture.ANS: AThe nurse is teaching a pregnantwoman with type 1 diabetes abouther diet during pregnancy. Whichclient statement indicates that thenurse's teaching was successful?A) "I'll basically follow the same dietthat I was following before Ibecame pregnant."B) "Because I need extra protein, I'llhave to increase my intake of milkand meat."C) "Pregnancy affects insulinproduction, so I'll need to makeadjustments in my diet."D) "I'll adjust my diet and insulinbased on the results of my urinetests for glucose."Ans: CIn pregnancy, placental hormones cause insulin resistance at a level thattends to parallel growth of the fetoplacental unit. Nutritionalmanagement focuses on maintaining balanced glucose levels. Thus, thewoman will probably need to make adjustments in her diet. Proteinneeds increase during pregnancy, but this is unrelated to diabetes.Blood glucose monitoring results typically guide therapy.fml
A pregnant client with iron-deficiency anemia is prescribed aniron supplement. Afterteaching the woman about using thesupplement, the nurse determinesthat more teaching isneeded based on which clientstatement?A. "Taking the iron supplement withfood will help with the side effects."B. "I will need to avoid coffee andtea when I take this supplement."C. "I will take the iron with milkinstead of orange or grapefruitjuice."D. "If I happen to miss a dose, I willtake it as soon as I remember."Answer: CRationale:The pregnant client should take the iron supplement with vitamin C-containing fluids such as orange juice, which will promote absorption,rather than milk, which can inhibit iron absorption. Taking iron on anempty stomach improves its absorption, but many women cannottolerate the gastrointestinal discomfort it causes. In such cases, thewoman is advised to take it with meals. The woman also needsinstruction about adverse effects, which are predominantlygastrointestinal and include gastric discomfort, nausea, vomiting,anorexia, diarrhea, metallic taste, and constipation. Taking the ironsupplement with meals and increasing intake of fiber and fluids helpsovercome the most common side effects. If the woman misses a dose,she should take a dose as soon as she remembers.A nurse is obtaining a medicationhistory from a pregnant client with ahistory of systemic lupuserythematosus (SLE). Whichmedication(s) would the nurseexpect the woman to report to becurrently using? Select all that apply.A. IbuprofenB. HydroxychloroquineC. MethotrexateD. LeflunomideE. PrednisoneAnswer: A, B, ERationale: Treatment of SLE in pregnancy is generally limited to NSAIDslike ibuprofen, prednisone, and an antimalarial agent,hydroxychloroquine. Methotrexate and leflunomide are used to treatrheumatoid arthritis but are contraindicated for use in pregnancybecause of the potential for fetal toxicity.fml
A pregnant woman with chronichypertension is entering her secondtrimester. The nurse is providinganticipatory guidance to the womanabout measures to promote ahealthy outcome. The nursedetermines that the teaching wassuccessful based on which clientstatement(s)? Select all that apply.A. "I will need to schedule follow-upappointments every 2 weeks until Ireach 32 weeks'gestation."B. "I should try to lie down and reston my left side for about an houreach day."C. "I will start doing daily counts ofmy baby's activity at about 24 weeks'gestation."D. "I will need to have an ultrasoundat each visit beginning at 28 weeks'gestation."E. "I should take my blood pressurefrequently at home and report anyhigh readings."Answer: B, C, ERationale: The woman with chronic hypertension will be seen morefrequently (every 2 weeks until 28 weeks' gestation and then weekly untilbirth) to monitor her blood pressure and to assess for any signs ofpreeclampsia. At approximately 24 weeks' gestation, the woman will beinstructed to document fetal movement. At this same time, serialultrasounds will be prescribed to monitor fetal growth and amnioticfluid volume. The woman should also have daily periods of rest (1 hour)in the left lateral recumbent position to maximize placental perfusionand use home blood pressure monitoring devices frequently (dailychecks would be preferred), reporting any elevations.fml
A woman with a history of systemiclupus erythematosus comes to theclinic for evaluation.The woman tells the nurse that sheand her partner would like to have ababy but that they areafraid her lupus will be a problem.Which response would be mostappropriate for the nurse tomake?A. "It's probably not a good idea foryou to get pregnant since you havelupus."B. "Be sure that your lupus is stableor in remission for 6 months beforegetting pregnant."C. "Your lupus will not have anyeffect on your pregnancywhatsoever."D. "If you get pregnant, we'll have toadd quite a few medications to yournormal treatment plan.Answer: BRationale: The time at which the nurse comes in contact with the womanin her childbearing life cycle will determine the focus of the assessment.If the woman is considering pregnancy, it is recommended that shepostpone conception until the disease has been stable or in remissionfor 6 months. Active disease at time of conception and history of renaldisease increase the likelihood of a poor pregnancy outcome(Cunningham et al., 2018). In particular, if pregnancy is planned duringperiods of inactive or stable disease, the result is often giving birth tohealthy full-term babies without increased risks of pregnancycomplications. Nonetheless, pregnancies with most autoimmunediseases are still classified as high risk because of the potential for majorcomplications. Preconception counseling should include the medicaland obstetric risks of spontaneous abortion, stillbirth, fetal death, fetalgrowth restriction, preeclampsia, preterm labor, and neonatal death andthe need for more frequent visits for monitoring the condition.Treatment of SLE in pregnancy is generally limited to NSAIDs (e.g.,ibuprofen), prednisone, and an antimalarial agent, hydroxychloroquine.During pregnancy in the woman with SLE, the goal is to keep drugtherapy to a minimum.A nurse is conducting a program forpregnant women with gestationaldiabetes about reducingcomplications. The nurse determinesthat the teaching was successfulwhen the group identifies whichfactor as being most important inhelping to reduce complicationsassociated with pregnancy anddiabetes?A. stability of the woman's emotionaland psychological statusB. degree of blood glucose controlachieved during the pregnancyC. reduction in retinopathy risk byfrequent ophthalmologicevaluationsD. control of blood urea nitrogen(BUN) levels for optimal kidneyfunctionAnswer: BRationale: Therapeutic management for the woman with diabetesfocuses on tight glucose control, thereby minimizing the risks to themother, fetus, and neonate. The woman's emotional and psychologicalstatus is highly variable and may or may not affect the pregnancy.Evaluating for long-term diabetic complications such as retinopathy ornephropathy, as evidenced by laboratory testing such as BUN levels, isan important aspect of preconception care to ensure that the motherenters the pregnancy in an optimal state.fml
Because a pregnant client's diabeteshas been poorly controlledthroughout her pregnancy, the nursewould be alert for which of thefollowing in the neonate at birth?A) MacrosomiaB) HyperglycemiaC) Low birth weightD) HypobilirubinemiaAns: APoorly controlled diabetes during pregnancy can result in macrosomiadue to hyperinsulinemia stimulated by fetal hyperglycemia. Typically theneonate is hypoglycemic due to the ongoing hyperinsulinemia thatoccurs after the placenta is removed. Infants of diabetic womentypically are large and are at risk for hyperbilirubinemia due toexcessive red blood cell breakdown.A woman with diabetes isconsidering becoming pregnant.She asks the nurse whether she willbe able to take oral hypoglycemicswhen she is pregnant. The nurse'sresponse is based on theunderstanding that oralhypoglycemics:A) Can be used as long as theycontrol serum glucose levelsB) Can be taken until thedegeneration of the placenta occursC) Are usually suggested primarilyfor women who develop gestationaldiabetesD) Show promising results but morestudies are needed to confirm theireffectivenessAns: DSeveral studies have used glyburide (Diabeta) with promising results.Many health care providers are using glyburide and metformin as analternative to insulin therapy because they do not cross the placentaand therefore do not cause fetal/neonatal hypoglycemia. Some oralhypoglycemic medications are considered safe and may be used ifnutrition and exercise alone are not adequate. Maternal and newbornoutcomes are similar to those seen in women who are treated withinsulin. It is essential that oral hypoglycemic agents are furtherinvestigated to determine their safety with confidence and providebetter treatment options for diabetes in pregnancy.fml
A client in her first trimester comesto the clinic for an evaluation.Assessment revealsreports of fatigue, anorexia, andfrequent upper respiratoryinfections. The client's skin is paleand the client is slightly tachycardic.The client also reports drinkingabout 6 cups of coffee onaverage each day. A diagnosis ofiron-deficiency anemia is suspected.The client is scheduled forlaboratory testing and the resultsare as follows:•Hemoglobin 11.5 g/dL (115 g/L)•Hematocrit 35% (0.35)•Serum iron 32 µg/dL (5.73 µmol/L)•Serum ferritin 90 ng/dL (90 µg/L)Which laboratory finding would thenurse correlate with the suspecteddiagnosis?A. HemoglobinB. HematocritC. Serum iron levelD. Serum ferritin leveAnswer: DRationale: Laboratory tests for iron-deficiency anemia usually reveal lowhemoglobin (less than11 g/dL or 110 g/L), low hematocrit (less than 35% or 0.35), low serum iron(less than 30 µg/dLor 5.37 µmol/L), microcytic and hypochromic cells, and low serumferritin (less than 100 ng/dLor 100 µg/L). The client's hemoglobin, hematocrit, and serum iron levelsare borderline lownormal, but the client's serum ferritin is below 100 ng/dL (100 µg/L),helping to support thediagnosis.A 10-week pregnant woman withdiabetes has a glycosylatedhemoglobin (HbA1C) level of 13%. Atthis time the nurse should be mostconcerned about which of thefollowing possible fetal outcomes?A. congenital anomaliesB. incompetent cervixC. placenta previaD. placental abruption (abruptioplacentae)Answer: ARationale: A HbA1c level of 13% indicates poor glucose control. This, inconjunction with the woman being in the first trimester, increases the riskfor congenital anomalies in the fetus. Elevated glucose levels are notassociated with incompetent cervix, placenta previa, or placentalabruption (abruptio placentae).fml
A nurse is conducting a review classfor a group of perinatal nursesworking at the local clinic. The clinicsees a high population of womenwho are HIV positive. Afterdiscussing the recommendations forantiretroviral therapy with the group,the nurse determines that theteaching was successful when thegroup identifies which rationale asthe underlying principle for thetherapy?A) Reduction in viral loads in thebloodB) Treatment of opportunisticinfectionsC) Adjunct therapy to radiation andchemotherapyD) Can cure acute HIV/AIDSinfectionsAns: ADrug therapy is the mainstay of treatment and is important in reducingthe viral load as much as possible. Viral load directly correlates with therisk of perinatal transmission. Antiretroviral agents do not treatopportunistic infections and are not adjunctive therapy. There is no curefor HIV/AIDS.Assessment of a pregnant womanand her fetus reveals tachycardiaand hypertension. There is alsoevidence suggestingvasoconstriction. The nurse wouldquestion the woman about use ofwhich substance?A) MarijuanaB) AlcoholC) HeroinD) CocaineAns: DCocaine use produces vasoconstriction, tachycardia, and hypertensionin both the mother and fetus. The effects of marijuana are not yet fullyunderstood. Alcohol ingestion would lead to cognitive and behavioralproblems in the newborn. Heroin is a central nervous systemdepressant.When teaching a class of pregnantwomen about the effects ofsubstance abuse during pregnancy,which of the following would thenurse most likely include?A) Low-birth-weight infantsB) Excessive weight gainC) Higher pain toleranceD) Longer gestational periodsAns: ASubstance abuse during pregnancy is associated with low-birth-weightinfants, preterm labor, abortion, intrauterine growth restriction, abruptioplacentae, neurobehavioral abnormalities, and long-term childhooddevelopmental consequences. Excessive weight gain, higher paintolerance, and longer gestational periods are not associated withsubstance abuse.fml
A client who is HIV-positive is in hersecond trimester and remainsasymptomatic. She voices concernabout her newborn's risk for theinfection. Which of the followingstatements by the nurse would bemost appropriate?A) "You'll probably have a cesareanbirth to prevent exposing yournewborn."B) "Antibodies cross the placentaand provide immunity to thenewborn."C) "Wait until after the infant is bornand then something can be done."D) "Antiretroviral medications areavailable to help reduce the risk oftransmission."Ans: DDrug therapy is the mainstay of treatment for pregnant women infectedwith HIV. The goal of therapy is to reduce the viral load as much aspossible; this reduces the risk of transmission to the fetus. Decisionsabout the method of delivery should be based on the woman's viralload, duration of ruptured membranes, progress of labor, and otherpertinent clinical factors. The newborn is at risk for HIV because ofpotential perinatal transmission. Waiting until after the infant is born maybe too late.The nurse reviews the medicalrecord of a woman who has cometo the clinic for an evaluation. Theclient has a history of mitral valveprolapse and is listed as risk class II.During the visit, the woman states,"We want to have a baby, but I knowI am at higher risk. But what is myrisk, really?" Which response by thenurse would be appropriate?A. "If you do get pregnant, you willneed to be seen by a cardiologistevery other month for monitoring."B. "Your risk during pregnancy issmall, but you should see yourcardiologist first before gettingpregnant."C. "Your heart disease would put toomuch strain on your heart if youwere to get pregnant."D. "Your pregnancy would beuneventful, but you would needspecialized care for labor and birth."Answer: BRationale: Typically, a woman with class I or II cardiac disease can gothrough a pregnancy without major complications. For class I disease,there is no detectable increased risk of maternal mortality and noincrease or a mild increase in morbidity. For class II disease, there is asmall increased risk of maternal mortality or moderate increase inmorbidity and cardiac consultation should occur every trimester. It isbest to have the woman see her cardiologist before becomingpregnant. A woman with class III disease needs frequent visits with thecardiac care team throughout pregnancy. There is a significantlyincreased risk of maternal mortality or severe morbidity and cardiologistconsult should occur every other month with prenatal care and deliveryoccurring at an appropriate level hospital. A woman with class IVdisease is typically advised to avoid pregnancy.fml
When assessing a pregnant womanwith heart disease throughout theantepartal period, the nurse wouldbe especially alert for signs andsymptoms of cardiacdecompensation at which time?A) 16 to 20 weeks' gestationB) 20 to 24 weeks' gestationC) 24 to 28 weeks' gestationD) 28 to 32 weeks' gestationAns: DA pregnant woman with heart disease is most vulnerable for cardiacdecompensation from 28 to 32 weeks' gestation.When preparing a schedule offollow-up visits for a pregnantwoman with chronic hypertension,which of the following would bemost appropriate?A) Monthly visits until 32 weeks, thenbi-monthly visitsB) Bi-monthly visits until 28 weeks,then weekly visitsC) Monthly visits until 20 weeks, thenbi-monthly visitsD) Bi-monthly visits until 36 weeks,then weekly visitsAns: BFor the woman with chronic hypertension, antepartum visits typicallyoccur every 2 weeks until 28 weeks' gestation and then weekly to allowfor frequent maternal and fetal surveillance.A woman with a history of asthmacomes to the clinic for evaluation forpregnancy. The woman's pregnancytest is positive. When reviewing thewoman's medication therapyregimen for asthma, whichmedication would the nurse identifyas problematic for the woman nowthat she is pregnant?A. ipratropiumB. albuterolC. salmeterolD. PrednisoneAnswer: DRationale: Oral corticosteroids such as prednisone are not preferred forthe long-term treatment of asthma during pregnancy. Inhaled steroidsare the choice for maintenance medications to reduce inflammation thatleads to bronchospasm. Common ones prescribed includebeclomethasone and salmeterol. Rescue agents such as albuterol oripratropium provide immediate symptomatic relief by reducing acutebronchospasm.fml
A pregnant woman is diagnosedwith iron-deficiency anemia and isprescribed an iron supplement.After teaching her about herprescribed iron supplement, whichstatement indicates successfulteaching?A. "I should take my iron with milk."B. "I should avoid drinking orangejuice."C. "I need to eat foods high in fiber."D. "I'll call the primary care providerif my stool is black and tarry."Answer: CRationale: Iron supplements can lead to constipation, so the womanneeds to increase her intake of fluids and high-fiber foods. Milk inhibitsabsorption and should be discouraged. Vitamin C- containing fluidssuch as orange juice are encouraged because they promote absorption.Ideallythe woman should take the iron on an empty stomach to improveabsorption, but many women cannot tolerate the gastrointestinaldiscomfort it causes. In such cases, the woman should take it with meals.Iron typically causes the stool to become black and tarry; there is noneed for the woman to notify her primary care provider.A nurse is providing care to severalpregnant women at the clinic. Thenurse would screen for group Bstreptococcus infection in a client at:A) 16 weeks' gestationB) 28 week' gestationC) 32 weeks' gestationD) 36 weeks' gestationAnswer: DRationale: Pregnant women between 36 and 37 weeks' gestation shouldbe universally screened for GBS infection during a prenatal visit and ifpositive, receive appropriate intrapartum antibiotic prophylaxis.The nurse is assessing a newborn ofa woman who is suspected ofabusing alcohol. Which newbornfinding would provide additionalevidence to support this suspicion?A) Wide large eyesB) Thin upper lipC) Protruding jawD) Elongated noseAns: BNewborn characteristics suggesting fetal alcohol spectrum disorderinclude thin upper lip, small head circumference, small eyes, recedingjaw, and short nose. Other features include a low nasal bridge, shortpalpebral fissures, flat midface, epicanthal folds, and minor earabnormalities.fml
After teaching a group of nursingstudents about the impact ofpregnancy on the older woman, theinstructor determines that theteaching was successful when thestudents state which of thefollowing?A) "The majority of women whobecome pregnant over age 35experience complications."B) "Women over the age of 35 whobecome pregnant require aspecialized type of assessment."C) "Women over age 35 and arepregnant have an increased risk forspontaneous abortions."D) "Women over age 35 are morelikely to have substance abuseproblems."Answer: CRationale: Whether childbearing is delayed by choice or by chance,women starting a family at age 35 or older are not doing so without risk.Women in this age group may already have chronic health conditionsthat can put the pregnancy at risk. In addition, numerous studies haveshown that increasing maternal age is a risk factor for infertility andspontaneous abortions, gestational diabetes, chronic hypertension,postpartum hemorrhage, preeclampsia, preterm labor and birth,multiple pregnancy, genetic disorders and chromosomal abnormalities,placenta previa, fetal growth restriction, low Apgar scores, and surgicalbirths (Dillion et al. 2019). However, even though increased age impliesincreased complications, most women today who become pregnantafter age 34, have healthy pregnancies and healthy newborns. Nursingassessment of the pregnant woman over age 35 is the same as that forany pregnant woman. Women of this age have the same risk for asubstance use disorder as any other age group.A young adult woman comes to theclinic for a routine check-up. Duringthe visit, the woman who works in aday care facility tells the nurse thatshe and her partner are consideringhaving a baby. "We are concernedthat I might be exposed to commonchildhood illnesses." The womanundergoes testing and finds out thatshe is not immune from chickenpox.Based on this information, whichinformation would the nurse give tothe client?A. "You will need to be vaccinatednow and wait at least 1 month beforegetting pregnant."B. "It is very likely that you will needto quit your job if you do getpregnant."C. "Because chickenpox is so rarenowadays, there is nothing to worryabout."D. "You will need to take a leave ofabsence during winter and springmonths."Answer: ARationale: Preconception counseling is important for preventingchickenpox (varicella). A major component of counseling involvesdetermining the woman's varicella immunity. Vaccination is thecornerstone of prevention. The vaccine is administered if needed.Varicella vaccine is a live attenuated viral vaccine. It should beadministered to all adolescents and adults 13 years of age and olderwho do not have evidence of varicella immunity. Therefore, the womanshould be vaccinated now before she becomes pregnant and then waitat least 1 month before getting pregnant. The varicella vaccine iscontraindicated for pregnant women because the effects of the vaccineon the fetus are unknown. There is no need for the woman to quit herjob once she is immunized nor does she need to take a leave ofabscence during the winter and spring months when the incidence ishighest. Chickenpox does occur and is highly contagious. Maternalvaricella can be transmitted to the fetus through the placenta, leadingto congenital varicella syndrome if the mother is infected during the firsthalf of pregnancy via an ascending aorta.fml
A nurse is conducting an in-servicepresentation to a group of perinatalnurses about sexually transmittedinfections and their effect onpregnancy. The nurse determinesthat the teaching was successfulwhen the group identifies whichinfection as being responsible forophthalmia neonatorum?A) SyphilisB) GonorrheaC) ChlamydiaD) HPVAns: BInfection with gonorrhea during pregnancy can cause ophthalmianeonatorum in the newborn from birth through an infected birth canal.Infection with syphilis can cause congenital syphilis in the neonate.Infection with chlamydia can lead to conjunctivitis or pneumonia in thenewborn. Exposure to HPV during birth is associated with laryngealpapillomas.A nurse is preparing a presentationfor a group of young adult pregnantwomen about common infectionsand their effect on pregnancy. Whendescribing the infections, whichinfection would the nurse include asthe most common congenital andperinatal viral infection in the world?A) RubellaB) Hepatitis BC) CytomegalovirusD) Parvovirus B19Ans: CAlthough rubella, hepatitis B, and parvovirus B19 can affect pregnantwomen and their fetuses, cytomegalovirus (CMV) is the most commoncongenital and perinatal viral infection in the world. CMV is the leadingcause of congenital infection, with morbidity and mortality at birth andsequelae. Each year approximately 1-7% of pregnant women acquire aprimary CMV infection. Of these, about 30-40% transmits infection totheir fetuses.A pregnant woman asks the nurse,"I'm a big coffee drinker. Will thecaffeine in my coffee hurt my baby?"Which response by the nurse wouldbe most appropriate?A) "The caffeine in coffee has beenlinked to birth defects."B) "Caffeine has been shown tocause growth restriction in thefetus."C) "Caffeine is a stimulant and needsto be avoided completely."D) "If you keep your intake to lessthan 300 mg/day, you should beokay."Answer: DRationale: The effect of caffeine intake during pregnancy on fetalgrowth and development is still unclear. A recent study found thatcaffeine intake of no more than 200 mg/day during pregnancy does notaffect pregnancy duration and the condition of the newborn. Birthdefects have not been linked to caffeine consumption, but maternalcoffee consumption decreases iron absorption and may increase therisk of anemia during pregnancy. It is not known if there is a correlationbetween high caffeine intake and miscarriage due to lack of sufficientstudies.fml
A neonate born to a mother whowas abusing heroin is exhibitingsigns and symptoms of withdrawal.Which of the following would thenurse assess? (Select all that apply.)A) Low whimpering cryB) HypertonicityC) LethargyD) Excessive sneezingE) Overly vigorous suckingF) TremorsAns: B, D, FSigns and symptoms of withdrawal, or neonatal abstinence syndrome,include: irritability, hypertonicity, excessive and often high-pitchedcrying, vomiting, diarrhea, feeding disturbances, respiratory distress,disturbed sleeping, excessive sneezing and yawning, nasal stuffiness,diaphoresis, fever, poor sucking, tremors, and seizures.A nurse has been invited to speak ata local high school aboutadolescent pregnancy. Whendeveloping the presentation, thenurse would incorporateinformation related to whichaspects? Select all that apply.A. peer pressure to becomesexually activeB. rise in teen birth rates over theyears.C. Asian Americans as having thehighest teen birth rateD. loss of self-esteem as a majorimpactE. about half occurring within a yearof first sexual intercourseAnswer: A, DRationale: Adolescent pregnancy has emerged as one of the mostsignificant social problems facing our society. Early pregnancies amongadolescents have major health consequences for mothers and theirinfants. The latest estimates show that approximately 1 million teenagersbecome pregnant each year in the United States, accounting for 13% ofall U.S. births, but the rates have been declining in the last several years.Teen birth rates in the United States have declined but remainhigh,especially among African American and Hispanic teenagers andadolescents in southern states. The most important impact lies in thepsychosocial area as it contributes to a loss of self-esteem, adestruction of life projects, and the maintenance of the circle ofpoverty. Moreover, about half of all teen pregnancies occur within 6months of first having sexual intercourse. About one in four teenmothers under age 18 have a second baby within 2 years after the birthof the first baby.A nurse is counseling a pregnantwoman with rheumatoid arthritisabout medications that can be usedduring pregnancy. Which drugwould the nurse emphasize as beingcontraindicated at this time?A) HydroxychloroquineB) Nonsteroidal anti-inflammatorydrugC) GlucocorticoidD) MethotrexateAns: DMethotrexate is a FDA Category X drug and is contraindicated duringpregnancy. For rheumatoid arthritis, medications are limited tohydroxychloroquine, glucocorticoids, and NSAIDS.fml
A nurse is preparing a teachingprogram for a group of pregnantwomen about preventing infectionsduring pregnancy. When describingmeasures for preventingcytomegalovirus infection, which ofthe following would the nurse mostlikely include?A) Frequent handwashingB) ImmunizationC) Prenatal screeningD) Antibody titer screeningAns: AMost women are asymptomatic and don't know they have beenexposed to CMV. Prenatal screening for CMV infection is not routinelyperformed. Since there is no therapy that prevents or treats CMVinfections, nurses are responsible for educating and supportingchildbearing-age women at risk for CMV infection. Stressing theimportance of good handwashing and use of sound hygiene practicescan help to reduce transmission of the virus. There is no immunizationfor CMV. Antibody titer levels would be useful for identifying women atrisk for rubella.A pregnant woman comes to theclinic for her first evaluation. Thewoman is screened for hepatitis B(HBV) and tests positive. The nursewould anticipate administeringwhich agent?A) HBV immune globulinB) HBV vaccineC) AcyclovirD) ValacyclovirAnswer: ARationale: If a woman tests positive for HBV, expect to administer HBVimmune globulin. The newborn will also receive HBV vaccine within 12hours of birth. Acyclovir or valacyclovir would be used to treat herpessimplex virus infection.After teaching a pregnant womanwith iron deficiency anemia aboutnutrition, the nurse determines thatthe teaching was successful whenthe woman identifies which of thefollowing as being good sources ofiron in her diet? (Select all thatapply.)A) Dried fruitsB) Peanut butterC) MeatsD) MilkE) White breadAns: A, B, CFeedback:Foods high in iron include meats, green leafy vegetables, legumes,dried fruits, whole grains, peanut butter, bean dip, whole-wheat fortifiedbreads and cereals.fml
A nurse is conducting a presentationfor a group of pregnant womenabout measures to preventtoxoplasmosis. The nursedetermines that additional teachingis needed when the group identifieswhich measure as preventive?A. washing raw fruits and vegetablesbefore eating themB. cooking all meat to an internaltemperature of 125°F (52°C)C. wearing gardening gloves whenworking in the soilD. avoiding contact with a cat's litterboxAnswer: BRationale: Meats should be cooked to an internal temperature of 160°F(71°C). Other measures to prevent toxoplasmosis include peeling orthoroughly washing all raw fruits and vegetablesbefore eating them, wearing gardening gloves when in contact withoutdoor soil, and avoiding the emptying or cleaning of a cat's litter box.A pregnant woman with gestationaldiabetes comes to the clinic for afasting blood glucose level. Whenreviewing the results, the nursedetermines that the woman isachieving good glucose controlbased on which result?A. 88 mg/dLB. 100 mg/dLC. 110 mg/dLD. 120 mg/dLAnswer: ARationale: For a pregnant woman with diabetes, the ADA and ACOGrecommend maintaining a fasting blood glucose level below 95 mg/dL,with postprandial levels below 140 mg/dL at 1 hour, below 120 mg/dL at2 hours.After spontaneous rupture ofmembranes, the nurse notices aprolapsed cord. The nurseimmediately places the woman inwhich position?A. supineB. side-lyingC. sittingD. knee-chestAnswer: DRationale: Pressure on the cord needs to be relieved. Therefore, thenurse would position the woman in a modified Sims, Trendelenburg, orknee-chest position. Supine, side-lying, or sitting would not providerelief of cord compression.fml
A primigravida whose labor wasinitially progressing normally is nowexperiencing a decrease in thefrequency and intensity of hercontractions. The nurse wouldassess the woman for whichcondition?A. a low-lying placentaB. fetopelvic disproportionC. contraction ringD. uterine bleedingAnswer: BRationale: The woman is experiencing dystocia most likely due tohypotonic uterine dysfunction and fetopelvic disproportion associatedwith a large fetus. A low-lying placenta, contraction ring, or uterinebleeding would not be associated with a change in labor pattern.Which assessment finding will alertthe nurse to be on the lookout forpossible placental abruption duringlabor?A. macrosomiaB. gestational hypertensionC. gestational diabetesD. low parityAnswer: BRationale: Risk factors for placental abruption include preeclampsia,gestational hypertension, seizure activity, uterine rupture, trauma,smoking, cocaine use, coagulation defects, previous history ofabruption, intimate partner violence, and placental pathology.Macrosomia, gestational diabetes, and low parity are not consideredrisk factors.A woman in labor is experiencinghypotonic uterine dysfunction.Assessment reveals no fetopelvicdisproportion. Which group ofmedications would the nurse expectto administer?A. sedativesB. tocolyticsC. uterine stimulantsD. corticosteroidsAnswer: CRationale: For hypotonic labor, a uterine stimulant such as oxytocin maybe prescribed once fetopelvic disproportion is ruled out. Sedativesmight be helpful for the woman with hypertonic uterine contractions topromote rest and relaxation. Tocolytics would be ordered to controlpreterm labor. Corticosteroids may be given to enhance fetal lungmaturity for women experiencing preterm labor.A woman gave birth to a newbornvia vaginal birth with the use of avacuum extractor. The nurse wouldbe alert for which possible effect inthe newborn?A. asphyxiaB. clavicular fractureC. cephalhematomaD. central nervous system injuryAnswer: CRationale: Use of forceps or a vacuum extractor poses the risk of tissuetrauma, such as ecchymoses, facial and scalp lacerations, facial nerveinjury, cephalhematoma, and caput succedaneum. Asphyxia may berelated to numerous causes, but it is not associated with use of avacuum extractor. Clavicular fracture is associated with shoulderdystocia. Central nervous system injury is not associated with the use ofa vacuum extractor.fml
A pregnant client undergoing laborinduction is receiving an oxytocininfusion. Which finding wouldrequire immediate intervention?A. fetal heart rate of 150beats/minuteB. contractions every 2 minutes,lasting 45 secondsC. uterine resting tone of 14 mm HgD. urine output of 20 mL/hourAnswer: DRationale: Oxytocin can lead to water intoxication. Therefore, a urineoutput of 20 mL/hour is below acceptable limits of 30 mL/hour andrequires intervention. FHR of 150 beats/minute is within the acceptedrange of 120 to 160 beats/minute. Contractions should occur every 2 to 3minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20mm Hg would require intervention.A woman with a history of crackcocaine use disorder is admitted tothe labor and birth area. Whilecaring for the client, the nurse notesa sudden onset of fetal bradycardia.Inspection of the abdomen revealsan irregular wall contour. The clientalso reports acute adominal painthat is continuous. Which conditionwould the nurse suspect?A. amniotic fluid embolismB. shoulder dystociaC. uterine ruptureD. umbilical cord prolapseAnswer: CRationale: Uterine rupture is associated with crack cocaine use disorder.Generally, the first and most reliable sign is sudden fetal distressaccompanied by acute abdominal pain, vaginal bleeding, hematuria,irregular wall contour, and loss of station in the fetal presenting part.Amniotic fluid embolism often is manifested with a sudden onset ofrespiratory distress. Shoulder dystocia is noted when continued fetaldescent is obstructed after the fetal head is delivered. Umbilical cordprolapse is noted as the protrusion of the cord alongside or ahead ofthe presenting part of the fetus.A woman receives magnesiumsulfate as treatment for pretermlabor. The nurse assess andmaintains the infusion at theprescribed rate based on whichfinding?A. Respiratory rate-16breaths/minuteB. Decreased fetal heart ratevariabilityC. Urine output 22 mL/hourD. Absent deep tendon reflexesAnswer: BRationale: A respiratory rate of 16 breaths per minute is appropriate andwithin acceptable parameters to continue the infusion. Whenadministering magnesium sulfate, the nurse would immediately reportdecreaed fetal heart rate variability, a urine output less than 30 mL/hour,and decreased or absent deep tendon reflexes.fml
The nurse is reviewing the physicalexamination findings for a client whois to undergo laborinduction. Which finding wouldindicate to the nurse that a woman'scervix is ripe in preparation for laborinduction?A. posterior positionB. firmC. closedD. shortenedAnswer: DRationale: A ripe cervix is shortened, centered (anterior), softened, andpartially dilated. An unripe cervix is long, closed, posterior, and firm.A woman with preterm labor isreceiving magnesium sulfate. Whichfinding would requirethe nurse to intervene immediately?A. respiratory rate of 16 breaths perminuteB. 1+ deep tendon reflexesC. urine output of 45 mL/hourD. alert level of consciousnessAnswer: BRationale: Diminished deep tendon reflexes (1+) suggest magnesiumtoxicity, which requires immediate intervention. Additional signs ofmagnesium toxicity include a respiratory rate less than 12breaths/minute, urine output less than 30 mL/hour, and a decreasedlevel of consciousness.After teaching a couple about whatto expect with their plannedcesarean birth, whichstatement indicates the need foradditional teaching?A. "Holding a pillow against myincision will help me when I cough."B. "I'm going to have to wait a fewdays before I can startbreastfeeding."C. "I guess the nurses will be gettingme up and out of bed ratherquickly."D. "I'll probably have a tube in mybladder for about 24 hours or so"Answer: BRationale: Typically, breastfeeding is initiated early as soon as possibleafter birth to promote bonding. The woman may need to use alternatepositioning techniques to reduce incisional discomfort. Splinting withpillows helps to reduce the discomfort associated with coughing. Earlyambulation is encouraged to prevent respiratory and cardiovascularproblems and promote peristalsis. An indwelling urinary catheter istypically inserted to drain the bladder. It usually remains in place forapproximately 24 hours.When describing the stages of laborto a pregnant woman, which of thefollowing would the nurse identifyas the major change occurringduring the first stage?A. Regular contractionsB. Cervical dilationC. Fetal movement through the birthcanalD. Placental separationAnswer: BRationale: The primary change occurring during the first stage of laboris progressive cervical dilation. Contractions occur during the first andsecond stages of labor. Fetal movement through the birth canal is themajor change during the second stage of labor. Placental separationoccurs during the third stage of labor.fml
The nurse is providing care toseveral pregnant women who maybe scheduled for labor induction.The nurse identifies the woman withwhich Bishop score as having thebest chance for a successfulinduction and vaginal birth?A. 11B. 7C. 5D. 3Answer: ARationale: The Bishop score helps identify women who would be mostlikely to achieve a successful induction. The duration of labor is inverselycorrelated with the Bishop score: a score over 8 indicates a successfulvaginal birth. Therefore the woman with a Bishop score of 11 would havethe greatest chance for success. Bishop scores of less than 6 usuallyindicate that a cervical ripening method should be used prior toinduction.A nurse is reviewing the medicalrecord of a pregnant client. Thenurse suspects that the client maybe at risk for dystocia based onwhich factors? Select all that apply.A. plan for pudendal blockanesthetic useB. multiparityC. short maternal statureD. Body mass index 30.2E. breech fetal presentationAnswer: C, D, ERationale: Risk factors for dystocia may include maternal short stature,obesity, hydramnios, uterine abnormalities, fetal malpresentation,cephalopelvic disproportion, overstimulation with oxytocin, maternalexhaustion, ineffective pushing, excessive size fetus, poor maternalpositioning in labor, and maternal anxiety and fearA nurse is preparing an inserviceeducation program for a group ofnurses about dystocia involvingproblems with the passenger. Whichproblem would the nurse likelyinclude as the most common?A. macrosomiaB. breech presentationC. persistent occiput posteriorpositionD. multifetal pregnancyAnswer: CRationale: Common problems involving the passenger include occiputposterior position, breech presentation, multifetal pregnancy, excessivesize (macrosomia) as it relates to cephalopelvic disproportion (CPD),and structural anomalies. Of these, persistent occiput posterior is themost common malposition, occurring in about 15% of laboring women.A nurse is conducting a reviewcourse on tocolytic therapy forperinatal nurses. After teaching thegroup, the nurse determines that theteaching was successful when theyidentify which drugs as being usedfor tocolysis? Select all that apply.A. nifedipineB. magnesium sulfateC. dinoprostoneD. misoprostolE. indomethacinAnswer: A, B, ERationale: Medications most commonly used for tocolysis includemagnesium sulfate (which reduces the muscle's ability to contract),indomethacin (a prostaglandin synthetase inhibitor), and nifedipine (acalcium channel blocker). These drugs are used "off label": this meansthey are effective for this purpose but have not been officially testedand developed for this purpose by the FDA. Dinoprostone andmisoprostol are used to ripen the cervix.fml
A nurse is teaching a pregnantwoman at risk for preterm laborabout what to do if she experiencessigns and symptoms. The nursedetermines that the teaching wassuccessful whenthe woman makes which statement?A. "I'll sit down to rest for 30minutes."B. "I'll try to move my bowels."C. "I'll lie down with my legs raised."D. "I'll drink several glasses of water."Answer: DRationale: If the woman experiences any signs and symptoms ofpreterm labor, she should stop what she is doing and rest for 1 hour,empty her bladder, lie down on her side, drink two to three glasses ofwater, feel her abdomen and note the hardness of the contraction, andcall her health care provider and describe the contraction.A nurse is describing the risksassociated with post-termpregnancies as part of an inservicepresentation. The nurse determinesthatmore teaching is needed whenthe group identifies which factor asan underlying reason for problemsin the fetus?A. aging of the placentaB. increased amniotic fluid volumeC. meconium aspirationD. cord compressionAnswer: BRationale: Fetal risks associated with a post-term pregnancy includemacrosomia, shoulder dystocia, brachial plexus injuries, low Apgarscores, postmaturity syndrome (loss of subcutaneous fat and muscleand meconium staining), and cephalopelvic disproportion. As theplacenta ages, its perfusion decreases and it becomes less efficient atdelivering oxygen and nutrients to the fetus. Amniotic fluid volume alsobegins to decline after 38 weeks' gestation, possibly leading tooligohydramnios, subsequently resulting in fetal hypoxia and anincreased risk of cord compression because the cushioning effectoffered by adequate fluid is no longer present. Hypoxia andoligohydramnios predispose the fetus to aspiration of meconium, whichis released by the fetus in response to a hypoxic insult (Norwitz, 2019).All of these issues can compromise fetal well-being and lead to fetaldistress.A nurse is explaining to a group ofnurses new to the labor and birthunit about methods used forcervical ripening. The groupdemonstrates understanding of theinformation when they identifywhich method as a mechanical one?A. herbal agentsB. laminariaC. membrane strippingD. amniotomyAnswer: BRationale: Laminaria is a hygroscopic dilator that is used as a mechanicalmethod for cervical ripening. Herbal agents are a nonpharmacologicmethod. Membrane stripping and amniotomy are considered surgicalmethods.fml
The nurse notifies the obstetricalteam immediately because the nursesuspects that the pregnant womanmay be exhibiting signs andsymptoms of amniotic fluidembolism. When reporting thissuspicion, which finding(s) would thenurse include in the report? SATAA. significant difficulty breathingB. hypertensionC. tachycardiaD. pulmonary edemaE. bleeding with bruisingAnswer: A, C, D, ERationale: Anaphylactoid syndrome of pregnancy (ASP), also known asamniotic fluid embolism, is an unforeseeable, life-threateningcomplication of childbirth. The etiology of ASP remains an enigmatic,devastating obstetric condition associated with significant maternal andnewborn morbidity and mortality. It is a rare and often fatal eventcharacterized by the sudden onset of hypotension, cardiopulmonarycollapse, hypoxia, and coagulopathy. ASP should be suspected in anypregnant women with an acute onset of dyspnea, hypotension, and DIC.By knowing how to intervene, the nurse can promote a better chance ofsurvival for both the mother and her newborn.A nurse is conducting an in-serviceprogram for a group of labor andbirth unit nurses about cesareanbirth. The group demonstratesunderstanding of the informationwhen they identify which conditionsas appropriate indications? Selectall that apply.A. active genital herpes infectionB. placenta previaC. previous cesarean birthD. prolonged laborE. fetal distressAnswer: A, B, C, ERationale: The leading indications for cesarean birth are previouscesarean birth, breech presentation, dystocia, and fetal distress.Examples of specific indications include active genital herpes, fetalmacrosomia, fetopelvic disproportion, prolapsed umbilical cord,placental abnormality (placenta previa or placental abruption), previousclassic uterine incision or scar, gestational hypertension, diabetes,positive human immunodeficiency virus (HIV) status, and dystocia. Fetalindications include malpresentation (nonvertex presentation), congenitalanomalies (fetal neural tube defects, hydrocephalus, abdominal walldefects), and fetal distress.A pregnant woman is receivingmisoprostol to ripen her cervix andinduce labor. The nurse assesses thewoman closely for which effect?A. uterine hyperstimulationB. headacheC. blurred visionD. hypotensionAnswer: ARationale: A major adverse effect of the obstetric use of misoprostol ishyperstimulation of the uterus, which may progress to uterine tetanywith marked impairment of uteroplacental blood flow, uterine rupture(requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism. Headache, blurred vision,and hypotension are associated with magnesium sulfate.fml
A nurse is teaching a woman aboutmeasures to prevent preterm laborin future pregnancies t because thewoman just experienced pretermlabor with her most recentpregnancy. The nurse determinesthat the teaching was successfulbased on which statement by thewoman?A. "I'll make sure to limit the amountof long distance traveling I do."B. "Stress isn't a problem that isrelated to preterm labor."C. "Separating pregnancies by abouta year should be helpful."D. "I'll need extra iron in my diet so Ihave extra for the baby."Answer: ARationale: Appropriate measures to reduce the risk for preterm laborinclude: avoiding travel for long distances in cars, trains, planes orbuses; achieving adequate iron store through balanced nutrition (excessiron is not necessary); waiting for at least 18 months betweenpregnancies, and using stress management techniques for stress.A pregnant woman at 31-weeks'gestation calls the clinic and tellsthe nurse that she is havingcontractions sporadically. Whichinstructions would be mostappropriate for the nurse to give thewoman? Select all that apply.A. "Walk around the house for thenext half hour."B. "Drink two or three glasses ofwater."C. "Lie down on your back."D. "Try emptying your bladder."E. "Stop what you are doing andrest."ANS: B, D, ERationale: Appropriate instructions for the woman who may beexperiencing preterm labor include having the client stop what she isdoing and rest for an hour, empty her bladder, lie down on her left side,and drink two to three glasses of water.A pregnant client has receiveddinoprostone. Followingadministration of this medication, thenurse assesses the client anddetermines that the client isexperiencing an adverse effect ofthe medication based on whichclient report? Select all that apply.A. headacheB. nauseaC. diarrheaD. tachycardiaE. hypotensionANS: A, B, CRationale: Adverse effects associated with dinoprostone includeheadache, nauseas and vomiting, and diarrhea. Tachycardia andhypotension are not associated with this drug.fml
A nurse is reading a journal articleabout cesarean births and theindications for them. Place theindications for cesarean birth belowin the proper sequence from mostfrequent to least frequent. Alloptions must be used.A. Labor dystociaB. Abnormal fetal heart rate tracingC. Fetal malpresentationD. Multiple gestationE. Suspected macrosomiaAnswer: A, B, C, D, ERationale: The most common indications for primary cesarean birthsinclude, in order of frequency: labor dystocia as the labor does notprogress, abnormal fetal heart rate tracing indicating fetal distress, fetalmalpresentation making a difficult progression of labor, multiplegestation , and suspected macrosomia.A nurse is taking a history on awoman who is at 20 weeks'gestation. The woman reports thatshe feels some heaviness in herthighs since yesterday. The nursesuspects that the woman may beexperiencing preterm labor basedon which additional assessmentfindings? SATAA. dull low backacheB. viscous vaginal dischargeC. dysuriaD. constipationE. occasional crampingAnswer: A, B, CRationale: Symptoms of preterm labor are often subtle and may includechange or increase in vaginal discharge with mucus, water, or blood init; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, andheaviness or aching in the thighs. Constipation is not known to be a signof preterm labor. Preterm labor is assessed when there are more thansix contractions per hour. Occasional asymptomatic cramping can benormal.A pregnant client at 24 weeks'gestation comes to the clinic for anevaluation. The client called theclinic earlier in the day stating thatshe had not felt the fetus movingsince yesterday evening. Furtherassessment reveals absent fetalheart tones. Intrauterine fetaldemise is suspected. The nursewould expect to prepare the clientfor which testing to confirm thesuspicion?A. UltrasoundB. AmniocentesisC. Human chorionic gonadotropin(hCG) levelD. Triple marker screeningAnswer: ARationale: A client experiencing an intrauterine fetal demise (IUFD) islikely to seek care when she notices that the fetus is not moving or whenshe experiences contractions, loss of fluid, or vaginal bleeding. Historyand physical examination frequently are of limited value in the diagnosisof fetal death, since many times the only history tends to be recentabsence of fetal movement and no fetal heart beat heard. An inability toobtain fetal heart sounds on examination suggests fetal demise, but anultrasound is necessary to confirm the absence of fetal cardiac activity.Once fetal demise is confirmed, induction of labor or expectantmanagement is offered to the client. An amniocentesis, hCG level, ortriple marker screening would not be used to confirm IUFD.fml
A 32-year-old black woman in hersecond trimester has come to theclinic for an evaluation. Whileinterviewing the client, she reports ahistory of fibroids and urinary tractinfection. The client states, "I knowsmoking is bad and I have tried tostop, but it is impossible. I have cutdown quite a bit though, and I donot drink alcohol." Complete bloodcount results reveal a low red bloodcell count, low hemoglobin, and lowhematocrit. When planning thisclient's care, which factor(s) wouldthe nurse identify as increasing theclient's risk for preterm labor?Selectall that apply.A. African heritageB. Maternal ageC. History of fibroidsD. Cigarette smokingE. History of urinary tract infectionsF. Complete blood count resultsAnswer: A, C, D, E, FRationale: For this client, risk factors associated with preterm labor andbirth would include African heritage, cigarette smoking, uterineabnormalities, such as fibroids, urinary tract infection, and possibleanemia based on her complete blood count results. Maternal ageextremes (younger than 16 years and older than 35 years) are also a riskfactor but do not apply to this client.A pregnant client at 30 weeks'gestation calls the clinic becauseshe thinks that she may be in stlabor. To determine if the client isexperiencing labor, whichquestion(s) would be appropriatefor the nurse to ask? Select all thatapply.A. "Are you feeling any pressure orheaviness in your pelvis?"B. "Are you having contractions thatcome and go, off and on?"C. "Have you noticed any fluidleaking from your vagina?"D. "Are you having problems withheartburn?"E. "Have you been having anynausea or vomiting?"Answer: A, B, C, ERationale: Frequently, women are unaware that uterine contractions,effacement, and dilation are occurring, thus making early interventionineffective in arresting preterm labor and preventing the birth of apremature newborn. The nurse should ask the client about anysigns/symptoms, being alert for subtle symptoms of preterm labor,which may include: a change or increase in vaginal discharge withmucous, water, or blood in it; pelvic pressure (pushing-down sensation);low dull backache; menstrual-like cramps; urinary tract infectionsymptoms; feeling of pelvic pressure or fullness; gastrointestinal upsetlike nausea, vomiting, and diarrhea; general sense of discomfort orunease; heaviness or aching in the thighs; uterine contractions with orwithout pain; more than six contractions per hour; intestinal crampingwith or without diarrhea. Contractions also must be persistent, such thatfour contractions occur every 20 minutes or eight contractions occur in 1hour. A report of heartburn is unrelated to preterm labor.fml
When reviewing the medical recordof a client, the nurse notes that thewoman has a condition in which thefetus cannot physically pass throughthe maternal pelvis. The nurseinterprets this asa. cervical insufficiency.b. contracted pelvis.c. maternal disproportion.d. fetopelvic disproportion.ANS: DThe nurse would anticipate acesarean birth for a client who haswhich active infection present at theonset of labor?a. Hepatitisb. Herpes simplex virusc. Toxoplasmosisd. Human papillomavirusANS: BAfter a vaginal examination, thenurse determines that the client'sfetus is in an occiput posteriorposition. The nurse would anticipatethat the client will havea. intense back pain.b. frequent leg cramps.c. nausea and vomiting.d. a precipitous birth.ANS: AWhen assessing the followingwomen, who would the nurseidentify as being at the greatest riskfor preterm labor?a. Woman who had twins in aprevious pregnancyb. Client living in a large city closeto the subwayc. Woman working full-time as acomputer programmerd. Client with a history of a previouspreterm birthANS: Dfml
The rationale for using aprostaglandin gel for a client priorto the induction of labor is toa. stimulate uterine contractions.b. numb cervical pain receptors.c. prevent cervical lacerations.d. soften and efface the cervix.ANS: DA client who is in active labor andwhose cervix had dilated to 6 cmexperiences a weakening in theintensity and frequency of hercontractions and exhibits no furtherprogress in labor. The nurseinterprets this as a sign ofa. hypertonic labor.b. precipitate labor.c. hypotonic labor.d. dysfunctional labor.ANS: CThe nurse is developing a plan ofcare for a woman experiencingdystocia. Which nursing interventionwould be the nurse's highestpriority?a. Changing the woman's positionfrequentlyb. Providing comfort measures tothe womanc. Monitoring the fetal heart ratepatternsd. Keeping the couple informed ofthe labor progressANS: CThe nurse is caring for a womanexperiencing hypertonic uterinedystocia. The woman's contractionsare erratic in their frequency,duration, and of high intensity. Thepriority nursing intervention wouldbe toa. encourage ambulation every 30minutes.b. provide pain relief measures.c. monitor the ocytocin infusion rateclosely.d. prepare the woman for anamniotomy.ANS: Bfml
What is the Bishop score used toassess?a. Presence of bacterial vaginosisb. Amount of amniotic fluid presentc. Overall fetal well-being in labord. Cervical readiness for inductionANS: D?A new mother asks the nurse whenthe "soft spot" on her son's head willgo away. The nurse's answer is basedon the knowledge that the anteriorfontanel closes after birth by _____months.a. 2b. 8c. 12d. 18ANS: DThe larger of the two fontanels, the anterior fontanel, closes by 18months after birth.When assessing a woman in labor,the nurse is aware that therelationship of the fetal body partsto one another is called fetal:a. Lie.b. Presentation.c. Attitude.d. Position.ANS: CAttitude is the relation of the fetal body parts to one another. Lie is therelation of the long axis (spine) of the fetus to the long axis (spine) of themother. Presentation refers to the part of the fetus that enters the pelvicinlet first and leads through the birth canal during labor at term. Positionis the relation of the presenting part to the four quadrants of themother's pelvis.When assessing the fetus usingLeopold maneuvers, the nurse feelsa round, firm, movable fetal part inthe fundal portion of the uterus anda long, smooth surface in themother's right side close to midline.What is the likely position of thefetus?a. ROAb. LSPc. RSAd. LOAANS: CThe fetus is positioned anteriorly in the right side of the maternal pelviswith the sacrum as the presenting part. RSA is the correct three-letterabbreviation to indicate this fetal position. The first letter indicates thepresenting part in either the right or left side of the maternal pelvis. Thesecond letter indicates the anatomic presenting part of the fetus. Thethird letter stands for the location of the presenting part in relation tothe anterior, posterior, or transverse portion of the maternal pelvis.Palpation of a round, firm fetal part in the fundal portion of the uteruswould be the fetal head, indicating that the fetus is in a breech positionwith the sacrum as the presenting part in the maternal pelvis. Palpationof the fetal spine along the mother's right side denotes the location ofthe presenting part in the mother's pelvis. The ability to palpate the fetalspine indicates that the fetus is anteriorly positioned in the maternalpelvis.fml
The nurse has received reportregarding her patient in labor. Thewoman's last vaginal examinationwas recorded as 3 cm, 30%, and ?2-2. The nurse's interpretation of thisassessment is that:a. The cervix is effaced 3 cm, it isdilated 30%, and the presenting partis 2 cm above the ischial spines.b. The cervix is 3 cm dilated, it iseffaced 30%, and the presentingpart is 2 cm above the ischial spines.c. The cervix is effaced 3 cm, it isdilated 30%, and the presenting partis 2 cm below the ischial spines.d. The cervix is dilated 3 cm, it iseffaced 30%, and the presentingpart is 2 cm below the ischial spines.ANS: BThe correct description of the vaginal examination for this woman inlabor is the cervix is 3 cm dilated, it is effaced 30%, and the presentingpart is 2 cm above the ischial spines. The sterile vaginal examination isrecorded as centimeters of cervical dilation, percentage of cervicaldilation, and the relationship of the presenting part to the ischial spines(either above or below).To care for a laboring womanadequately, the nurse understandsthat the __________ stage of labor variesthe most in length?a. Firstb. Secondc. Thirdd. FourthANS: AThe first stage of labor is considered to last from the onset of regularuterine contractions to full dilation of the cervix. The first stage is muchlonger than the second and third stages combined. In a first-timepregnancy the first stage of labor can take up to 20 hours. The secondstage of labor lasts from the time the cervix is fully dilated to the birth ofthe fetus. The average length is 20 minutes for a multiparous woman and50 minutes for a nulliparous woman. The third stage of labor lasts fromthe birth of the fetus until the placenta is delivered. This stage may be asshort as 3 minutes or as long as 1 hour. The fourth stage of labor,recovery, lasts about 2 hours after delivery of the placenta.The nurse would expect whichmaternal cardiovascular findingduring labor?a. Increased cardiac outputb. Decreased pulse ratec. Decreased white blood cell(WBC) countd. Decreased blood pressureANS: ADuring each contraction, 400 mL of blood is emptied from the uterusinto the maternal vascular system. This increases cardiac output byabout 51% above baseline pregnancy values at term. The heart rateincreases slightly during labor. The WBC count can increase duringlabor. During the first stage of labor, uterine contractions cause systolicreadings to increase by about 10 mm Hg. During the second stage,contractions may cause systolic pressures to increase by 30 mm Hg anddiastolic readings to increase by 25 mm Hg.The factors that affect the processof labor and birth, known commonlyas the five Ps, include all except:a. Passenger.b. Passageway.c. Powers.d. Pressure.ANS: DThe five Ps are passenger (fetus and placenta), passageway (birth canal),powers (contractions), position of the mother, and psychologicresponse.fml
The slight overlapping of cranialbones or shaping of the fetal headduring labor is called:a. Lightening.b. Molding.c. Ferguson reflex.d. Valsalva maneuver.ANS: BFetal head formation is called molding. Molding also permits adaptationto various diameters of the maternal pelvis. Lightening is the mother'ssensation of decreased abdominal distention, which usually occurs theweek before labor. The Ferguson reflex is the contraction urge of theuterus after stimulation of the cervix. The Valsalva maneuver describesconscious pushing during the second stage of labor.Which presentation is describedaccurately in terms of bothpresenting part and frequency ofoccurrence?a. Cephalic: occiput; at least 95%b. Breech: sacrum; 10% to 15%c. Shoulder: scapula; 10% to 15%d. Cephalic: cranial; 80% to 85%ANS: AIn cephalic presentations (head first), the presenting part is the occiput;this occurs in 96% of births. In a breech birth, the sacrum emerges first;this occurs in about 3% of births. In shoulder presentations, the scapulaemerges first; this occurs in only 1% of births.With regard to factors that affecthow the fetus moves through thebirth canal, nurses should be awarethat:a. The fetal attitude describes theangle at which the fetus exits theuterus.b. Of the two primary fetal lies, thehorizontal lie is that in which thelong axis of the fetus is parallel tothe long axis of the mother.c. The normal attitude of the fetus iscalled general flexion.d. The transverse lie is preferred forvaginal birth.ANS: CThe normal attitude of the fetus is general flexion. The fetal attitude isthe relation of fetal body parts to one another. The horizontal lie isperpendicular to the mother; in the longitudinal (or vertical) lie the longaxes of the fetus and the mother are parallel. Vaginal birth cannot occurif the fetus stays in a transverse lie.As relates to fetal positioning duringlabor, nurses should be aware that:a. Position is a measure of thedegree of descent of the presentingpart of the fetus through the birthcanal.b. Birth is imminent when thepresenting part is at +4 to +5 cmbelow the spine.c. The largest transverse diameter ofthe presenting part is thesuboccipitobregmatic diameter.d. Engagement is the term used todescribe the beginning of labor.ANS: BThe station of the presenting part should be noted at the beginning oflabor so that the rate of descent can be determined. Position is therelation of the presenting part of the fetus to the four quadrants of themother's pelvis;station is the measure of degree of descent. The largestdiameter usually is the biparietal diameter. The suboccipitobregmaticdiameter is the smallest, although one of the most critical. Engagementoften occurs in the weeks just before labor in nulliparas and before orduring labor in multiparas.fml
Which basic type of pelvis includesthe correct description andpercentage of occurrence inwomen?a. Gynecoid: classic female; heartshaped; 75%b. Android: resembling the male;wider oval; 15%c. Anthropoid: resembling the ape;narrower; 10%d. Platypelloid: flattened, wide,shallow; 3%ANS: DA platypelloid pelvis is flattened, wide, and shallow; about 3% of womenhave this shape. The gynecoid shape is the classical female shape,slightly ovoid and rounded; about 50% of women have this shape. Anandroid, or malelike, pelvis is heart shaped; about 23% of women havethis shape. An anthropoid, or apelike, pelvis is oval and wider; about 24%of women have this shape.In relation to primary and secondarypowers, the maternity nursecomprehends that:a. Primary powers are responsiblefor effacement and dilation of thecervix.b. Effacement generally is wellahead of dilation in women givingbirth for the first time; they arecloser together in subsequentpregnancies.c. Scarring of the cervix caused by aprevious infection or surgery maymake the delivery a bit more painful,but it should not slow or inhibitdilation.d. Pushing in the second stage oflabor is more effective if the womancan breathe deeply and controlsome of her involuntary needs topush, as the nurse directs.ANS: AThe primary powers are responsible for dilation and effacement;secondary powers are concerned with expulsion of the fetus.Effacement generally is well ahead of dilation in first-timers; they arecloser together in subsequent pregnancies. Scarring of the cervix mayslow dilation. Pushing is more effective and less fatiguing when thewoman begins to push only after she has the urge to do so.fml
While providing care to a patient inactive labor, the nurse shouldinstruct the woman that:a. The supine position commonlyused in the United States increasesblood flow.b. The "all fours" position, on herhands and knees, is hard on herback.c. Frequent changes in position willhelp relieve her fatigue and increaseher comfort.d. In a sitting or squatting position,her abdominal muscles will have towork harder.ANS: CFrequent position changes relieve fatigue, increase comfort, andimprove circulation. Blood flow can be compromised in the supineposition; any upright position benefits cardiac output. The "all fours"position is used to relieve backache in certain situations. In a sitting orsquatting position, the abdominal muscles work in greater harmony withuterine contractions.Which description of the four stagesof labor is correct for both definitionand duration?a. First stage: onset of regularuterine contractions to full dilation;less than 1 hour to 20 hoursb. Second stage: full effacement to4 to 5 cm; visible presenting part; 1to 2 hoursc. Third state: active pushing to birth;20 minutes (multiparous women), 50minutes (first-timer)d. Fourth stage: delivery of theplacenta to recovery; 30 minutes to1 hourANS: AFull dilation may occur in less than 1 hour, but in first-time pregnancies itcan take up to 20 hours. The second stage extends from full dilation tobirth and takes an average of 20 to 50 minutes, although 2 hours is stillconsidered normal. The third stage extends from birth to expulsion ofthe placenta and usually takes a few minutes. The fourth stage beginsafter expulsion of the placenta and lasts until homeostasis isreestablished (about 2 hours).fml
With regard to the turns and otheradjustments of the fetus during thebirth process, known as themechanism of labor, nurses shouldbe aware that:a. The seven critical movementsmust progress in a more or lessorderly sequence.b. Asynclitism sometimes is achievedby means of the Leopold maneuver.c. The effects of the forcesdetermining descent are modifiedby the shape of the woman's pelvisand the size of the fetal head.d. At birth the baby is said toachieve "restitution" (i.e., a return tothe C-shape of the womb).ANS: CThe size of the maternal pelvis and the ability of the fetal head to moldalso affect the process. The seven identifiable movements of themechanism of labor occur in combinations simultaneously, not in precisesequences. Asynclitism is the deflection of the baby's head; the Leopoldmaneuver is a means of judging descent by palpating the mother'sabdomen. Restitution is the rotation of the baby's head after the infant isborn.In order to evaluate the condition ofthe patient accurately during labor,the nurse should be aware that:a. The woman's blood pressure willincrease during contractions and fallback to prelabor normal betweencontractions.b. Use of the Valsalva maneuver isencouraged during the secondstage of labor to relieve fetalhypoxia.c. Having the woman point her toeswill reduce leg cramps.d. The endogenous endorphinsreleased during labor will raise thewoman's pain threshold andproduce sedation.ANS: DThe endogenous endorphins released during labor will raise thewoman's pain threshold and produce sedation. In addition, physiologicanesthesia of the perineal tissues, caused by the pressure of thepresenting part, decreases the mother's perception of pain. Bloodpressure increases during contractions but remains somewhat elevatedbetween them. Use of the Valsalva maneuver is discouraged duringsecond stage labor because of a number of unhealthy outcomes,including fetal hypoxia. Pointing the toes can cause leg cramps, as canthe process of labor itself.The maternity nurse understandsthat as the uterus contracts duringlabor, maternal-fetal exchange ofoxygen and waste products:a. Continues except when placentalfunctions are reduced.b. Increases as blood pressuredecreases.c. Diminishes as the spiral arteriesare compressed.d. Is not significantly affected.ANS: CUterine contractions during labor tend to decrease circulation throughthe spiral electrodes and subsequent perfusion through the intervillousspace. The maternal blood supply to the placenta gradually stops withcontractions. The exchange of oxygen and waste products decreases.The exchange of oxygen and waste products is affected bycontractions.fml
Which statement is the bestrationale for assessing maternal vitalsigns between contractions?a. During a contraction, assessingfetal heart rates is the priority.b. Maternal circulating bloodvolume increases temporarily duringcontractions.c. Maternal blood flow to the heartis reduced during contractions.d. Vital signs taken duringcontractions are not accurate.ANS: BDuring uterine contractions, blood flow to the placenta temporarilystops, causing a relative increase in the mother's blood volume, which inturn temporarily increases blood pressure and slows pulse. It isimportant to monitor fetal response to contractions; however, thisquestion is concerned with the maternal vital signs. Maternal blood flowis increased during a contraction. Vital signs are altered by contractionsbut are considered accurate for that period of time.In order to care for obstetricpatients adequately, the nurseunderstands that labor contractionsfacilitate cervical dilation by:a. Contracting the lower uterinesegment.b. Enlarging the internal size of theuterus.c. Promoting blood flow to thecervix.d. Pulling the cervix over the fetusand amniotic sac.ANS: DEffective uterine contractions pull the cervix upward at the same timethat the fetus and amniotic sac are pushed downward. The contractionsare stronger at the fundus. The internal size becomes smaller with thecontractions; this helps to push the fetus down. Blood flow decreases tothe uterus during a contraction.To teach patients about the processof labor adequately, the nurseknows that which event is the bestindicator of true labor?a. Bloody showb. Cervical dilation and effacementc. Fetal descent into the pelvic inletd. Uterine contractions every 7minutesANS: BThe conclusive distinction between true and false labor is thatcontractions of true labor cause progressive change in the cervix.Bloody show can occur before true labor. Fetal descent can occurbefore true labor. False labor may have contractions that occur thisfrequently; however, this is usually inconsistent.Which occurrence is associated withcervical dilation and effacement?a. Bloody showb. False laborc. Lighteningd. Bladder distentionANS: AAs the cervix begins to soften, dilate, and efface, expulsion of themucous plug that sealed the cervix during pregnancy occurs. Thiscauses rupture of small cervical capillaries. Cervical dilation andeffacement do not occur with false labor. Lightening is the descent ofthe fetus toward the pelvic inlet before labor. Bladder distention occurswhen the bladder is not emptied frequently. It may slow down thedescent of the fetus during labor.fml
The primary difference between thelabor of a nullipara and that of amultipara is the:a.Amount of cervical dilation.c.Level of pain experienced.b.Total duration of labor.d.Sequence of labor mechanisms.ANS: BIn a first-time pregnancy, descent is usually slow but steady; insubsequent pregnancies, descent is more rapid, resulting in a shorterduration of labor. Cervical dilation is the same for all labors. Level ofpain is individual to the woman, not to the number of labors she hasexperienced. The sequence of labor mechanisms is the same with alllabors.A primigravida at 39 weeks ofgestation is observed for 2 hours inthe intrapartum unit. The fetal heartrate has been normal. Contractionsare 5 to 9 minutes apart, 20 to 30seconds in duration, and of mildintensity. Cervical dilation is 1 to 2cm and uneffaced (unchanged fromadmission). Membranes are intact.The nurse should expect the womanto be:a. Admitted and prepared for acesarean birth.b. Admitted for extendedobservation.c. Discharged home with a sedative.d. Discharged home to await theonset of true labor.ANS: DThis situation describes a woman with normal assessments who isprobably in false labor and will probably not deliver rapidly once truelabor begins. These are all indications of false labor without fetaldistress. There is no indication that further assessment or cesarean birthis indicated. The patient will likely be discharged; however, there is noindication that a sedative is needed.Which nursing assessment indicatesthat a woman who is in second-stage labor is almost ready to givebirth?a. The fetal head is felt at 0 stationduring vaginal examination.b. Bloody mucus dischargeincreases.c. The vulva bulges and encircles thefetal head.d. The membranes rupture during acontraction.ANS: CDuring the active pushing (descent) phase, the woman has strong urgesto bear down as the presenting part of the fetus descends and presseson the stretch receptors of the pelvic floor. The vulva stretches andbegins to bulge encircling the fetal head. Birth of the head occurs whenthe station is +4. A 0 station indicates engagement. Bloody show occursthroughout the labor process and is not an indication of an imminentbirth. Rupture of membranes can occur at any time during the laborprocess and does not indicate an imminent birth.fml
Signs that precede labor include(Select all that apply):a. Lightening.b. Exhaustion.c. Bloody show.d. Rupture of membranes.e. Decreased fetal movement.ANS: A, C, DSigns that precede labor may include lightening, urinary frequency,backache, weight loss, surge of energy, bloody show, and rupture ofmembranes. Many women experience a burst of energy before labor. Adecrease in fetal movement is an ominous sign that does not alwayscorrelate with labor.Which factors influence cervicaldilation (Select all that apply) ?a. Strong uterine contractionsb. The force of the presenting fetalpart against the cervixc. The size of the female pelvisd. The pressure applied by theamniotic sace. Scarring of the cervixANS: A, B, D, EDilation of the cervix occurs by the drawing upward of themusculofibrous components of the cervix, which is caused by stronguterine contractions. Pressure exerted by the amniotic fluid while themembranes are intact or by the force applied by the presenting partalso can promote cervical dilation. Scarring of the cervix as a result of aprevious infection or surgery may slow cervical dilation. Pelvic size doesnot affect cervical dilation.1. In planning for home care of awoman with preterm labor, whichconcern must the nurse address?a.Nursing assessments will bedifferent from those done in thehospital setting.b.Restricted activity and medicationswill be necessary to preventrecurrence of preterm labor.c.Prolonged bed rest may causenegative physiologic effects.d.Home health care providers will benecessary.ANS: CProlonged bed rest may cause adverse effects such as weight loss, lossof appetite, muscle wasting, weakness, bone demineralization,decreased cardiac output, risk for thrombophlebitis, alteration in bowelfunctions, sleep disturbance, and prolonged after birth recovery.Nursing assessments will differ somewhat from those performed in theacute care setting, but this is not the concern that needs to beaddressed. Restricted activity and medication may prevent pretermlabor, but not in all women. In addition, the plan of care is individualizedto meet the needs of each woman. Many women will receive homehealth nurse visits, but care is individualized for each woman.PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenancefml
2. The nurse providing care for awoman with preterm labor who isreceiving terbutaline would includewhich intervention to identify sideeffects of the drug?a.Assessing deep tendon reflexes(DTRs)b.Assessing for chest discomfort andpalpitationsc.Assessing for bradycardiad.Assessing for hypoglycemiaANS: BTerbutaline is a 2-adrenergic agonist that affects the cardiopulmonaryand metabolic systems of the mother. Signs of cardiopulmonarydecompensation would include chest pain and palpitations. AssessingDTRs would not address these concerns. 2-Adrenergic agonist drugscause tachycardia, not bradycardia. The metabolic effect leads tohyperglycemia, not hypoglycemia.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity3. In evaluating the effectiveness ofmagnesium sulfate for the treatmentof preterm labor, what findingwould alert the nurse to possibleside effects?a.Urine output of 160 mL in 4 hoursb.Deep tendon reflexes 2+ and noclonusc.Respiratory rate of 16 breaths/mind.Serum magnesium level of 10 mg/dLANS: DThe therapeutic range for magnesium sulfate management is 5 to 8mg/dL. A serum magnesium level of 10 mg/dL could lead to signs andsymptoms of magnesium toxicity, including oliguria and respiratorydistress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ withno clonus, and respiratory rate of 16 breaths/min are normal findings.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:EvaluationMSC: Client Needs: Physiologic Integrityfml
4. A woman in preterm labor at 30weeks of gestation receives two 12-mg doses of betamethasoneintramuscularly. The purpose of thispharmacologic treatment is to:a.stimulate fetal surfactant production.b.reduce maternal and fetaltachycardia associated withritodrine administration.c.suppress uterine contractions.d.maintain adequate maternalrespiratory effort and ventilationduring magnesium sulfate therapy.ANS: AAntenatal glucocorticoids given as intramuscular injections to themother accelerate fetal lung maturity. Inderal would be given to reducethe effects of ritodrine administration. Betamethasone has no effect onuterine contractions. Calcium gluconate would be given to reverse therespiratory depressive effects of magnesium sulfate therapy.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Physiologic Integrity5. A woman at 26 weeks of gestationis being assessed to determinewhether she is experiencing pretermlabor. What finding indicates thatpreterm labor is occurring?a.Estriol is not found in maternalsaliva.b.Irregular, mild uterine contractionsare occurring every 12 to 15 minutes.c.Fetal fibronectin is present in vaginalsecretions.d.The cervix is effacing and dilated to2 cm.ANS: DCervical changes such as shortened endocervical length, effacement,and dilation are predictors of imminent preterm labor. Changes in thecervix accompanied by regular contractions indicate labor at anygestation. Estriol is a form of estrogen produced by the fetus that ispresent in plasma at 9 weeks of gestation. Levels of salivary estriol havebeen shown to increase before preterm birth. Irregular, mildcontractions that do not cause cervical change are not considered athreat. The presence of fetal fibronectin in vaginal secretions between24 and 36 weeks of gestation could predict preterm labor, but it hasonly a 20% to 40% positive predictive value. Of more importance areother physiologic clues of preterm labor such as cervical changes.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment, PlanningMSC: Client Needs: Health Promotion and Maintenancefml
6. A primigravida at 40 weeks ofgestation is having uterinecontractions every 1.5 to 2 minutesand says that they are very painful.Her cervix is dilated 2 cm and hasnot changed in 3 hours. The womanis crying and wants an epidural.What is the likely status of thiswoman's labor?a.She is exhibiting hypotonic uterinedysfunction.b.She is experiencing a normal latentstage.c.She is exhibiting hypertonic uterinedysfunction.d.She is experiencing pelvic dystocia.ANS: CWomen who experience hypertonic uterine dysfunction, or primarydysfunctional labor, often are anxious first-time mothers who are havingpainful and frequent contractions that are ineffective at causing cervicaldilation or effacement to progress. With hypotonic uterine dysfunction,the woman initially makes normal progress into the active stage oflabor; then the contractions become weak and inefficient or stopaltogether. The contraction pattern seen in this woman signifieshypertonic uterine activity. Typically uterine activity in this phase occursat 4- to 5-minute intervals lasting 30 to 45 seconds. Pelvic dystocia canoccur whenever contractures of the pelvic diameters reduce thecapacity of the bony pelvis, including the inlet, midpelvis, outlet, or anycombination of these planes.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: DiagnosisMSC: Client Needs: Health Promotion and Maintenance7. Which assessment is least likely tobe associated with a breechpresentation?a.Meconium-stained amniotic fluidb.Fetal heart tones heard at or abovethe maternal umbilicusc.Preterm labor and birthd.Postterm gestationANS: DPostterm gestation is not likely to be seen with a breech presentation.The presence of meconium in a breech presentation may result frompressure on the fetal wall as it traverses the birth canal. Fetal heart tonesheard at the level of the umbilical level of the mother are a typicalfinding in a breech presentation because the fetal back would belocated in the upper abdominal area. Breech presentations often occurin preterm births.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
8. A woman is having her first child.She has been in labor for 15 hours.Two hours ago her vaginalexamination revealed the cervix tobe dilated to 5 cm and 100%effaced, and the presenting partwas at station 0. Five minutes agoher vaginal examination indicatedthat there had been no change.What abnormal labor pattern isassociated with this description?a.Prolonged latent phaseb.Protracted active phasec.Arrest of active phased.Protracted descentANS: CWith an arrest of the active phase, the progress of labor has stopped.This patient has not had any anticipated cervical change, thus indicatingan arrest of labor. In the nulliparous woman a prolonged latent phasetypically would last more than 20 hours. A protracted active phase, thefirst or second stage of labor, would be prolonged (slow dilation). Withprotracted descent, the fetus would fail to descend at an anticipatedrate during the deceleration phase and second stage of labor.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment, DiagnosisMSC: Client Needs: Health Promotion and Maintenance9. In evaluating the effectiveness ofoxytocin induction, the nurse wouldexpect:a.contractions lasting 80 to 90seconds, 2 to 3 minutes apart.b.the intensity of contractions to be atleast 110 to 130 mm Hg.c.labor to progress at least 2 cm/hrdilation.d.At least 30 mU/min of oxytocin willbe needed to achieve cervicaldilation.ANS: AThe goal of induction of labor would be to produce contractions thatoccur every 2 to 3 minutes and last 60 to 90 seconds. The intensity ofthe contractions should be 80 to 90 mm Hg by intrauterine pressurecatheter. Cervical dilation of 1 cm/hr in the active phase of labor wouldbe the goal in an oxytocin induction. The dose is increased by 1 to 2mU/min at intervals of 30 to 60 minutes until the desired contractionpattern is achieved. Doses are increased up to a maximum of 20 to 40mU/min.PTS: 1 DIF: Cognitive Level: Analysis OBJ: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenancefml
10. A pregnant woman's amnioticmembranes rupture. Prolapsedumbilical cord is suspected. Whatintervention would be the toppriority?a.Placing the woman in the knee-chest position.b.Covering the cord in sterile gauzesoaked in saline.c.Preparing the woman for a cesareanbirth.d.Starting oxygen by face mask.ANS: AThe woman is assisted into a position (e.g., modified Sims position,Trendelenburg position, or the knee-chest position) in which gravitykeeps the pressure of the presenting part off the cord. Althoughcovering the cord in sterile gauze soaked saline, preparing the womanfor a cesarean, and starting oxygen by face mark are appropriatenursing interventions in the event of a prolapsed cord, the interventionof top priority would be positioning the mother to relieve cordcompression.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity11. Prepidil (prostaglandin gel) hasbeen ordered for a pregnant womanat 43 weeks of gestation. The nurserecognizes that this medication willbe administered to:a.enhance uteroplacental perfusion inan aging placenta.b.increase amniotic fluid volume.c.ripen the cervix in preparation forlabor induction.d.stimulate the amniotic membranesto rupture.ANS: CIt is accurate to state that Prepidil will be administered to ripen thecervix in preparation for labor induction. It is not administered toenhance uteroplacental perfusion in an aging placenta, increaseamniotic fluid volume, or stimulate the amniotic membranes to rupture.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: PlanningMSC: Client Needs: Physiologic Integrityfml
12. The nurse, caring for a patientwhose labor is being augmentedwith oxytocin, recognizes that theoxytocin should be discontinuedimmediately if there is evidence of:a.uterine contractions occurring every8 to 10 minutes.b.a fetal heart rate (FHR) of 180 withabsence of variability.c.the patient's needing to void.d.rupture of the patient's amnioticmembranes.ANS: BThis FHR is nonreassuring. The oxytocin should be discontinuedimmediately, and the physician should be notified. The oxytocin shouldbe discontinued if uterine hyperstimulation occurs. Uterine contractionsthat are occurring every 8 to 10 minutes do not qualify ashyperstimulation. The patient's needing to void is not an indication todiscontinue the oxytocin induction immediately or to call the physician.Unless a change occurs in the FHR pattern that is nonreassuring or thepatient experiences uterine hyperstimulation, the oxytocin does notneed to be discontinued. The physician should be notified that thepatient's membranes have ruptured.PTS: 1 DIF: Cognitive Level: Evaluation OBJ: Nursing Process: PlanningMSC: Client Needs: Physiologic Integrity13. Nurses should know some basicdefinitions concerning pretermbirth, preterm labor, and low birthweight. For instance:a.the terms preterm birth and lowbirth weight can be usedinterchangeably.b.preterm labor is defined as cervicalchanges and uterine contractionsoccurring between 20 and 37 weeksof pregnancy.c.low birth weight is anything below3.7 lbs.d.in the United States early in thiscentury, preterm birth accounted for18% to 20% of all births.ANS: BBefore 20 weeks, it is not viable (miscarriage); after 37 weeks, it can beconsidered term. Although these terms are used interchangeably, theyhave different meanings: preterm birth describes the length of gestation(37 weeks) regardless of weight; low birth weight describes weight only(2500 g or less) at the time of birth, whenever it occurs. Low birth weightis anything less than 2500 g, or about 5.5 lbs. In 2003 the preterm birthrate in the United States was 12.3%, but it is increasing in frequency.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
14. With regard to the caremanagement of preterm labor,nurses should be aware that:a.all women must be considered atrisk for preterm labor and predictionis so hit-and-miss, teaching pregnantwomen the symptoms probablycauses more harm through falsealarms.b.Braxton Hicks contractions oftensignal the onset of preterm labor.c.preterm labor is likely to be the startof an extended labor, a woman withsymptoms can wait several hoursbefore contacting the primarycaregiver.d.the diagnosis of preterm labor isbased on gestational age, uterineactivity, and progressive cervicalchange.ANS: DGestational age of 20 to 37 weeks, uterine contractions, and a cervixthat is 80% effaced or dilated 2 cm indicates preterm labor. It is essentialthat nurses teach women how to detect the early symptoms of pretermlabor. Braxton Hicks contractions resemble preterm labor contractions,but they are not true labor. Waiting too long to see a health careprovider could result in not administering essential medications. Pretermlabor is not necessarily long-term labor.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Safe and Effective Care Environment15. As relates to the use of tocolytictherapy to suppress uterine activity,nurses should be aware that:a.the drugs can be given efficaciouslyup to the designated beginning ofterm at 37 weeks.b.there are no important maternal (asopposed to fetal) contraindications.c.its most important function is toafford the opportunity to administerantenatal glucocorticoids.d.if the patient develops pulmonaryedema while receiving tocolytics,intravenous (IV) fluids should begiven.ANS: CBuying time for antenatal glucocorticoids to accelerate fetal lungdevelopment may be the best reason to use tocolytics. Once thepregnancy has reached 34 weeks, the risks of tocolytic therapyoutweigh the benefits. There are important maternal contraindications totocolytic therapy. Tocolytic-induced edema can be caused by IV fluids.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Physiologic Integrityfml
16. With regard to dysfunctionallabor, nurses should be aware that:a.women who are underweight aremore at risk.b.women experiencing precipitouslabor are about the only"dysfunctionals" not to beexhausted.c.hypertonic uterine dysfunction ismore common than hypotonicdysfunction.d.abnormal labor patterns are mostcommon in older women.ANS: BPrecipitous labor lasts less than 3 hours. Short women more than 30 lbsoverweight are more at risk for dysfunctional labor. Hypotonic uterinedysfunction, in which the contractions become weaker, is morecommon. Abnormal labor patterns are more common in women lessthan 20 years of age.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenance17. The least common cause of long,difficult, or abnormal labor(dystocia) is:a.midplane contracture of the pelvis.b.compromised bearing-down effortsas a result of pain medication.c.disproportion of the pelvis.d.low-lying placenta.ANS: CThe least common cause of dystocia is disproportion of the pelvis.PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance18. Nurses should be aware that theinduction of labor:a.can be achieved by external andinternal version techniques.b.is also known as a trial of labor(TOL).c.is almost always done for medicalreasons.d.is rated for viability by a Bishopscore.ANS: DInduction of labor is likely to be more successful with a Bishop score of9 or higher for first-time mothers and 5 or higher for veterans. Version isturning of the fetus to a better position by a physician for an easier orsafer birth. A trial of labor is the observance of a woman and her fetusfor several hours of active labor to assess the safety of vaginal birth. Twothirds of cases of induced labor are elective and are not done formedical reasons.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:DiagnosisMSC: Client Needs: Safe and Effective Care Environmentfml
19. While caring for the patient whorequires an induction of labor, thenurse should be cognizant that:a.ripening the cervix usually results ina decreased success rate forinduction.b.labor sometimes can be inducedwith balloon catheters or laminariatents.c.oxytocin is less expensive thanprostaglandins and more effectivebut creates greater health risks.d.amniotomy can be used to make thecervix more favorable for labor.ANS: BBalloon catheters or laminaria tents are mechanical means of ripeningthe cervix. Ripening the cervix, making it softer and thinner, increasesthe success rate of induced labor. Prostaglandin E1 is less expensive andmore effective than oxytocin but carries a greater risk. Amniotomy is theartificial rupture of membranes, which is used to induce labor only whenthe cervix is already ripe.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenance20. With regard to the process ofaugmentation of labor, the nurseshould be aware that it:a.is part of the active management oflabor that is instituted when thelabor process is unsatisfactory.b.relies on more invasive methodswhen oxytocin and amniotomy havefailed.c.is a modern management term tocover up the negative connotationsof forceps-assisted birth.d.uses vacuum cups.ANS: AAugmentation is part of the active management of labor that stimulatesuterine contractions after labor has started but is not progressingsatisfactorily. Augmentation uses amniotomy and oxytocin infusion, aswell as some gentler, noninvasive methods. Forceps-assisted births andvacuum-assisted births are appropriately used at the end of labor andare not part of augmentation.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenancefml
21. The exact cause of preterm laboris unknown and believed to bemultifactorial. Infection is thought tobe a major factor in many pretermlabors. Select the type of infectionthat has not been linked to pretermbirths.a.Viralb.Periodontalc.Cervicald.Urinary tractANS: AThe infections that increase the risk of preterm labor and birth are allbacterial. They include cervical, urinary tract, periodontal, and otherbacterial infections. Therefore, it is important for the patient toparticipate in early, continual, and comprehensive prenatal care.Evidence has shown a link between periodontal infections and pretermlabor. Researchers recommend regular dental care before and duringpregnancy, oral assessment as a routine part of prenatal care, andscrupulous oral hygiene to prevent infection. Cervical infections of abacterial nature have been linked to preterm labor and birth. Thepresence of urinary tract infections increases the risk of preterm laborand birth.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity22. The standard of care forobstetrics dictates that an internalversion may be used to manipulatethe:a.fetus from a breech to a cephalicpresentation before labor begins.b.fetus from a transverse lie to alongitudinal lie before cesareanbirth.c.second twin from an oblique lie to atransverse lie before labor begins.d.second twin from a transverse lie toa breech presentation duringvaginal birth.ANS: DInternal version is used only during vaginal birth to manipulate thesecond twin into a presentation that allows it to be born vaginally. Forinternal version to occur, the cervix needs to be completely dilated.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrityfml
23. The nurse practicing in a laborsetting knows that the woman mostat risk for uterine rupture is:a.a gravida 3 who has had two low-segment transverse cesarean births.b.a gravida 2 who had a low-segmentvertical incision for delivery of a 10-lb infant.c.a gravida 5 who had two vaginalbirths and two cesarean births.d.a gravida 4 who has had allcesarean births.ANS: DThe risk of uterine rupture increases for the patient who has hadmultiple prior births with no vaginal births. As the number of prioruterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient touterine rupture.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity24. Before the physician performsan external version, the nurse shouldexpect an order for a:a.tocolytic drug.b.contraction stress test (CST).c.local anesthetic.d.Foley catheter.ANS: AA tocolytic drug will relax the uterus before and during version, thusmaking manipulation easier. CST is used to determine the fetal responseto stress. A local anesthetic is not used with external version. Thebladder should be emptied; however, catheterization is not necessary.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Physiologic Integrity25. A maternal indication for the useof forceps is:a.a wide pelvic outlet.b.maternal exhaustion.c.a history of rapid deliveries.d.failure to progress past 0 station.ANS: BA mother who is exhausted may be unable to assist with the expulsionof the fetus.The patient with a wide pelvic outlet will likely not require vacuumextraction. With a rapid delivery, vacuum extraction is not necessary. Astation of 0 is too high for a vacuum extraction.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrityfml
26. The priority nursing interventionafter an amniotomy should be to:a.assess the color of the amnioticfluid.b.change the patient's gown.c.estimate the amount of amnioticfluid.d.assess the fetal heart rate.ANS: DThe fetal heart rate must be assessed immediately after the rupture ofthe membranes to determine whether cord prolapse or compressionhas occurred. Secondary to FHR assessment, amniotic fluid amount,color, odor, and consistency is assessed. Dry clothing is important forpatient comfort; however, it is not the top priority.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity27. The priority nursing careassociated with an oxytocin (Pitocin)infusion is:a.measuring urinary output.b.increasing infusion rate every 30minutes.c.monitoring uterine response.d.evaluating cervical dilation.ANS: CBecause of the risk of hyperstimulation, which could result in decreasedplacental perfusion and uterine rupture, the nurse's priority interventionis monitoring uterine response. Monitoring urinary output is alsoimportant; however, it is not the top priority during the administration ofPitocin. The infusion rate may be increased after proper assessment thatit is an appropriate interval to do so. Monitoring labor progression is thestandard of care for all labor patients.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity28. Immediately after the forceps-assisted birth of an infant, the nurseshould:a.assess the infant for signs of trauma.b.give the infant prophylacticantibiotics.c.apply a cold pack to the infant'sscalp.d.measure the circumference of theinfant's head.ANS: AThe infant should be assessed for bruising or abrasions at the site ofapplication, facial palsy, and subdural hematoma. Prophylacticantibiotics are not necessary with a forceps delivery. A cold pack wouldput the infant at risk for cold stress and is contraindicated. Measuringthe circumference of the head is part of the initial nursing assessment.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrityfml
29. Surgical, medical, or mechanicalmethods may be used for laborinduction. Which technique isconsidered a mechanical method ofinduction?a.Amniotomyb.Intravenous Pitocinc.Transcervical catheterd.Vaginal insertion of prostaglandinsANS: CPlacement of a balloon-tipped Foley catheter into the cervix is amechanical method of induction. Other methods to expand andgradually dilate the cervix include hydroscopic dilators such aslaminaria tents (made from desiccated seaweed), or Lamicel (containsmagnesium sulfate). Amniotomy is a surgical method of augmentationand induction.Intravenous Pitocin and insertion of prostaglandins are medical methodsof induction.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity1. Complications and risks associatedwith cesarean births include: (Selectall that apply.)a.placental abruption.b.wound dehiscence.c.hemorrhage.d.urinary tract infections.e.fetal injuries.ANS: B, C, D, EPlacental abruption and placenta previa are both indications forcesarean birth and are not complications thereof. Wound dehiscence,hemorrhage, urinary tract infection, and fetal injuries are all possiblecomplications and risks associated with delivery by cesarean section.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:EvaluationMSC: Client Needs: Physiologic Integrityfml
2. Induction of labor is consideredan acceptable obstetric procedureif it is in the best interest to deliverthe fetus. The charge nurse in thelabor and delivery unit is oftenasked to schedule patients for thisprocedure and therefore must becognizant of the specific conditionsappropriate for labor induction.These include: (Select all that apply.)a.rupture of membranes at or nearterm.b.convenience of the woman or herphysician.c.chorioamnionitis (inflammation ofthe amniotic sac).d.postterm pregnancy.e.fetal death.ANS: A, C, D, EThese are all acceptable indications for induction. Other conditionsinclude intrauterine growth retardation (IUGR), maternal-fetal bloodincompatibility, hypertension, and placental abruption. Electiveinductions for the convenience of the woman or her provider are notrecommended; however, they have become commonplace. Factorssuch as rapid labors and living a long distance from a health care facilitymay be valid reasons in such a circumstance. Elective delivery shouldnot occur before 39 weeks' completed gestation.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: PlanningMSC: Client Needs: Physiologic IntegrityAn 18-year-old pregnant woman,gravida 1, para 0, is admitted to thelabor and birth unit with moderatecontractions every 5 minutes thatlast 40 seconds. The client states,"My contractions are so strong, Idon't know what to do." Beforemaking a plan of care, what shouldthe nurse's first action be?a.Assess for fetal well-being.b.Encourage the woman to lie onher side.c.Disturb the woman as little aspossible.d.Recognize that pain ispersonalized for each individual.ANS: DEach woman's pain during childbirth is unique and is influenced by avariety of physiologic, psychosocial, and environmental factors. Acritical issue for the nurse is how support can make a difference in thepain of the woman during labor and birth. This scenario includes noinformation that would indicate fetal distress or a logical reason to beoverly concerned about the well-being of the fetus. The left lateralposition is used to alleviate fetal distress, not maternal stress. The nursehas an obligation to provide physical, emotional, and psychosocial careand support to the laboring woman. This client clearly needs support.fml
A woman who is pregnant for thefirst time is dilated 3 cm and havingcontractions every 5 minutes. She isgroaning and perspiring excessively;she states that she did not attendchildbirth classes. What is theoptimal intervention for the nurse toprovide at this time?a.Notify the woman's health careprovider.b.Administer the prescribed narcoticanalgesic.c.Assure her that her labor will beover soon.d.Assist her with simple breathingand relaxation instructions.ANS: DBy reducing tension and stress, both focusing and relaxation techniqueswill allow the woman in labor to rest and conserve energy for the task ofgiving birth. For those who have had no preparation, instruction insimple breathing and relaxation can be given in early labor and is oftensuccessful. The nurse can independently perform many functions inlabor and birth, such as teaching and support. Pain medication may bean option for this client. However, the initial response of the nurseshould include teaching the client about her options. The length of laborvaries among individuals, but the first stage of labor is the longest. At 3cm of dilation with contractions every 5 minutes, this woman has asignificant amount of labor yet to experience.Nursing care measures arecommonly offered to women inlabor. Which nursing measurereflects the application of the gate-control theory?a.Massage the woman's back.b.Change the woman's position.c.Give the prescribed medication.d.Encourage the woman to restbetween contractions.ANS: AAccording to the gate-control theory, pain sensations travel alongsensory nerve pathways to the brain, but only a limited number ofsensations, or messages, can travel through these nerve pathways atone time. Distraction techniques, such as massage or stroking, music,focal points, and imagery, reduce or completely block the capacity ofthe nerve pathways to transmit pain. These distractions are thought towork by closing down a hypothetic gate in the spinal cord, thuspreventing pain signals from reaching the brain. The perception of painis thereby diminished. Changing the woman's position, administeringpain medication, and resting between contractions do not reduce orblock the capacity of the nerve pathways to transmit pain using thegate-control theory.fml
Breathing patterns are taught tolaboring women. Which breathingpattern should the nurse support forthe woman and her coach duringthe latent phase of the first stage oflabor if the couple has attendedchildbirth preparation classes?a.Slow-paced breathingb.Deep abdominal breathingc.Modified-paced breathingd.Patterned-paced breathingANS: ASlow-paced breathing is approximately one half the woman's normalbreathing rate and is used during the early stages of labor when awoman can no longer walk or talk through her contractions. No suchpattern called deep abdominal breathing exists in childbirthpreparation. Modified-paced breathing is shallow breathing that is twicethe woman's normal breathing rate. It is used when labor progressesand the woman can no longer maintain relaxation through pacedbreathing. Patterned-pace breathing is a fast, 4:1 breathe, breathe,breathe, blow pattern that is used during the transitional phase of laborjust before pushing and delivery.A laboring woman has receivedmeperidine (Demerol) intravenously(IV), 90 minutes before giving birth.Which medication should beavailable to reduce the postnataleffects of meperidine on theneonate?a.Fentanyl (Sublimaze)b.Promethazine (Phenergan)c.Naloxone (Narcan)d.Nalbuphine (Nubain)ANS: CAn opioid antagonist can be given to the newborn as one part of thetreatment for neonatal narcosis, which is a state of central nervoussystem (CNS) depression in the newborn produced by an opioid.Opioid antagonists, such as naloxone (Narcan), can promptly reversethe CNS depressant effects, especially respiratory depression. Fentanyl(Sublimaze), promethazine (Phenergan), and nalbuphine (Nubain) do notact as opioid antagonists to reduce the postnatal effects of meperidineon the neonate.fml
What should the laboring client whoreceives an opioid antagonist betold to expect?a.Her pain will decrease.b.Her pain will return.c.She will feel less anxious.d.She will no longer feel the urge topush.ANS: BOpioid antagonists such as naloxone (Narcan) promptly reverse theCNS-depressant effects of opioids. In addition, the antagonist countersthe effect of the stress-induced levels of endorphins. An opioidantagonist is especially valuable if the labor is more rapid thanexpected and the birth is anticipated when the opioid is at its peakeffect. The woman should be told that the pain that was relieved by theopioid analgesic will return with the administration of the opioidantagonist. Her pain level will increase rather than decrease. Opioidantagonists have no effect on anxiety levels. They are primarilyadministered to reverse the excessive CNS depression in the mother,newborn, or both. An opioid antagonist (e.g., naloxone) has no effect onthe mother's urge or ability to push. The practice of giving lower dosesof IV opioids has reduced the incidence and severity of opioid-inducedCNS depression; therefore, opioid antagonists are used less frequently.A client is in early labor, and hernurse is discussing the pain reliefoptions she is considering. Theclient states that she wants anepidural "no matter what!" What isthe nurse's best response?a."I'll make sure you get yourepidural."b."You may only have an epidural ifyour physician allows it."c."You may only have an epidural ifyou are going to deliver vaginally."d."The type of analgesia oranesthesia used is determined, inpart, by the stage of your labor andthe method of birth."ANS: DTo avoid suppressing the progress of labor, pharmacologic measuresfor pain relief are generally not implemented until labor has advancedto the active phase of the first stage and the cervix is dilatedapproximately 4 to 5 cm. A plan of care is developed for each womanthat addresses her particular clinical and nursing problems. The nursecollaborates with the primary health care provider and the laboringwoman in selecting features of care relevant to the woman and herfamily. The decision whether to use an epidural to relieve labor pain ismultifactorial. The nurse should not make a blanket statementguaranteeing the client one pharmacologic option over another until acomplete history and physical examination has been obtained. Aphysician's order is required for pharmacologic options for painmanagement. However, expressing this requirement is not the nurse'sbest response. An epidural is an effective pharmacologic painmanagement option for many laboring women. It can also be used foranesthesia control if the woman undergoes an operative delivery.fml
What is the role of the nurse as itapplies to informed consent?a.Inform the client about theprocedure, and ask her to sign theconsent form.b.Act as a client advocate, and helpclarify the procedure and theoptions.c.Call the physician to see the client.d.Witness the signing of the consentform.ANS: BNurses play a part in the informed consent process by clarifying anddescribing procedures or by acting as the woman's advocate and askingthe primary health care provider for further explanations. The physicianis responsible for informing the woman of her options, explaining theprocedure, and advising the client about potential risk factors. Thephysician must be present to explain the procedure to the client.However, the nurse's responsibilities go further than simply asking thephysician to see the client. The nurse may witness the signing of theconsent form. However, depending on the state's guidelines, thewoman's husband or another hospital health care employee may sign asa witness.A first-time mother is concernedabout the type of medications shewill receive during labor. The clientis in a fair amount of pain and isnauseated. In addition, she appearsto be very anxious. The nurseexplains that opioid analgesics areoften used along with sedatives.How should the nurse phrase therationale for this medicationcombination?a."The two medications, together,reduce complications."b."Sedatives enhance the effect ofthe pain medication."c."The two medications work bettertogether, enabling you to sleep untilyou have the baby."d."This is what your physician hasordered for you."ANS: BSedatives may be used to reduce the nausea and vomiting that oftenaccompany opioid use. In addition, some ataractic drugs reduce anxietyand apprehension and potentiate the opioid analgesic affects. Apotentiator may cause two drugs to work together more effectively, butit does not ensure zero maternal or fetal complications. Sedation maybe a related effect of some ataractic drugs; however, sedation is not thegoal. Furthermore, a woman is unlikely to be able to sleep throughtransitional labor and birth. Although the physician may have orderedthe medication, "This is what your physician has ordered for you" is notan acceptable comment for the nurse to make.fml
The nurse should be cognizant ofwhich physiologic effect of pain?a.Predominant pain of the first stageof labor is visceral pain that islocated in the lower portion of theabdomen.b.Referred pain is the extremediscomfort experienced betweencontractions.c.Somatic pain of the second stageof labor is more generalized andrelated to fatigue.d.Pain during the third stage is asomewhat milder version of the painexperienced during the secondstage.ANS: APredominant pain comes from cervical changes, the distention of thelower uterine segment, and uterine ischemia. Referred pain occurs whenthe pain that originates in the uterus radiates to the abdominal wall,lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stagelabor pain is similar to that of the first stage.Which statement correctly describesthe effects of various pain factors?a.Higher prostaglandin levels arisingfrom dysmenorrhea can blunt thepain of childbirth.b.Upright positions in labor increasethe pain factor because they causegreater fatigue.c.Women who move around tryingdifferent positions experience morepain.d.Levels of pain-mitigating beta-endorphins are higher during aspontaneous, natural childbirth.ANS: DHigher endorphin levels help women tolerate pain and reduce anxietyand irritability. Higher prostaglandin levels correspond to more severelabor pains. Upright positions in labor usually result in improved comfortand less pain. Moving freely to find more comfortable positions isimportant for reducing pain and muscle tension.fml
Nurses with an understanding ofcultural differences regarding likelyreactions to pain may be better ableto help their clients. Which clientsmay initially appear very stoic butthen become quite vocal as laborprogresses until late in labor, whenthey become more vocal andrequest pain relief?a.Chineseb.Arab or Middle Easternc.Hispanicd.African-AmericanANS: CHispanic women may be stoic early in labor but more vocal and readyfor medications later. Chinese women may not show reactions to pain.Medical interventions must be offered more than once. Arab or MiddleEastern women may be vocal in response to labor pain from the start;they may prefer pain medications. African-American women may openlyexpress pain; the use of medications for pain is more likely to vary withthe individual.Anxiety is commonly associatedwith pain during labor. Whichstatement regarding anxiety iscorrect?a.Even mild anxiety must be treated.b.Severe anxiety increases tension,increases pain, and then, in turn,increases fear and anxiety, and soon.c.Anxiety may increase theperception of pain, but it does notaffect the mechanism of labor.d.Women who have had a painfullabor will have learned from theexperience and have less anxietythe second time because ofincreased familiarity.ANS: BAnxiety and pain reinforce each other in a negative cycle that will slowthe progress of labor. Mild anxiety is normal for a woman in labor andlikely needs no special treatment other than the standard reassurances.Anxiety increases muscle tension and ultimately can sufficiently build toslow the progress of labor. Unfortunately, an anxious, painful first laboris likely to carry over, through expectations and memories, into ananxious and painful experience in the second pregnancy.fml
Which statement is not an expectedoutcome for the client who attendsa reputable childbirth preparationprogram?a.Childbirth preparation programsincrease the woman's sense ofcontrol.b.Childbirth preparation programsprepare a support person to helpduring labor.c.Childbirth preparation programsguarantee a pain-free childbirth.d.Childbirth preparation programsteach distraction techniques.ANS: CAll methods try to increase a woman's sense of control, prepare asupport person, and train the woman in physical conditioning, whichincludes breathing techniques. These programs cannot, and reputableones do not, promise a pain-free childbirth. Increasing a woman's senseof control is the goal of all childbirth preparation methods. Preparing asupport person to help in labor is a vitally important component of anychildbirth education program. The coach may learn how to touch awoman's body to detect tense and contracted muscles. The woman thenlearns how to relax in response to the gentle stroking by the coach.Distraction techniques are a form of care that are effective to somedegree in relieving labor pain and are taught in many childbirthprograms. These distractions include imagery, feedback relaxation, andattention-focusing behaviors.Maternity nurses often have toanswer questions about the many,sometimes unusual, ways peoplehave tried to make the birthingexperience more comfortable.Which information regardingnonpharmacologic pain reliefisaccurate?a.Music supplied by the supportperson has to be discouragedbecause it could disturb others orupset the hospital routine.b.Women in labor can benefit fromsitting in a bathtub, but they mustlimit immersion to no longer than 15minutes at a time.c.Effleurage is permissible, butcounterpressure is almost alwayscounterproductive.d.Electrodes attached to either sideof the spine to provide high-intensity electrical impulses facilitatethe release of endorphins.ANS: DTranscutaneous electrical nerve stimulation (TENS) may help and is mostuseful for lower back pain that occurs during the first stage of labor.Music may be very helpful for reducing tension and certainly can beaccommodated by the hospital. Women can stay in a bath as long asthey want, although repeated baths with breaks might be more effectivethan one long bath. Counterpressure can help the woman cope withlower back pain.fml
The nurse should be cognizant ofwhich important informationregarding nerve block analgesia andanesthesia?a.Most local agents are chemicallyrelated to cocaine and end in thesuffix -caine.b.Local perineal infiltrationanesthesia is effective whenepinephrine is added, but it can beinjected only once.c.Pudendal nerve block is designedto relieve the pain from uterinecontractions.d.Pudendal nerve block, ifperformed correctly, does notsignificantly lessen the bearing-down reflex.ANS: ACommon agents include lidocaine and chloroprocaine. Injections canbe repeated to prolong the anesthesia. A pudendal nerve block relievespain in the vagina, vulva, and perineum but not the pain from uterinecontractions. A pudendal nerve block lessens or shuts down thebearing-down reflex.A woman in labor is breathing into amouthpiece just before the start ofher regular contractions. As sheinhales, a valve opens and gas isreleased. She continues to inhalethe gas slowly and deeply until thecontraction starts to subside. Whenthe inhalation stops, the valvecloses. Which statement regardingthis procedure is correct?a.The application of nitrous oxidegas is not often used anymore.b.An inhalation of gas is likely to beused in the second stage of labor,not during the first stage.c.An application of nitrous oxide gasis administered for pain relief.d.The application of gas is a preludeto a cesarean birth.ANS: CA mixture of nitrous oxide with oxygen in a low concentration can beused in combination with other nonpharmacologic and pharmacologicmeasures for pain relief. This procedure is still commonly used inCanada and in the United Kingdom. Nitrous oxide inhaled in a lowconcentration will reduce but not eliminate pain during the first andsecond stages of labor. Nitrous oxide inhalation is not generally usedbefore a caesarean birth. Nitrous oxide does not appear to depressuterine contractions or cause adverse reactions in the newborn.fml
According to professional standards(the Association of Women's Health,Obstetric and Neonatal Nurses[AWHONN], 2007), which actioncannot be performed by thenonanesthetist registered nurse whois caring for a woman with epiduralanesthesia?a.Monitoring the status of thewoman and fetusb.Initiating epidural anesthesiac.Replacing empty infusion bagswith the same medication andconcentrated.Stopping the infusion, andinitiating emergency measuresANS: BOnly qualified, licensed anesthesia care providers are permitted toinsert a catheter, initiate epidural anesthesia, verify catheter placement,inject medication through the catheter, or alter the medication ormedications including type, amount, or rate of infusion. Thenonanesthetist nurse is permitted to monitor the status of the woman,the fetus, and the progress of labor. Replacement of the empty infusionbags or syringes with the same medication and concentration ispermitted. If the need arises, the nurse may stop the infusion, initiateemergency measures, and remove the catheter if properly educated todo so. Complications can require immediate interventions. Nurses mustbe prepared to provide safe and effective care during an emergencysituation.Conscious relaxation is associatedwith which method of childbirthpreparation?a.Grantly Dick-Read childbirthmethodb.Lamaze methodc.Bradley methodd.Psychoprophylactic methodANS: AWith the Grantly Dick-Read method, women are taught to consciouslyand progressively relax different muscle groups throughout the bodyuntil a high degree of skill at relaxation is achieved. The Lamaze methodcombines controlled muscular relaxation with breathing techniques. TheBradley method advocates natural labor, without any form of anesthesiaor analgesia, assisted by a husband-coach and using breathingtechniques for labor. The psychoprophylactic method is another namefor the Lamaze method.fml
A woman in labor has just receivedan epidural block. What is the mostimportant nursing intervention at thistime?a.Limit parenteral fluids.b.Monitor the fetus for possibletachycardia.c.Monitor the maternal bloodpressure for possible hypotension.d.Monitor the maternal pulse forpossible bradycardia.ANS: CThe most important nursing intervention for a woman who has receivedan epidural block is for the nurse to monitor the maternal bloodpressure frequently for signs of hypotension. IV fluids are increased fora woman receiving an epidural to prevent hypotension. The nurse alsoobserves for signs of fetal bradycardia and monitors for signs ofmaternal tachycardia, secondary to hypotension.A woman in the active phase of thefirst stage of labor is using a shallowpattern of breathing, which isapproximately twice the normaladult breathing rate. She starts tocomplain about feeling lightheadedand dizzy and states that her fingersare tingling. Which interventionshould the nurse immediatelyinitiate?a.Contact the woman's physician.b.Tell the woman to slow her pace ofher breathing.c.Administer oxygen via a mask ornasal cannula.d.Help her breathe into a paper bag.ANS: DThis woman is experiencing the side effects of hyperventilation, whichinclude the symptoms of lightheadedness, dizziness, tingling of thefingers, or circumoral numbness. Having the woman breathe into apaper bag held tightly around her mouth and nose may eliminaterespiratory alkalosis and enable her to rebreathe carbon dioxide andreplace the bicarbonate ion.fml
A client is experiencing back laborand complains of intense pain in herlower back. Which measure wouldbest support this woman in labor?a.Counterpressure against thesacrumb.Pant-blow (breaths and puffs)breathing techniquesc.Effleuraged.Conscious relaxation or guidedimageryANS: ACounterpressure is steady pressure applied by a support person to thesacral area with the fist or heel of the hand. This technique helps thewoman cope with the sensations of internal pressure and pain in thelower back. The pain management techniques of pant-blow, effleurage,and conscious relaxation or guided imagery are usually helpful forcontractions per the gate-control theoryA woman has requested an epiduralfor her pain. She is 5 cm dilated and100% effaced. The baby is in a vertexposition and is engaged. The nurseincreases the woman's IV fluid for apreprocedural bolus. The nursereviews her laboratory values andnotes that the woman's hemoglobinis 12 g/dl, hematocrit is 38%,platelets are 67,000, and whiteblood cells (WBCs) are 12,000/mm3.Which factor would contraindicatean epidural for this woman?a.She is too far dilated.b.She is anemic.c.She has thrombocytopenia.d.She is septic.ANS: CThe platelet count indicates a coagulopathy, specifically,thrombocytopenia (low platelets), which is a contraindication to epiduralanalgesia and anesthesia. Typically, epidural analgesia and anesthesiaare used in the laboring woman when a regular labor pattern has beenachieved, as evidenced by progressive cervical change. The laboratoryvalues show that the woman's hemoglobin and hematocrit levels are inthe normal range and show a slight increase in the WBC count that isnot uncommon in laboring women.fml
Which alterations in the perceptionof pain by a laboring client shouldthe nurse understand?a.Sensory pain for nulliparouswomen is often greater than formultiparous women during earlylabor.b.Affective pain for nulliparouswomen is usually less than formultiparous women throughout thefirst stage of labor.c.Women with a history of substanceabuse experience more pain duringlabor.d.Multiparous women have morefatigue from labor and thereforeexperience more pain.ANS: ASensory pain is greater for nulliparous women because theirreproductive tract structures are less supple. Affective pain is greater fornulliparous women during the first stage but decreases for bothnulliparous and multiparous during the second stage. Women with ahistory of substance abuse experience the same amount of pain asthose without such a history. Nulliparous women have longer labors andtherefore experience more fatigue.The nurse should be aware of whatimportant information regardingsystemic analgesics administeredduring labor?a.Systemic analgesics cross thematernal blood-brain barrier aseasily as they do the fetal blood-brain barrier.b.Effects on the fetus and newborncan include decreased alertnessand delayed sucking.c.Intramuscular (IM) administration ispreferred over IV administration.d.IV patient-controlled analgesia(PCA) results in increased use of ananalgesic.ANS: BThe effects of analgesics depend on the specific drug administered, thedosage, and the timing. Systemic analgesics cross the fetal blood-brainbarrier more readily than the maternal blood-brain barrier. IVadministration is preferred over IM administration because the drug actsfaster and more predictably. PCA results in a decrease in the use of ananalgesic.fml
Developing a realistic birth plan withthe pregnant woman regarding hercare is important for the nurse. Howwould the nurse explain the majoradvantage of nonpharmacologicpain management?a.Greater and more complete painrelief is possible.b.No side effects or risks to the fetusare involved.c.The woman will remain fully alertat all times.d.Labor will likely be more rapid.ANS: BBecause nonpharmacologic pain management does not includeanalgesics, adjunct drugs, or anesthesia, it is harmless to the mother andthe fetus. However, pain relief is lessened with nonpharmacologic painmanagement during childbirth. Although the woman's alertness is notaltered by medication, the increase in pain may decrease alertness. Painmanagement may or may not alter the length of labor. At times whenpain is decreased, the mother relaxes and labor progresses at a quickerpace.What is the correct terminology forthe nerve block that providesanesthesia to the lower vagina andperineum?a.Epiduralb.Pudendalc.Locald.Spinal blockANS: BA pudendal block anesthetizes the lower vagina and perineum toprovide anesthesia for an episiotomy and the use of low forceps, ifneeded. An epidural provides anesthesia for the uterus, perineum, andlegs. A local provides anesthesia for the perineum at the site of theepisiotomy. A spinal block provides anesthesia for the uterus, perineum,and down the legs.The obstetric nurse is preparing theclient for an emergency cesareanbirth, with no time to administerspinal anesthesia. The nurse is awareof and prepared for the greatest riskof administering general anesthesiato the client. What is this risk?a.Respiratory depressionb.Uterine relaxationc.Inadequate muscle relaxationd.Aspiration of stomach contentsANS: DAspiration of acidic gastric contents with possible airway obstruction isa potentially fatal complication of general anesthesia. Respirations canbe altered during general anesthesia, and the anesthesiologist will takeprecautions to maintain proper oxygenation. Uterine relaxation canoccur with some anesthesia but can be monitored and prevented.Inadequate muscle relaxation can be improved with medication.fml
What is the rationale for the use of ablood patch after spinal anesthesia?a.Hypotensionb.Headachec.Neonatal respiratory depressiond.Loss of movementANS: BThe subarachnoid block may cause a postspinal headache resultingfrom the loss of cerebrospinal fluid from the puncture in the dura. Whenblood is injected into the epidural space in the area of the duralpuncture, it forms a seal over the hole to stop the leaking ofcerebrospinal fluid. Hypotension is prevented by increasing fluidvolume before the procedure. Neonatal respiratory depression is not anexpected outcome with spinal anesthesia. Loss of movement is anexpected outcome of spinal anesthesia.Maternal hypotension is a potentialside effect of regional anesthesiaand analgesia. What nursinginterventions could the nurse use toincrease the client's blood pressure?(Select all that apply.)a.Place the woman in a supineposition.b.Place the woman in a lateralposition.c.Increase IV fluids.d.Administer oxygen.e.Perform a vaginal examination.ANS: B, C, DNursing interventions for maternal hypotension arising from analgesia oranesthesia include turning the woman to a lateral position, increasing IVfluids, administering oxygen via face mask, elevating the woman's legs,notifying the physician, administering an IV vasopressor, and monitoringthe maternal and fetal status at least every 5 minutes until the woman isstable. Placing the client in a supine position causes venouscompression, thereby limiting blood flow to and oxygenation of theplacenta and fetus. A sterile vaginal examination has no bearing onmaternal blood pressure.Which alternative approaches torelaxation have proven successfulwhen working with the client inlabor? (Select all that apply.)a.Aromatherapyb.Massagec.Hypnosisd.Cesarean birthe.BiofeedbackANS: A, B, C, EApproaches to relaxation can include neuromuscular relaxation,aromatherapy, music, massage, imagery, hypnosis, or touch relaxation.Cesarean birth is a method of delivery, not a method of relaxation.fml
A woman has requested an epiduralblock for her pain. She is 5 cmdilated and 100% effaced. The babyis in a vertex position and isengaged. The nurse increases thewoman's IV fluid for a preproceduralbolus. Before the initiation of theepidural, the woman should beinformed regarding thedisadvantages of an epidural block.Which concerns should the nurseshare with this client? (Select all thatapply.)a.Ability to move freely is limited.b.Orthostatic hypotension anddizziness may occur.c.Gastric emptying is not delayed.d.Higher body temperature mayoccur.e.Blood loss is not excessive.ANS: A, B, DThe woman's ability to move freely and to maintain control of her laboris limited, related to the use of numerous medical interventions (IV linesand electronic fetal monitoring [EFM]). Significant disadvantages of anepidural block include the occurrence of orthostatic hypotension,dizziness, sedation, and leg weakness. Women who receive an epiduralblock have a higher body temperature (38°C or higher), especiallywhen labor lasts longer than 12 hours, and may result in an unnecessaryneonatal workup for sepsis. An advantage of an epidural block is thatblood loss is not excessive. Other advantages include the following: thewoman remains alert and able to participate, good relaxation isachieved, airway reflexes remain intact, and only partial motor paralysisdevelops.fml
The class of drugs known as opioidanalgesics (butorphanol,nalbuphine) is not suitable foradministration to women with knownopioid dependence. Theantagonistic activity couldprecipitate withdrawal symptoms(abstinence syndrome) in bothmothers and newborns. Which signswould indicate opioid or narcoticwithdrawal in the mother? (Select allthat apply.)a.Yawning, runny noseb.Increase in appetitec.Chills or hot flashesd.Constipatione.Irritability, restlessnessANS: A, C, EThe woman experiencing maternal opioid withdrawal syndrome willexhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes,vomiting, diarrhea, abdominal pain, irritability, restlessness, musclespasms, weakness, and drowsiness. Assessing both the mother and thenewborn and planning the care accordingly are important steps for thenurse to takeWhile developing an intrapartumcare plan for the client in earlylabor, which psychosocial factorswould the nurse recognize upon theclient's pain experience? (Select allthat apply.)a.Cultureb.Anxiety and fearc.Previous experiences with paind.Intervention of caregiverse.Support systemsANS: A, B, C, ECulture: A woman's sociocultural roots influence how she perceives,interprets, and responds to pain during childbirth. Some culturesencourage loud and vigorous expressions of pain, whereas others valueself-control. The nurse should avoid praising some behaviors (stoicism)while belittling others (noisy expression). Anxiety and fear: Extremeanxiety and fear magnify the sensitivity to pain and impair a woman'sability to tolerate it. Anxiety and fear increase muscle tension in thepelvic area, which counters the expulsive forces of uterine contractionsand pushing efforts. Previous experiences with pain: Fear andwithdrawal are a natural response to pain during labor. Learning aboutthese normal sensations ahead of time helps a woman suppress hernatural reactions of fear regarding the impending birth. If a womanpreviously had a long and difficult labor, she is likely to be anxious. Shemay also have learned ways to cope and may use these skills to adaptto the present labor experience. Support systems: An anxious partner isless able to provide help and support to a woman during labor. Awoman's family and friends can be an important source of support ifthey convey realistic and positive information about labor and delivery.Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort tothe natural pain of labor (i.e., fetal monitor straps, IV lines).fml
1. Women with hyperemesisgravidaruma. are a majority because 80% of allpregnant women suffer from it atsome time.b. have vomiting severe andpersistent enough to cause weightloss, dehydration, and electrolyteimbalance.c. need intravenous (IV) fluid andnutrition for most of their pregnancy.d. often inspire similar, mildersymptoms in their male partners andmothers.ANS: b. have vomiting severe and persistent enough to cause weightloss, dehydration, and electrolyte imbalance.Women with hyperemesis gravidarum have severe vomiting; however,treatment for several days sets things right in most cases. Although 80%of pregnant women experience nausea and vomiting, fewer than 1%(0.5%) proceed to this severe level. IV administration may be used at firstto restore fluid levels, but it is seldom needed for very long. Womensuffering from this condition want sympathy because some authoritiesbelieve that difficult relationships with mothers and/or partners may bethe cause.Because pregnant women may needsurgery during pregnancy, nursesshould be aware thata. the diagnosis of appendicitis maybe difficult because the normalsigns and symptoms mimic somenormal changes in pregnancy.b. rupture of the appendix is lesslikely in pregnant women becauseof the close monitoring.c. surgery for intestinal obstructionsshould be delayed as long aspossible because it usually affectsthe pregnancy.d. when pregnancy takes over, awoman is less likely to have ovarianproblems that require invasiveresponses.ANS: a. the diagnosis of appendicitis may be difficult because thenormal signs and symptoms mimic some normal changes in pregnancy.Both appendicitis and pregnancy are linked with nausea, vomiting, andincreased white blood cell count. Rupture of the appendix is two tothree times more likely in pregnant women. Surgery to removeobstructions should be done right away. It usually does not affect thepregnancy. Pregnancy predisposes a woman to ovarian problems.What laboratory marker is indicativeof disseminated intravascularcoagulation (DIC)?a. Bleeding time of 10 minutesb. Presence of fibrin split productsc. Thrombocytopeniad. HyperfibrinogenemiaANS: b. Presence of fibrin split productsDegradation of fibrin leads to the accumulation of fibrin split products inthe blood. Bleeding time in DIC is normal. Low platelets may occur withbut are not indicative of DIC because they may result from othercoagulopathies. Hypofibrinogenemia would occur with DIC.fml
In caring for an immediate after birthpatient, you note petechiae andoozing from her IV site. You wouldmonitor her closely for the clottingdisordera. disseminated intravascularcoagulation (DIC).b. amniotic fluid embolism (AFE).c. hemorrhage.d. HELLP syndrome.ANS: a. disseminated intravascular coagulation (DIC).The diagnosis of DIC is made according to clinical findings andlaboratory markers. Physical examination reveals unusual bleeding.Petechiae may appear around a blood pressure cuff on the woman'sarm. Excessive bleeding may occur from the site of slight trauma such asvenipuncture sites. These symptoms are not associated with AFE, nor isAFE a bleeding disorder. Hemorrhage occurs for a variety of reasons inthe after birth patient. These symptoms are associated with DIC.Hemorrhage would be a finding associated with DIC and is not aclotting disorder in and of itself. HELLP is not a clotting disorder, but itmay contribute to the clotting disorder DIC.. In caring for the woman withdisseminated intravascularcoagulation (DIC), what ordershould the nurse anticipate?a. Administration of bloodb. Preparation of the patient forinvasive hemodynamic monitoringc. Restriction of intravascular fluidsd. Administration of steroidsANS: a. Administration of bloodPrimary medical management in all cases of DIC involves correction ofthe underlying cause, volume replacement, blood component therapy,optimization of oxygenation and perfusion status, and continuedreassessment of laboratory parameters. Central monitoring would notbe ordered initially in a patient with DIC because this can contribute tomore areas of bleeding. Management of DIC would include volumereplacement, not volume restriction. Steroids are not indicated for themanagement of DIC.A primigravida is being monitored inher prenatal clinic for preeclampsia.What finding should concern hernurse?a. Blood pressure (BP) increase to138/86 mm Hg.b. Weight gain of 0.5 kg during thepast 2 weeks.c. A dipstick value of 3+ for proteinin her urine.d. Pitting pedal edema at the end ofthe day.ANS: c. A dipstick value of 3+ for protein in her urine.Proteinuria is defined as a concentration of 1+ or greater via dipstickmeasurement. A dipstick value of 3+ should alert the nurse thatadditional testing or assessment should be made. Generally,hypertension is defined as a BP of 140/90 or an increase in systolicpressure of 30 mm Hg or in diastolic pressure of 15 mm Hg.Preeclampsia may be manifested as a rapid weight gain of more than 2kg in 1 week. Edema occurs in many normal pregnancies and in womenwith preeclampsia. Therefore, the presence of edema is no longerconsidered diagnostic of preeclampsia.fml
The labor of a pregnant woman withpreeclampsia is going to beinduced. Before initiating the Pitocininfusion, the nurse reviews thewoman's latest laboratory testfindings, which reveal a plateletcount of 90,000, an elevatedaspartate transaminase (AST) level,and a falling hematocrit. The nursenotifies the physician because thelaboratory results are indicative ofa. eclampsia.b. disseminated intravascularcoagulation (DIC).c. HELLP syndrome.d. idiopathic thrombocytopenia.ANS: c. HELLP syndrome.HELLP syndrome is a laboratory diagnosis for a variant of severepreeclampsia that involves hepatic dysfunction characterized byhemolysis (H), elevated liver enzymes (EL), and low platelets (LP).Eclampsia is determined by the presence of seizures. DIC is a potentialcomplication associated with HELLP syndrome. Idiopathicthrombocytopenia is the presence of low platelets of unknown causeand is not associated with preeclampsia.A woman with preeclampsia has aseizure. The nurse's primary dutyduring the seizure is toa. insert an oral airway.b. suction the mouth to preventaspiration.c. administer oxygen by mask.d. stay with the patient and call forhelp.ANS: d. stay with the patient and call for help.If a patient becomes eclamptic, the nurse should stay her and call forhelp. Insertion of an oral airway during seizure activity is no longer thestandard of care. The nurse should attempt to keep the airway patent byturning the patient's head to the side to prevent aspiration. Once theseizure has ended, it may be necessary to suction the patient's mouth.Oxygen would be administered after the convulsion has ended.A pregnant woman has beenreceiving a magnesium sulfateinfusion for treatment of severepreeclampsia for 24 hours. Onassessment the nurse finds thefollowing vital signs: temperature of37.3 C, pulse rate of 88 beats/min,respiratory rate of 10 breaths/min,blood pressure (BP) of 148/90 mmHg, absent deep tendon reflexes,and no ankle clonus. The patientcomplains, ―I'm so thirsty andwarm.The nursea. calls for a stat magnesium sulfatelevel.b. administers oxygen.c. discontinues the magnesiumsulfate infusion.d. prepares to administerhydralazine.ANS: c. discontinues the magnesium sulfate infusion.The patient is displaying clinical signs and symptoms of magnesiumtoxicity. Magnesium should be discontinued immediately. In addition,calcium gluconate, the antidote for magnesium, may be administered.Hydralazine is an antihypertensive commonly used to treat hypertensionin severe preeclampsia. Typically, it is administered for a systolic BPgreater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.fml
A woman with severe preeclampsiahas been receiving magnesiumsulfate by intravenous infusion for 8hours. The nurse assesses thewoman and documents thefollowing findings: temperature of37.1 C, pulse rate of 96 beats/min,respiratory rate of 24 breaths/min,blood pressure (BP) of 155/112 mmHg, 3+ deep tendon reflexes, and noankle clonus. The nurse calls thephysician, anticipating an order fora. hydralazine.b. magnesium sulfate bolus.c. diazepam.d. calcium gluconate.ANS: a. hydralazine.Hydralazine is an antihypertensive commonly used to treat hypertensionin severe preeclampsia. Typically, it is administered for a systolic BPgreater than 160 mm Hg or a diastolic BP greater than 110 mm Hg. Anadditional bolus of magnesium sulfate may be ordered for increasingsigns of central nervous system irritability related to severepreeclampsia (e.g., clonus) or if eclampsia develops. Diazepamsometimes is used to stop or shorten eclamptic seizures. Calciumgluconate is used as the antidote for magnesium sulfate toxicity. Thepatient is not currently displaying any signs or symptoms of magnesiumtoxicityA woman at 39 weeks of gestationwith a history of preeclampsia isadmitted to the labor and birth unit.She suddenly experiences increasedcontraction frequency of every 1 to 2minutes; dark red vaginal bleeding;and a tense, painful abdomen. Thenurse suspects the onset ofa. eclamptic seizure.b. rupture of the uterus.c. placenta previa.d. placental abruption.ANS: d. placental abruption.Uterine tenderness in the presence of increasing tone may be theearliest finding of premature separation of the placenta (abruptioplacentae or placental abruption). Women with hypertension are atincreased risk for an abruption. Eclamptic seizures are evidenced by thepresence of generalized tonic-clonic convulsions. Uterine rupturemanifests as hypotonic uterine activity, signs of hypovolemia, and inmany cases the absence of pain. Placenta previa manifests with brightred, painless vaginal bleeding.The patient that you are caring forhas severe preeclampsia and isreceiving a magnesium sulfateinfusion. You become concernedafter assessment when the womanexhibitsa. a sleepy, sedated affect.b. a respiratory rate of 10breaths/min.c. deep tendon reflexes of 2.d. absent ankle clonus.ANS: b. a respiratory rate of 10 breaths/min.A respiratory rate of 10 breaths/min indicates that the patient isexperiencing respiratory depression from magnesium toxicity. Becausemagnesium sulfate is a central nervous system depressant, the patientwill most likely become sedated when the infusion is initiated. Deeptendon reflexes of two and absent ankle clonus are normal findings.fml
The nurse caring for pregnantwomen must be aware that the mostcommon medical complication ofpregnancy isa. hypertension.b. hyperemesis gravidarum.c. hemorrhagic complications.d. infectionsANS: a. hypertension.Preeclampsia and eclampsia are two noted deadly forms ofhypertension. A large percentage of pregnant women will have nauseaand vomiting, but a relatively few have the severe form calledhyperemesis gravidarum. Hemorrhagic complications are the secondmost common medical complication of pregnancy; hypertension is themost common.Nurses should be aware that HELLPsyndromea. is a mild form of preeclampsia.b. can be diagnosed by a nurse alertto its symptoms.c. is characterized by hemolysis,elevated liver enzymes, and lowplatelets.d. is associated with preterm laborbut not perinatal mortality.ANS: c. is characterized by hemolysis, elevated liver enzymes, and lowplatelets.The acronym HELLP stands for hemolysis (H), elevated liver enzymes(EL), and low platelets (LP). HELLP syndrome is a variant of severepreeclampsia. HELLP syndrome is difficult to identify because thesymptoms often are not obvious. It must be diagnosed in the laboratory.Preterm labor is greatly increased, and so is perinatal mortality.Nurses should be aware that chronichypertensiona. is defined as hypertension thatbegins during pregnancy and lastsfor the duration of pregnancy.b. is considered severe when thesystolic blood pressure (BP) isgreater than 140 mm Hg or thediastolic BP is greater than 90 mmHg.c. is general hypertension plusproteinuria.d. can occur independently of orsimultaneously with gestationalhypertension.ANS: d. can occur independently of or simultaneously with gestationalhypertension.Hypertension is present before pregnancy or diagnosed before 20weeks of gestation and persists longer than 6 weeks after birth. Therange for hypertension is systolic BP greater than 140 mm Hg ordiastolic BP greater than 90 mm Hg. It becomes severe with a diastolicBP of 110 mm Hg or higher. Proteinuria is an excessive concentration ofprotein in the urine. It is a complication of hypertension, not a definingcharacteristic.In planning care for women withpreeclampsia, nurses should beaware thata. induction of labor is likely, as nearterm as possible.b. if at home, the woman should beconfined to her bed, even with mildpreeclampsia.c. a special diet low in protein andsalt should be initiated.d. vaginal birth is still an option,even in severe cases.ANS: a. induction of labor is likely, as near term as possible.Induction of labor is likely, as near term as possible; however, at lessthan 37 weeks of gestation, immediate delivery may not be in the bestinterest of the fetus. Strict bed rest is becoming controversial for mildcases; some women in the hospital are even allowed to move around.Diet and fluid recommendations are much the same as for healthypregnant women, although some authorities have suggested a diet highin protein. Women with severe preeclampsia should expect a cesareandelivery.fml
Magnesium sulfate is given towomen with preeclampsia andeclampsia toa. improve patellar reflexes andincrease respiratory efficiency.b. shorten the duration of labor.c. prevent and treat convulsions.d. prevent a boggy uterus andlessen lochial flow.ANS: c. prevent and treat convulsions.Magnesium sulfate is the drug of choice to prevent convulsions,although it can generate other problems. Loss of patellar reflexes andrespiratory depression are signs of magnesium toxicity. Magnesiumsulfate can increase the duration of labor. Women are at risk for a boggyuterus and heavy lochial flow as a result of magnesium sulfate therapyA woman presents to theemergency department withcomplaints of bleeding andcramping. The initial nursing historyis significant for a last menstrualperiod 6 weeks ago. On sterilespeculum examination, the primarycare provider finds that the cervix isclosed. The anticipated plan of carefor this woman would be based on aprobable diagnosis of which type ofspontaneous abortion?a. Incompleteb. Inevitablec. Threatenedd. SepticANS: c. ThreatenedA woman with a threatened abortion presents with spotting, mildcramps, and no cervical dilation. A woman with an incomplete abortionwould present with heavy bleeding, mild to severe cramping, andcervical dilation. An inevitable abortion manifests with the samesymptoms as an incomplete abortion: heavy bleeding, mild to severecramping, and cervical dilation. A woman with a septic abortionpresents with malodorous bleeding and typically a dilated cervix.fml
The perinatal nurse is givingdischarge instructions to a womanafter suction curettage secondary toa hydatidiform mole. The womanasks why she must take oralcontraceptives for the next 12months. The best response from thenurse would bea. ―If you get pregnant within 1year, the chance of a successfulpregnancy is very small. Therefore, ifyou desire a future pregnancy, itwould be better for you to use themost reliable method ofcontraception available.b. ―The major risk to you after amolar pregnancy is a type of cancerthat can be diagnosed only bymeasuring the same hormone thatyour body produces duringpregnancy. If you were to getpregnant, it would make thediagnosis of this cancer moredifficult.c. ―If you can avoid a pregnancyfor the next year, the chance ofdeveloping a second molarpregnancy is rare. Therefore, toimprove your chance of a successfulpregnancy, it is better not to getpregnantANS: b. ―The major risk to you after a molar pregnancy is a type ofcancer that can be diagnosed only by measuring the same hormonethat your body produces during pregnancy. If you were to getpregnant, it would make the diagnosis of this cancer more difficult.This is an accurate statement. Beta-human chorionic gonadotropin(hCG) levels will be drawn for 1 year to ensure that the mole iscompletely gone. There is an increased chance of developingchoriocarcinoma after the development of a hydatidiform mole. Thegoal is to achieve a ―zerohCG level. If the woman were to becomepregnant, it could obscure the presence of the potentially carcinogeniccells. Women should be instructed to use birth control for 1 year aftertreatment for a hydatidiform mole. The rationale for avoiding pregnancyfor 1 year is to ensure that carcinogenic cells are not present. Anycontraceptive method except an intrauterine device is acceptable.The most prevalent clinicalmanifestation of abruptio placentae(as opposed to placenta previa) isa. bleeding.b. intense abdominal pain.c. uterine activity.d. cramping.b. intense abdominal pain.Pain is absent with placenta previa and may be agonizing with abruptioplacentae. Bleeding may be present in varying degrees for bothplacental conditions. Uterine activity and cramping may be present withboth placental conditions1. Methotrexate is recommended aspart of the treatment plan for whichobstetric complication?a. Complete hydatidiform moleb. Missed abortionc. Unruptured ectopic pregnancyd. Abruptio placentaeANS: c. Unruptured ectopic pregnancyMethotrexate is an effective, nonsurgical treatment option for ahemodynamically stable woman whose ectopic pregnancy isunruptured and less than 4 cm in diameter. Methotrexate is notindicated or recommended as a treatment option for completehydatidiform mole, missed abortion, and abruptio placentae.fml
A 26-year-old pregnant woman,gravida 2, para 1-0-0-1 is 28 weekspregnant when she experiencesbright red, painless vaginalbleeding. On her arrival at thehospital, what would be anexpected diagnostic procedure?a. Amniocentesis for fetal lungmaturityb. Ultrasound for placental locationc. Contraction stress test (CST)d. Internal fetal monitoringANS: b. Ultrasound for placental locationThe presence of painless bleeding should always alert the health careteam to the possibility of placenta previa. This can be confirmed throughultrasonography. Amniocentesis would not be performed on a womanwho is experiencing bleeding. In the event of an imminent delivery, thefetus would be presumed to have immature lungs at this gestational age,and the mother would be given corticosteroids to aid in fetal lungmaturity. A CST would not be performed at a preterm gestational age.Furthermore, bleeding would be a contraindication to this test. Internalfetal monitoring would be contraindicated in the presence of bleeding.A laboring woman with no knownrisk factors suddenly experiencesspontaneous rupture of membranes(ROM). The fluid consists of brightred blood. Her contractions areconsistent with her current stage oflabor. There is no change in uterineresting tone. The fetal heart ratebegins to decline rapidly after theROM. The nurse should suspect thepossibility ofa. placenta previa.b. vasa previa.c. severe abruptio placentae.d. disseminated intravascularcoagulation (DIC).b. vasa previa.Vasa previa is the result of a velamentous insertion of the umbilical cord.The umbilical vessels are not surrounded by Wharton jelly and have nosupportive tissue. They are at risk for laceration at any time, butlaceration occurs most frequently during ROM. The sudden appearanceof bright red blood at the time of ROM and a sudden change in the fetalheart rate without other known risk factors should immediately alert thenurse to the possibility of vasa previa. The presence of placenta previamost likely would be ascertained before labor and would beconsidered a risk factor for this pregnancy. In addition, if the woman hada placenta previa, it is unlikely that she would be allowed to pursuelabor and a vaginal birth. With the presence of severe abruptioplacentae, the uterine tonicity would typically be tetanus (i.e., a board-like uterus). DIC is a pathologic form of diffuse clotting that consumeslarge amounts of clotting factors and causes widespread externalbleeding, internal bleeding, or both. DIC is always a secondarydiagnosis, often associated with obstetric risk factors such as HELLPsyndrome. This woman did not have any prior risk factors.fml
A woman arrives for evaluation ofher symptoms, which include amissed period, adnexal fullness,tenderness, and dark red vaginalbleeding. On examination the nursenotices an ecchymotic bluenessaround the woman's umbilicus andrecognizes this assessment findingasa. normal integumentary changesassociated with pregnancy.b. Turner's sign associated withappendicitis.c. Cullen's sign associated with aruptured ectopic pregnancy.d. Chadwick's sign associated withearly pregnancyANS: c. Cullen's sign associated with a ruptured ectopic pregnancy.Cullen's sign, the blue ecchymosis seen in the umbilical area, indicateshematoperitoneum associated with an undiagnosed rupturedintraabdominal ectopic pregnancy. Linea nigra on the abdomen is thenormal integumentary change associated with pregnancy. It manifestsas a brown, pigmented, vertical line on the lower abdomen. Turner's signis ecchymosis in the flank area, often associated with pancreatitis.Chadwick's sign is the blue-purple color of the cervix that may be seenduring or around the eighth week of pregnancy.As related to the care of the patientwith miscarriage, nurses should beaware thata. it is a natural pregnancy lossbefore labor begins.b. it occurs in fewer than 5% of allclinically recognized pregnancies.c. it often can be attributed tocareless maternal behavior such aspoor nutrition or excessive exercise.d. if it occurs before the 12th weekof pregnancy, it may manifest onlyas moderate discomfort and bloodloss.ANS: d. if it occurs before the 12th week of pregnancy, it may manifestonly as moderate discomfort and blood loss.Before the sixth week the only evidence may be a heavy menstrual flow.After the 12th week more severe pain, similar to that of labor, is likely.Miscarriage is a natural pregnancy loss, but by definition it occursbefore 20 weeks of gestation, before the fetus is viable. Miscarriagesoccur in approximately 10% to 15% of all clinically recognizedpregnancies. Miscarriage can be caused by a number of disorders orillnesses outside of the mother's control or knowledge.Which condition would not beclassified as a bleeding disorder inlate pregnancy?a. Placenta previab. Abruptio placentaec. Spontaneous abortiond. Cord insertionANS: c. Spontaneous abortionSpontaneous abortion is another name for miscarriage; by definition itoccurs early in pregnancy. Placenta previa is a cause of bleedingdisorders in later pregnancy. Abruptio placentae is a cause of bleedingdisorders in later pregnancy. Cord insertion is a cause of bleedingdisorders in later pregnancy.fml
In providing nutritional counselingfor the pregnant womanexperiencing cholecystitis, the nursewoulda. assess the woman's dietary historyfor adequate calories and proteins.b. instruct the woman that the bulkof calories should come fromproteins.c. instruct the woman to eat a low-fat diet and avoid fried foods.d. instruct the woman to eat a low-cholesterol, low-salt diet.ANS: c. instruct the woman to eat a low-fat diet and avoid fried foods.Instructing the woman to eat a low-fat diet and avoid fried foods isappropriate nutritional counseling for this patient. Caloric and proteinintake do not predispose a woman to the development of cholecystitis.The woman should be instructed to limit protein intake and choosefoods that are high in carbohydrates. A low-cholesterol diet may be theresult of limiting fats. However, a low-salt diet is not indicated.Which maternal condition alwaysnecessitates delivery by cesareansection? a. Partial abruptioplacentaeb. Total placenta previac. Ectopic pregnancyd. EclampsiaANS: b. Total placenta previaIn total placenta previa, the placenta completely covers the cervical os.The fetus would die if a vaginal delivery occurred. If the mother hasstable vital signs and the fetus is alive, a vaginal delivery can beattempted in cases of partial abruptio placentae. If the fetus has died, avaginal delivery is preferred. The most common ectopic pregnancy is atubal pregnancy, which is usually detected and treated in the firsttrimester. Labor can be safely induced if the eclampsia is under control.Spontaneous termination of apregnancy is considered to be anabortion ifa. the pregnancy is less than 20weeks.b. the fetus weighs less than 1000 g.c. the products of conception arepassed intact.d. no evidence exists of intrauterineinfection.ANS: a. the pregnancy is less than 20 weeks.An abortion is the termination of pregnancy before the age of viability(20 weeks). The weight of the fetus is not considered because someolder fetuses may have a low birth weight. A spontaneous abortion maybe complete or incomplete. A spontaneous abortion may be caused bymany problems, one being intrauterine infection.An abortion in which the fetus diesbut is retained within the uterus iscalled a(n)a. inevitable abortion.b. missed abortion.c. incomplete abortion.d. threatened abortion.ANS: b. missed abortion.Missed abortion refers to retention of a dead fetus in the uterus. Aninevitable abortion means that the cervix is dilating with thecontractions. An incomplete abortion means that not all of the productsof conception were expelled. With a threatened abortion the womanhas cramping and bleeding but not cervical dilation.fml
A placenta previa in which theplacental edge just reaches theinternal os is more commonly knownasa. total.b. partial.c. complete.d. marginal.ANS: d. marginal.A placenta previa that does not cover any part of the cervix is termedmarginal. With a total placenta previa, the placenta completely coversthe os. When the patient experiences a partial placenta previa, thelower border of the placenta is within 3 cm of the internal cervical osbut does not completely cover the os. A complete placenta previa istermed total. The placenta completely covers the internal cervical osWhich condition indicatesconcealed hemorrhage when thepatient experiences an abruptioplacentae?a. Decrease in abdominal painb. Bradycardiac. Hard, board-like abdomend. Decrease in fundal heightANS: c. Hard, board-like abdomenConcealed hemorrhage occurs when the edges of the placenta do notseparate. The formation of a hematoma behind the placenta andsubsequent infiltration of the blood into the uterine muscle results in avery firm, board-like abdomen. Abdominal pain may increase. Thepatient will have shock symptoms that include tachycardia. As bleedingoccurs, the fundal height will increase.The priority nursing interventionwhen admitting a pregnant womanwho has experienced a bleedingepisode in late pregnancy is toa. assess fetal heart rate (FHR) andmaternal vital signs.b. perform a venipuncture forhemoglobin and hematocrit levels.c. place clean disposable pads tocollect any drainage.d. monitor uterine contractionsANS: a. assess fetal heart rate (FHR) and maternal vital signs.Assessment of the FHR and maternal vital signs will assist the nurse indetermining the degree of the blood loss and its effect on the motherand fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. It is important to assessfuture bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the toppriority.A patient with pregnancy-inducedhypertension is admittedcomplaining of pounding headache,visual changes, and epigastric pain.Nursing care is based on theknowledge that these signs are anindication ofa. anxiety due to hospitalization.b. worsening disease and impendingconvulsion.c. effects of magnesium sulfate.d. gastrointestinal upset.ANS: b. worsening disease and impending convulsion.Headache and visual disturbances are caused by increased cerebraledema. Epigastric pain indicates distention of the hepatic capsules andoften warns that a convulsion is imminent. These are danger signsshowing increased cerebral edema and impending convulsion andshould be treated immediately. The patient has not been started onmagnesium sulfate treatment yet. Also, these are not anticipated effectsof the medication.fml
Which order should the nurseexpect for a patient admitted with athreatened abortion?a. Bed restb. Ritodrine IVc. NPOd. Narcotic analgesia every 3 hours,prnANS: a. Bed restDecreasing the woman's activity level may alleviate the bleeding andallow the pregnancy to continue. Ritodrine IV is not the first drug ofchoice for tocolytic medications. There is no reason for having thewoman placed NPO. At times dehydration may produce contractions, sohydration is important. Narcotic analgesia will not decrease thecontractions. It may mask the severity of the contractions.A 32-year-old primigravida isadmitted with a diagnosis of ectopicpregnancy. Nursing care is based onthe knowledge thata. bed rest and analgesics are therecommended treatment.b. she will be unable to conceive inthe future.c. a D&C will be performed toremove the products of conception.d. hemorrhage is the major concern.ANS: d. hemorrhage is the major concern.Severe bleeding occurs if the fallopian tube ruptures. Therecommended treatment is to remove the pregnancy before rupture inorder to prevent hemorrhaging. If the tube must be removed, thewoman's fertility will decrease; however, she will not be infertile. D&C isperformed on the inside of the uterine cavity. The ectopic pregnancy islocated within the tubes.Approximately 10% to 15% of allclinically recognized pregnanciesend in miscarriage. Which is themost common cause ofspontaneous abortion?a. Chromosomal abnormalitiesb. Infectionsc. Endocrine imbalanced. Immunologic factorsANS: a. Chromosomal abnormalitiesAt least 50% of pregnancy losses result from chromosomalabnormalities that are incompatible with life. Maternal infection may bea cause of early miscarriage. Endocrine imbalances such ashypothyroidism or diabetes are possible causes for early pregnancyloss. Women who have repeated early pregnancy losses appear to haveimmunologic factors that play a role in spontaneous abortion incidentsThe nurse caring for a womanhospitalized for hyperemesisgravidarum should expect that initialtreatment to involvea. corticosteroids to reduceinflammation.b. IV therapy to correct fluid andelectrolyte imbalances.c. an antiemetic, such as pyridoxine,to control nausea and vomiting.d. enteral nutrition to correctnutritional deficits.ANS: b. IV therapy to correct fluid and electrolyte imbalances.Initially, the woman who is unable to keep down clear liquids by mouthrequires IV therapy for correction of fluid and electrolyte imbalances.Corticosteroids have been used successfully to treat refractoryhyperemesis gravidarum; however, they are not the expected initialtreatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic.Promethazine, a common antiemetic, may be prescribed. In severecases of hyperemesis gravidarum, enteral nutrition via a feeding tubemay be necessary to correct maternal nutritional deprivation. This is notan initial treatment for this patient.fml
A patient who has undergone adilation and curettage for earlypregnancy loss is likely to bedischarged the same day. The nursemust ensure that vital signs arestable, bleeding has beencontrolled, and the woman hasadequately recovered from theadministration of anesthesia. Topromote an optimal recovery,discharge teaching should include:(Select all that apply.)A. iron supplementation.B. resumption of intercourse at 6weeks following the procedure.C. referral to a support group ifnecessary.D. expectation of heavy bleeding forat least 2 weeks.E. emphasizing the need for rest.ANS: A, C, EThe reported incidence of ectopicpregnancy in the United States hasrisen steadily over the past twodecades. Causes include theincrease in STDs accompanied bytubal infection and damage. Thepopularity of contraceptive devicessuch as the IUD has also increasedthe risk for ectopic pregnancy. Thenurse who suspects that a patienthas early signs of ectopicpregnancy should be observing herfor symptoms such as: (Select allthat apply.)pelvic pain.abdominal pain.unanticipated heavy bleeding.vaginal spotting or light bleeding.missed period.pelvic pain.abdominal pain.vaginal spotting or light bleeding.missed period.fml
In assessing the knowledge of apregestational woman with type 1diabetes concerning changinginsulin needs during pregnancy, thenurse recognizes that furtherteaching is warranted when theclient states:a. I will need to increase my insulindosage during the first 3 months ofpregnancy.b. Insulin dosage will likely need tobe increased during the second andthird trimesters.c. Episodes of hypoglycemia aremore likely to occur during the first3 months.d. Insulin needs should return tonormal within 7 to 10 days after birthif I am bottle-feeding.ANS: AInsulin needs are reduced in the first trimester because of increasedinsulin production by the pancreas and increased peripheral sensitivityto insulin. Insulin dosage will likely need to be increased during thesecond and third trimesters, Episodes of hypoglycemia are more likelyto occur during the first 3 months, and Insulin needs should return tonormal within 7 to 10 days after birth if I am bottle-feeding are accuratestatements and signify that the woman has understood the teachingsregarding control of her diabetes during pregnancy.Preconception counseling is criticalto the outcome of diabeticpregnancies because poor glycemiccontrol before and during earlypregnancy is associated with:a. Frequent episodes of maternalhypoglycemia.b. Congenital anomalies in the fetus.c. Polyhydramnios.d. Hyperemesis gravidarum.ANS: BPreconception counseling is particularly important because strictmetabolic control before conception and in the early weeks ofgestation is instrumental in decreasing the risks of congenital anomalies.Frequent episodes of maternal hypoglycemia may occur during the firsttrimester (not before conception) as a result of hormone changes andthe effects on insulin production and usage. Hydramnios occurs about10 times more often in diabetic pregnancies than in nondiabeticpregnancies. Typically it is seen in the third trimester of pregnancy.Hyperemesis gravidarum may exacerbate hypoglycemic eventsbecause the decreased food intake by the mother and glucose transferto the fetus contribute to hypoglycemia.In planning for the care of a 30-year-old woman with pregestationaldiabetes, the nurse recognizes thatthe most important factor affectingpregnancy outcome is the:a. Mothers age.b. Number of years since diabeteswas diagnosed.c. Amount of insulin requiredprenatally.d. Degree of glycemic controlduring pregnancy.ANS: DWomen with excellent glucose control and no blood vessel diseaseshould have good pregnancy outcomes.fml
Concerning the use and abuse oflegal drugs or substances, nursesshould be aware that:a. Although cigarette smokingcauses a number of healthproblems, it has little direct effecton maternity-related health.b. Caucasian women are more likelyto experience alcohol-relatedproblems.c. Coffee is a stimulant that caninterrupt body functions and hasbeen related to birth defects.d. Prescription psychotherapeuticdrugs taken by the mother do notaffect the fetus; otherwise, theywould not have been prescribed.ANS: BAfrican-American and poor women are more likely to use illicitsubstances, particularly cocaine, whereas Caucasian and educatedwomen are more likely to use alcohol. Cigarette smoking impairs fertilityand is a cause of low birth weight. Caffeine consumption has not beenrelated to birth defects. Psychotherapeutic drugs have some effect onthe fetus, and that risk must be weighed against their benefit to themother.Screening at 24 weeks of gestationreveals that a pregnant woman hasgestational diabetes mellitus (GDM).In planning her care, the nurse andthe woman mutually agree that anexpected outcome is to preventinjury to the fetus as a result of GDM.The nurse identifies that the fetus isat greatest risk for:a. Macrosomia.b. Congenital anomalies of thecentral nervous system.c. Preterm birth.d. Low birth weight.ANS: APoor glycemic control later in pregnancy increases the rate of fetalmacrosomia. Poor glycemic control during the preconception timeframe and into the early weeks of the pregnancy is associated withcongenital anomalies. Preterm labor or birth is more likely to occur withsevere diabetes and is the greatest risk in women with pregestationaldiabetes. Increased weight, or macrosomia, is the greatest risk factor forthis woman.fml
A 26-year-old primigravida hascome to the clinic for her regularprenatal visit at 12 weeks. Sheappears thin and somewhat nervous.She reports that she eats a well-balanced diet, although her weightis 5 pounds less than it was at herlast visit. The results of laboratorystudies confirm that she has ahyperthyroid condition.Based on the available data, thenurse formulates a plan of care.What nursing diagnosis is mostappropriate for the woman at thistime?a. Deficient fluid volumeb. Imbalanced nutrition: less thanbody requirementsc. Imbalanced nutrition: more thanbody requirementsd. Disturbed sleep patternANS: BThis client's clinical cues include weight loss, which would support thenursing diagnosis of Imbalanced nutrition: less than body requirements.No clinical signs or symptoms support the nursing diagnosis of Deficientfluid volume. This client reports weight loss, not weight gain. Imbalancednutrition: more than body requirements is not an appropriate nursingdiagnosis. Although the client reports nervousness, based on the client'sother clinical symptoms the most appropriate nursing diagnosis wouldbe Imbalanced nutrition: less than body requirements.Maternal phenylketonuria (PKU) isan important health concern duringpregnancy because:a. It is a recognized cause ofpreterm labor.b. The fetus may develop neurologicproblems.c. A pregnant woman is more likelyto die without dietary control.d. Women with PKU are usuallyretarded and should not reproduce.ANS: BChildren born to women with untreated PKU are more likely to be bornwith mental retardation, microcephaly, congenital heart disease, and lowbirth weight. Maternal PKU has no effect on labor. Women withoutdietary control of PKU are more likely to miscarry or bear a child withcongenital anomalies. Screening for undiagnosed maternal PKU at thefirst prenatal visit may be warranted, especially in individuals with afamily history of the disorder, with low intelligence of uncertain etiology,or who have given birth to microcephalic infants.In terms of the incidence andclassification of diabetes, maternitynurses should know that:a. Type 1 diabetes is most common.b. Type 2 diabetes often goesundiagnosed.c. Gestational diabetes mellitus(GDM) means that the woman willbe receiving insulin treatment until 6weeks after birth.d. Type 1 diabetes may become type2 during pregnancy.ANS: BType 2 diabetes often goes undiagnosed because hyperglycemiadevelops gradually and often is not severe. Type 2 diabetes, sometimescalled adult onset diabetes, is the most common. GDM refers to anydegree of glucose intolerance first recognized during pregnancy.Insulin may or may not be needed. People do not go back and forthbetween types 1 and 2 diabetes.fml
Metabolic changes throughoutpregnancy that affect glucose andinsulin in the mother and the fetusare complicated but important tounderstand. Nurses shouldunderstand that:a. Insulin crosses the placenta to thefetus only in the first trimester, afterwhich the fetus secretes its own.b. Women with insulin-dependentdiabetes are prone tohyperglycemia during the firsttrimester because they areconsuming more sugar.c. During the second and thirdtrimesters, pregnancy exerts adiabetogenic effect that ensures anabundant supply of glucose for thefetus.d. Maternal insulin requirementssteadily decline during pregnancy.ANS: CPregnant women develop increased insulin resistance during thesecond and third trimesters. Insulin never crosses the placenta; the fetusstarts making its own insulin around the tenth week. As a result of normalmetabolic changes during pregnancy, insulin-dependent women areprone to hypoglycemia (low levels). Maternal insulin requirements maydouble or quadruple by the end of pregnancy.With regard to the association ofmaternal diabetes and other risksituations affecting mother andfetus, nurses should be aware that:a. Diabetic ketoacidosis (DKA) canlead to fetal death at any timeduring pregnancy.b. Hydramnios occurs approximatelytwice as often in diabeticpregnancies.c. Infections occur about as oftenand are considered about as seriousin diabetic and nondiabeticpregnancies.d. Even mild to moderatehypoglycemic episodes can havesignificant effects on fetal well-being.ANS: APrompt treatment of DKA is necessary to save the fetus and the mother.Hydramnios occurs 10 times more often in diabetic pregnancies.Infections are more common and more serious in pregnant women withdiabetes. Mild to moderate hypoglycemic episodes do not appear tohave significant effects on fetal well-being.fml
Diabetes in pregnancy puts the fetusat risk in several ways. Nurses shouldbe aware that:a. With good control of maternalglucose levels, sudden andunexplained stillbirth is no longer amajor concern.b. The most important cause ofperinatal loss in diabetic pregnancyis congenital malformations.c. Infants of mothers with diabeteshave the same risks for respiratorydistress syndrome because of thecareful monitoring.d. At birth the neonate of a diabeticmother is no longer in any risk.ANS: BCongenital malformations account for 30% to 50% of perinatal deaths.Even with good control, sudden and unexplained stillbirth remains amajor concern. Infants of diabetic mothers are at increased risk forrespiratory distress syndrome. The transition to extrauterine life often ismarked by hypoglycemia and other metabolic abnormalities.The nurse providing care for awoman with gestational diabetesunderstands that a laboratory testfor glycosylated hemoglobin Alc:a. Is now done for all pregnantwomen, not just those with or likelyto have diabetes.b. Is a snapshot of glucose controlat the moment.c. Would be considered evidence ofgood diabetes control with a resultof 5% to 6%.d. Is done on the patients urine, nother blood.ANS: CA score of 5% to 6% indicates good control. This is an extra test fordiabetic women, not one done for all pregnant women. This test definesglycemic control over the previous 4 to 6 weeks. Glycosylatedhemoglobin level tests are done on the blood.fml
A woman with gestational diabeteshas had little or no experiencereading and interpreting glucoselevels. She shows the nurse herreadings for the past few days.Which one should the nurse tell herindicates a need for adjustment(insulin or sugar)?a. 75 mg/dL before lunch. This is low;better eat now.b. 115 mg/dL 1 hour after lunch. This isa little high; maybe eat a little lessnext time.c. 115 mg/dL 2 hours after lunch; Thisis too high; it is time for insulin.d. 60 mg/dL just after waking upfrom a nap. This is too low; maybeeat a snack before going to sleep.ANS: D60 mg/dL after waking from a nap is too low. During hours of sleepglucose levels should not be less than 70 mg/dL. Snacks beforesleeping can be helpful. The premeal acceptable range is 65 to 95mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL.Two hours after eating, the readings should be less than 120 mg/dL.A new mother with which of thesethyroid disorders would be stronglydiscouraged from breastfeeding?a. Hyperthyroidismb. Phenylketonuria (PKU)c. Hypothyroidismd. Thyroid stormANS: BPKU is a cause of mental retardation in infants; mothers with PKU passon phenylalanine. A woman with hyperthyroidism or hypothyroidismwould have no particular reason not to breastfeed. A thyroid storm is acomplication of hyperthyroidism.fml
An 18-year-old client who hasreached 16 weeks of gestation wasrecently diagnosed withpregestational diabetes. She attendsher centering appointmentaccompanied by one of hergirlfriends. This young womanappears more concerned abouthow her pregnancy will affect hersocial life than about her recentdiagnosis of diabetes. Severalnursing diagnoses are applicable toassist in planning adequate care. Themost appropriate diagnosis at thistime is:a. Risk for injury to the fetus relatedto birth trauma.b. Noncompliance related to lack ofunderstanding of diabetes andpregnancy and requirements of thetreatment plan.c. Deficient knowledge related toinsulin administration.d. Risk for injury to the motherrelated to hypoglycemia orhyperglycemia.ANS: BBefore a treatment plan is developed or goals for the outcome of careare outlined, this client must come to an understanding of diabetes andthe potential effects on her pregnancy. She appears to have greaterconcern for changes to her social life than adoption of a new self-careregimen. Risk for injury to the fetus related to either placentalinsufficiency or birth trauma may come much later in the pregnancy. Atthis time the client is having difficulty acknowledging the adjustmentsthat she needs to make to her lifestyle to care for herself duringpregnancy. The client may not yet be on insulin. Insulin requirementsincrease with gestation. The importance of glycemic control must bepart of health teaching for this client. However, she has not yetacknowledged that changes to her lifestyle need to be made, and shemay not participate in the plan of care until understanding takes place.When caring for a pregnant womanwith cardiac problems, the nursemust be alert for signs andsymptoms of cardiacdecompensation, which include:a. A regular heart rate andhypertension.b. An increased urinary output,tachycardia, and dry cough.c. Shortness of breath, bradycardia,and hypertension.d. Dyspnea; crackles; and anirregular, weak pulse.ANS: DSigns of cardiac decompensation include dyspnea; crackles; anirregular, weak, rapid pulse; rapid respirations; a moist, frequent cough;generalized edema; increasing fatigue; and cyanosis of the lips and nailbeds. A regular heart rate and hypertension are not generallyassociated with cardiac decompensation. Tachycardia would indicatecardiac decompensation, but increased urinary output and a dry coughwould not. Shortness of breath would indicate cardiac decompensation,but bradycardia and hypertension would not.fml
Prophylaxis of subacute bacterialendocarditis is given before andafter birth when a pregnant womanhas:a. Valvular disease.b. Congestive heart disease.c. Arrhythmias.d. Postmyocardial infarction.ANS: AProphylaxis for intrapartum endocarditis and pulmonary infection maybe provided for women who have mitral valve stenosis. Prophylaxis forintrapartum endocarditis is not indicated for congestive heart disease,arrhythmias, or after myocardial infarction.While providing care in an obstetricsetting, the nurse should understandthat postpartum care of the womanwith cardiac disease:a. Is the same as that for anypregnant woman.b. Includes rest, stool softeners, andmonitoring of the effect of activity.c. Includes ambulating frequently,alternating with active range ofmotion.d. Includes limiting visits with theinfant to once per day.ANS: BBed rest may be ordered, with or without bathroom privileges. Bowelmovements without stress or strain for the woman are promoted withstool softeners, diet, and fluid. Care of the woman with cardiac diseasein the postpartum period is tailored to the woman's functional capacity.The woman will be on bed rest to conserve energy and reduce thestrain on the heart. Although the woman may need help caring for theinfant, breastfeeding and infant visits are not contraindicated.A woman with asthma isexperiencing a postpartumhemorrhage. Which drug would notbe used to treat her bleedingbecause it may exacerbate herasthma?a. Pitocinb. Nonsteroidal anti-inflammatorydrugs (NSAIDs)c. Hemabated. FentanylANS: CProstaglandin derivatives should not be used to treat women withasthma, because they may exacerbate symptoms. Pitocin would be thedrug of choice to treat this woman's bleeding because it would notexacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanylis used to treat pain, not bleeding.fml
The use of methamphetamine (meth)has been described as a significantdrug problem in the United States.In order to provide adequatenursing care to this client populationthe nurse must be cognizant thatmethamphetamine:a. Is similar to opiates.b. Is a stimulant withvasoconstrictive characteristics.c. Should not be discontinuedduring pregnancy.d. Is associated with a low rate ofrelapse.ANS: BMethamphetamines are stimulants with vasoconstrictive characteristicssimilar to cocaine and are used similarly. As is the case with cocaineusers, methamphetamine users are urged to immediately stop all useduring pregnancy. Unfortunately, because methamphetamine users areextremely psychologically addicted, the rate of relapse is very high.Since the gene for cystic fibrosiswas identified in 1989, data can becollected for the purposes ofgenetic counseling for couplesregarding carrier status. Accordingto statistics, how often does cysticfibrosis occur in Caucasian livebirths?a. 1 in 100b. 1 in 1200c. 1 in 2500d. 1 in 3000ANS: DCystic fibrosis occurs in about 1 in 3000 Caucasian live births.Which heart condition is not acontraindication for pregnancy?a. Peripartum cardiomyopathyb. Eisenmenger syndromec. Heart transplantd. All of these contraindicatepregnancy.ANS: CPregnancy is contraindicated for peripartum cardiomyopathy andEisenmenger syndrome. Women who have had heart transplants aresuccessfully having babies. However, conception should be postponedfor at least 1 year after transplantation.During a physical assessment of anat-risk client, the nurse notesgeneralized edema, crackles at thebase of the lungs, and some pulseirregularity. These are most likelysigns of:a. Euglycemia.b. Rheumatic fever.c. Pneumonia.d. Cardiac decompensation.ANS: DSymptoms of cardiac decompensation may appear abruptly orgradually. Euglycemia is a condition of normal glucose levels. Thesesymptoms indicate cardiac decompensation. Rheumatic fever can causeheart problems, but it does not manifest with these symptoms, whichindicate cardiac decompensation. Pneumonia is an inflammation of thelungs and would not likely generate these symptoms, which indicatecardiac decompensation.fml
Nurses caring for antepartumwomen with cardiac conditionsshould be aware that:a. Stress on the heart is greatest inthe first trimester and the last 2weeks before labor.b. Women with class II cardiacdisease should avoid heavy exertionand any activity that causes evenminor symptoms.c. Women with class III cardiacdisease should have 8 to 10 hours ofsleep every day and limithousework, shopping, and exercise.d. Women with class I cardiacdisease need bed rest through mostof the pregnancy and face thepossibility of hospitalization nearterm.ANS: BClass II cardiac disease is symptomatic with ordinary activity. Women inthis category need to avoid heavy exertion and limit regular activities assymptoms dictate. Stress is greatest between weeks 28 and 32, whenhomodynamic changes reach their maximum. Class III cardiac disease issymptomatic with less than ordinary activity. These women need bedrest most of the day and face the possibility of hospitalization near term.Class I cardiac disease is asymptomatic at normal levels of activity.These women can carry on limited normal activities with discretion,although they still need a good amount of sleep.As related to the care of the patientwith anemia, the nurse should beaware that:a. It is the most common medicaldisorder of pregnancy.b. It can trigger reflex brachycardia.c. The most common form of anemiais caused by folate deficiency.d. Thalassemia is a European versionof sickle cell anemia.ANS: ACombined with any other complication, anemia can result in congestiveheart failure. Reflex bradycardia is a slowing of the heart in response tothe blood flow increases immediately after birth. The most commonform of anemia is iron deficiency anemia. Both thalassemia and sicklecell hemoglobinopathy are hereditary but not directly related orconfined to geographic areas.The most common neurologicdisorder accompanying pregnancyis:a. Eclampsia.b. Bells palsy.c. Epilepsy.d. Multiple sclerosis.ANS: CThe effects of pregnancy on epilepsy are unpredictable. Eclampsiasometimes may be confused with epilepsy, which is the most commonneurologic disorder accompanying pregnancy. Bells palsy is a form offacial paralysis. Multiple sclerosis is a patchy demyelinization of thespinal cord that does not affect the normal course of pregnancy orbirth.fml
Marfan syndrome is an autosomaldominant genetic disorder thatdisplays as weakness of theconnective tissue, joint deformities,ocular dislocation, and weakness tothe aortic wall and root. Whileproviding care to a client withMarfan syndrome during labor,which intervention should the nursecomplete first?a. Antibiotic prophylaxisb. b-Blockersc. Surgeryd. Regional anesthesiaANS: ABecause of the potential for cardiac involvement during the thirdtrimester and after birth, treatment with prophylactic antibiotics is highlyrecommended. b-Blockers and restricted activity are recommended astreatment modalities earlier in the pregnancy. Regional anesthesia iswell tolerated by clients with Marfan syndrome; however, it is notessential to care. Adequate labor support may be all that is necessary ifan epidural is not part of the womans birth plan. Surgery forcardiovascular changes such as mitral valve prolapse, aorticregurgitation, root dilation, or dissection may be necessary. Mortalityrates may be as high as 50% in women who have severe cardiac disease.With one exception, the safestpregnancy is one in which thewoman is drug and alcohol free. Forwomen addicted to opioids,________________________ treatment is thecurrent standard of care duringpregnancy.a. Methadone maintenance c.Smoking cessationb. Detoxificationc. Smoking cessationd. 4 Ps PlusANS: AMethadone maintenance treatment (MMT) is currently considered thestandard of care for pregnant women who are dependent on heroin orother narcotics. Buprenorphine is another medication approved foropioid addiction treatment that is increasingly being used duringpregnancy. Opioid replacement therapy has been shown to decreaseopioid and other drug use, reduce criminal activity, improve individualfunctioning, and decrease rates of infections such as hepatitis B and C,HIV, and other sexually transmitted infections.Detoxification is the treatment used for alcohol addiction. Pregnantwomen requiring withdrawal from alcohol should be admitted forinpatient management. Women are more likely to stop smoking duringpregnancy than at any other time in their lives. A smoking cessationprogram can assist in achieving this goal. The 4 Ps Plus is a screeningtool designed specifically to identify pregnant women who need in-depth assessment related to substance abuse._____ use/abuse during pregnancycauses vasoconstriction anddecreased placental perfusion,resulting in maternal and neonatalcomplications.a. Alcoholb. Caffeinec. Tobaccod. ChocolateANS: CSmoking in pregnancy is known to cause a decrease in placentalperfusion and has serious health risks, including bleeding complications,low birth weight, prematurity, miscarriage, stillbirth, and sudden infantdeath syndrome. Prenatal alcohol exposure is the single greatestpreventable cause of mental retardation. Alcohol use during pregnancycan cause high blood pressure, miscarriage, premature birth, stillbirth,and anemia. Caffeine and chocolate may safely be consumed in smallquantities during pregnancy.fml
Which major neonatal complicationis carefully monitored after the birthof the infant of a diabetic mother?a. Hypoglycemiab. Hypercalcemiac. Hypobilirubinemiad. HypoinsulinemiaANS: AThe neonate is at highest risk for hypoglycemia because fetal insulinproduction is accelerated duringpregnancy to metabolize excessive glucose from the mother. At birth,the maternal glucose supply stops and the neonatal insulin exceeds theavailable glucose, thus leading to hypoglycemia. Hypocalcemia isassociated with preterm birth, birth trauma, and asphyxia, all commonproblems of the infant of a diabetic mother. Excess erythrocytes arebroken down after birth and release large amounts of bilirubin into theneonates circulation, with resulting hyperbilirubinemia. Because fetalinsulin production is accelerated during pregnancy, the neonatepresents with hyperinsulinemia.Which factor is known to increasethe risk of gestational diabetesmellitus?a. Underweight before pregnancyb. Maternal age younger than 25yearsc. Previous birth of large infantd. Previous diagnosis of type 2diabetes mellitusANS: CPrevious birth of a large infant suggests gestational diabetes mellitus.Obesity (BMI of 30 or greater) creates a higher risk for gestationaldiabetes. A woman younger than 25 years generally is not at risk forgestational diabetes mellitus. The person with type 2 diabetes mellitusalready has diabetes and will continue to have it after pregnancy. Insulinmay be required during pregnancy because oral hypoglycemia drugsare contraindicated during pregnancy.Glucose metabolism is profoundlyaffected during pregnancy because:a. Pancreatic function in the islets ofLangerhans is affected bypregnancy.b. The pregnant woman usesglucose at a more rapid rate thanthe nonpregnant woman.c. The pregnant woman increasesher dietary intake significantly.d. Placental hormones areantagonistic to insulin, thus resultingin insulin resistance.ANS: DPlacental hormones, estrogen, progesterone, and human placentallactogen (HPL) create insulin resistance. Insulin also is broken downmore quickly by the enzyme placental insulinase. Pancreatic functioningis not affected by pregnancy. The glucose requirements differ becauseof the growing fetus. The pregnant woman should increase her intake by200 calories a day.fml
To manage her diabetesappropriately and ensure a goodfetal outcome, the pregnant womanwith diabetes will need to alter herdiet by:a. Eating six small equal meals perday.b. Reducing carbohydrates in herdiet.c. Eating her meals and snacks on afixed schedule.d. Increasing her consumption ofprotein.ANS: CHaving a fixed meal schedule will provide the woman and the fetus witha steadier blood sugar level, provide better balance with insulinadministration, and help prevent complications. It is more important tohave a fixed meal schedule than equal division of food intake.Approximately 45% of the food eaten should be in the form ofcarbohydrates.When the pregnant diabetic womanexperiences hypoglycemia whilehospitalized, the nurse shouldintervene by having the patient:a. Eat six saltine crackers.b. Drink 8 oz of orange juice with 2tsp of sugar added.c. Drink 4 oz of orange juicefollowed by 8 oz of milk.d. Eat hard candy or commercialglucose wafers.ANS: ACrackers provide carbohydrates in the form of polysaccharides. Orangejuice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharideand orange juice is a monosaccharide. They will provide an increase inblood sugar but will not sustain the level. Hard candy or commercialglucose wafers provide only monosaccharides.Nursing intervention for thepregnant diabetic patient is basedon the knowledge that the need forinsulin:a. Increases throughout pregnancyand the postpartum period.b. Decreases throughout pregnancyand the postpartum period.c. Varies depending on the stage ofgestation.d. Should not change because thefetus produces its own insulin.ANS: CInsulin needs decrease during the first trimester, when nausea, vomiting,and anorexia are a factor. They increase during the second and thirdtrimesters, when the hormones of pregnancy create insulin resistance inmaternal cells. Insulin needs increase during the second and thirdtrimesters, when the hormones of pregnancy create insulin resistance inmaternal cells. The insulin needs change throughout the different stagesof pregnancy.What form of heart disease inwomen of childbearing years usuallyhas a benign effect on pregnancy?a. Cardiomyopathyb. Rheumatic heart diseasec. Congenital heart diseased. Mitral valve prolapseANS: DMitral valve prolapse is a benign condition that is usually asymptomatic.Cardiomyopathy produces congestive heart failure during pregnancy.Rheumatic heart disease can lead to heart failure during pregnancy.Some congenital heart diseases produce pulmonary hypertension orendocarditis during pregnancy.fml
In caring for a pregnant woman withsickle cell anemia, the nurse is awarethat signs and symptoms of sicklecell crisis include:a. Anemia.b. Endometritis.c. Fever and pain.d. Urinary tract infection.ANS: CWomen with sickle cell anemia have recurrent attacks (crisis) of feverand pain, most often in the abdomen, joints, and extremities. Theseattacks are attributed to vascular occlusion when RBCs assume thecharacteristic sickled shape. Crises are usually triggered by dehydration,hypoxia, or acidosis. Women with sickle cell anemia are not irondeficient. Therefore, routine iron supplementation, even that found inprenatal vitamins, should be avoided in order to prevent iron overload.Women with sickle cell trait usually are at greater risk for postpartumendometritis (uterine wall infection); however, this is not likely to occur inpregnancy and is not a sign of crisis. These women are at an increasedrisk for UTIs; however, this is not an indication of sickle cell crisis.A woman has a history of drug useand is screened for hepatitis Bduring the first trimester. What is anappropriate action?a. Provide a low-protein diet.b. Offer the vaccine.c. Discuss the recommendation tobottle-feed her baby.d. Practice respiratory isolation.ANS: BA person who has a history of high risk behaviors should be offered thehepatitis B vaccine. Care is supportive and includes bed rest and a high-protein, low-fat diet. The first trimester is too early to discuss feedingmethods with a woman in the high risk category. Hepatitis B istransmitted through blood.Congenital anomalies can occurwith the use of antiepileptic drugs(AEDs), including (Select all thatapply):a. Cleft lip.b. Congenital heart disease.c. Neural tube defects.d. Gastroschisis.e. Diaphragmatic hernia.ANS: A, B, CCongenital anomalies that can occur with AEDs include cleft lip orpalate, congenital heart disease, urogenital defects, and neural tubedefects. Gastroschisis and diaphragmatic hernia are not associated withthe use of AEDs.Diabetes refers to a group ofmetabolic diseases characterized byhyperglycemia resulting fromdefects in insulin action, insulinsecretion, or both. Over time,diabetes causes significant changesin the microvascular andmacrovascular circulations. Thesecomplications include:a. Atherosclerosis.b. Retinopathy.c. IUFD.d. Nephropathy.e. Neuropathy.f. Autonomcs neuropathy.ANS: A, B, D, EThese structural changes are most likely to affect a variety of systems,including the heart, eyes, kidneys, and nerves. Intrauterine fetal death(stillbirth) remains a major complication of diabetes in pregnancy;however, this is a fetal complication.fml
Autoimmune disorders often occurduring pregnancy because a largepercentage of women with anautoimmune disorder are ofchildbearing age. Identify alldisorders that fall into the categoryof collagen vascular disease.a. Multiple sclerosisb. Systemic lupus erythematosusc. Antiphospholipid syndromed. Rheumatoid arthritise. Myasthenia gravisANS: B, C, D, EMultiple sclerosis is not an autoimmune disorder. This patchydemyelinization of the spinal cord may be a viral disorder. Autoimmunedisorders (collagen vascular disease) make up a large group ofconditions that disrupt the function of the immune system of the body.They include those listed, as well as systemic sclerosis.1. The nurse recognizes that awoman is in true labor when shestates:a."I passed some thick, pink mucuswhen I urinated this morning."b."My bag of waters just broke."c."The contractions in my uterus aregetting stronger and closertogether."d."My baby dropped, and I have tourinate more frequently now."ANS: CRegular, strong contractions with the presence of cervical changeindicate that the woman is experiencing true labor. Loss of the mucousplug (operculum) often occurs during the first stage of labor or beforethe onset of labor, but it is not the indicator of true labor. Spontaneousrupture of membranes often occurs during the first stage of labor, but itis not the indicator of true labor. The presenting part of the fetustypically becomes engaged in the pelvis at the onset of labor, but this isnot the indicator of true labor.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance2. The nurse teaches a pregnantwoman about the characteristics oftrue labor contractions. The nurseevaluates the woman'sunderstanding of the instructionswhen she states, "True laborcontractions will:a.subside when I walk around."b.cause discomfort over the top of myuterus."c.continue and get stronger even if Irelax and take a shower."d.remain irregular but becomestronger."ANS: CTrue labor contractions occur regularly, becoming stronger, lastinglonger, and occurring closer together. They may become intense duringwalking and continue despite comfort measures. Typically true laborcontractions are felt in the lower back, radiating to the lower portion ofthe abdomen. During false labor, contractions tend to be irregular andfelt in the abdomen above the navel. Typically the contractions oftenstop with walking or a change of position.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: EvaluationMSC: Client Needs: Health Promotion and Maintenancefml
3. When a nulliparous womantelephones the hospital to reportthat she is in labor, the nurse initiallyshould:a.tell the woman to stay home untilher membranes rupture.b.emphasize that food and fluid intakeshould stop.c.arrange for the woman to come tothe hospital for labor evaluation.d.ask the woman to describe why shebelieves she is in labor.ANS: DAssessment begins at the first contact with the woman, whether bytelephone or in person. By asking the woman to describe her signs andsymptoms, the nurse can begin the assessment and gather data. Theamniotic membranes may or may not spontaneously rupture duringlabor. The patient may be instructed to stay home until the uterinecontractions become strong and regular. The nurse may want to discussthe appropriate oral intake for early labor such as light foods or clearliquids, depending on the preference of the patient or her primaryhealth care provider. Before instructing the woman to come to thehospital, the nurse should initiate the assessment during the telephoneinterview.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance4. When planning care for a laboringwoman whose membranes haveruptured, the nurse recognizes thatthe woman's risk for_________________________ has increased.a.intrauterine infectionb.hemorrhagec.precipitous labord.supine hypotensionANS: AWhen the membranes rupture, microorganisms from the vagina canascend into the amniotic sac and cause chorioamnionitis and placentitis.Rupture of membranes (ROM) is not associated with fetal or maternalbleeding. Although ROM may increase the intensity of contractions andfacilitate active labor, it does not result in precipitous labor. ROM has nocorrelation with supine hypotension.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Diagnosis, PlanningMSC: Client Needs: Physiologic Integrityfml
5. Which action is correct whenpalpation is used to assess thecharacteristics and pattern ofuterine contractions?a.Place the hand on the abdomenbelow the umbilicus and palpateuterine tone with the fingertips.b.Determine the frequency by timingfrom the end of one contraction tothe end of the next contraction.c.Evaluate the intensity by pressingthe fingertips into the uterinefundus.d.Assess uterine contractions every 30minutes throughout the first stage oflabor.ANS: CThe nurse or primary care provider may assess uterine activity bypalpating the fundal section of the uterus using the fingertips. Manywomen may experience labor pain in the lower segment of the uterusthat may be unrelated to the firmness of the contraction detectable inthe uterine fundus. The frequency of uterine contractions is determinedby palpating from the beginning of one contraction to the beginning ofthe next contraction. Assessment of uterine activity is performed inintervals based on the stage of labor. As labor progresses thisassessment is performed more frequently.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance6. When assessing a woman in thefirst stage of labor, the nurserecognizes that the most conclusivesign that uterine contractions areeffective would be:a.dilation of the cervix.b.descent of the fetus.c.rupture of the amniotic membranes.d.increase in bloody show.ANS: AThe vaginal examination reveals whether the woman is in true labor.Cervical change, especially dilation, in the presence of adequate laborindicates that the woman is in true labor. Descent of the fetus, orengagement, may occur before labor. Rupture of membranes mayoccur with or without the presence of labor. Bloody show may indicateslow, progressive cervical change (e.g., effacement) in both true andfalse labor.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment, DiagnosisMSC: Client Needs: Health Promotion and Maintenancefml
7. The nurse who performs vaginalexaminations to assess a woman'sprogress in labor should:a.perform an examination at leastonce every hour during the activephase of labor.b.perform the examination with thewoman in the supine position.c.wear two clean gloves for eachexamination.d.discuss the findings with the womanand her partner.ANS: DThe nurse should discuss the findings of the vaginal examination with thewoman and her partner and report them to the primary care provider. Avaginal examination should be performed only when indicated by thestatus of the woman and her fetus. The woman should be positioned toavoid supine hypotension. The examiner should wear a sterile glovewhile performing a vaginal examination for a laboring woman.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: PsychosocialIntegrity8. A multiparous woman has been inlabor for 8 hours. Her membraneshave just ruptured. The nurse's initialresponse would be to:a.prepare the woman for imminentbirth.b.notify the woman's primary healthcare provider.c.document the characteristics of thefluid.d.assess the fetal heart rate andpattern.ANS: DThe umbilical cord may prolapse when the membranes rupture. The fetalheart rate and pattern should be monitored closely for several minutesimmediately after ROM to ascertain fetal well-being, and the findingsshould be documented. Rupture of membranes (ROM) may increase theintensity and frequency of the uterine contractions, but it does notindicate that birth is imminent. The nurse may notify the primary careprovider after ROM occurs and fetal well-being and the response toROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amnioticfluid, but the initial response is to assess fetal well-being and theresponse to ROM.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
9. A nulliparous woman who has justbegun the second stage of herlabor would most likely:a.experience a strong urge to beardown.b.show perineal bulging.c.feel tired yet relieved that the worstis over.d.show an increase in bright redbloody show.ANS: CCommon maternal behaviors during the latent phase of the secondstage of labor include feeling a sense of accomplishment and optimismbecause "the worst is over." During the latent phase of the second stageof labor, the urge to bear down often is absent or only slight during theacme of contractions. Perineal bulging occurs during the transitionphase of the second stage of labor, not at the beginning of the secondstage. An increase in bright red bloody show occurs during the descentphase of the second stage of labor.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:EvaluationMSC: Client Needs: Psychosocial Integrity10. The nurse knows that the secondstage of labor, the descent phase,has begun when:a.the amniotic membranes rupture.b.the cervix cannot be felt during avaginal examination.c.the woman experiences a strongurge to bear down.d.the presenting part is below theischial spines.ANS: CDuring the descent phase of the second stage of labor, the woman mayexperience an increase in the urge to bear down. Rupture ofmembranes has no significance in determining the stage of labor. Thesecond stage of labor begins with full cervical dilation. Many womenmay have an urge to bear down when the presenting part is below thelevel of the ischial spines. This can occur during the first stage of labor,as early as 5-cm dilation.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenancefml
11. When managing the care of awoman in the second stage of labor,the nurse uses various measures toenhance the progress of fetaldescent. These measures include:a.encouraging the woman to tryvarious upright positions, includingsquatting and standing.b.telling the woman to start pushingas soon as her cervix is fully dilated.c.continuing an epidural anesthetic sopain is reduced and the woman canrelax.d.coaching the woman to usesustained, 10- to 15-second, closed-glottis bearing-down efforts witheach contraction.ANS: AUpright positions and squatting both may enhance the progress of fetaldescent. Many factors dictate when a woman will begin pushing.Complete cervical dilation is necessary, but it is only one factor. If thefetal head is still in a higher pelvic station, the physician or midwife mayallow the woman to "labor down" (allowing more time for fetal descent,thereby reducing the amount of pushing needed) if the woman is able.The epidural may mask the sensations and muscle control needed forthe woman to push effectively. Closed glottic breathing may trigger theValsalva maneuver, which increases intrathoracic and cardiovascularpressures, reducing cardiac output and inhibiting perfusion of the uterusand placenta. In addition, holding the breath for longer than 5 to 7seconds diminishes the perfusion of oxygen across the placenta andresults in fetal hypoxia.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenance12. Through vaginal examination thenurse determines that a woman is 4cm dilated, and the external fetalmonitor shows uterine contractionsevery 3.5 to 4 minutes. The nursewould report this as:a.first stage, latent phase.b.first stage, active phase.c.first stage, transition phase.d.second stage, latent phase.ANS: BThe first stage, active phase of maternal progress indicates that thewoman is in the active phase of the first stage of labor. During the latentphase of the first stage of labor, the expected maternal progress wouldbe 0 to 3 cm dilation with contractions every 5 to 30 minutes. During thetransition phase of the first stage of labor, the expected maternalprogress is 8 to 10 cm dilation with contractions every 2 to 3 minutes.During the latent phase of the second stage of labor, the woman iscompletely dilated and experiences a restful period of "laboring down."PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
13. The most critical nursing action incaring for the newborn immediatelyafter birth is:a.keeping the newborn's airway clear.b.fostering parent-newbornattachment.c.drying the newborn and wrappingthe infant in a blanket.d.administering eyedrops and vitaminK.ANS: AThe care given immediately after the birth focuses on assessing andstabilizing the newborn. Although fostering parent-infant attachment isan important task for the nurse, it is not the most critical nursing action incaring for the newborn immediately after birth. The nursing activitieswould be (in order of importance) to maintain a patent airway, supportrespiratory effort, and prevent cold stress by drying the newborn andcovering the infant with a warmed blanket or placing the newbornunder a radiant warmer. After the newborn has been stabilized, thenurse assesses the newborn's physical condition, weighs and measuresthe newborn, administers prophylactic eye ointment and a vitamin Kinjection, affixes an identification bracelet, wraps the newborn in warmblankets, and then gives the infant to the partner or mother when he orshe is ready.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenance14. When assessing a multiparouswoman who has just given birth toan 8-lb boy, the nurse notes that thewoman's fundus is firm and hasbecome globular in shape. A gushof dark red blood comes from hervagina. The nurse concludes that:a.the placenta has separated.b.a cervical tear occurred during thebirth.c.the woman is beginning tohemorrhage.d.clots have formed in the upperuterine segment.ANS: APlacental separation is indicated by a firmly contracting uterus, a changein the uterus from a discoid to a globular ovoid shape, a sudden gush ofdark red blood from the introitus, an apparent lengthening of theumbilical cord, and a finding of vaginal fullness. Cervical tears that donot extend to the vagina result in minimal blood loss. Signs ofhemorrhage are a boggy uterus, bright red vaginal bleeding, alterationsin vital signs, pallor, lightheadedness, restlessness, decreased urinaryoutput, and alteration in the level of consciousness. If clots have formedin the upper uterine segment, the nurse would expect to find the uterusboggy and displaced to the side.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment, DiagnosisMSC: Client Needs: Health Promotion and Maintenancefml
15. The nurse expects to administeran oxytocic (e.g., Pitocin,Methergine) to a woman afterexpulsion of her placenta to:a.relieve pain.b.stimulate uterine contraction.c.prevent infection.d.facilitate rest and relaxation.ANS: BOxytocics stimulate uterine contractions, which reduce blood loss afterthe third stage of labor. Oxytocics are not used to treat pain or preventinfection. They cause the uterus to contract, which reduces blood loss.Oxytocics do not facilitate rest and relaxation.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Planning, ImplementationMSC: Client Needs: Health Promotion and Maintenance16. After an emergency birth, thenurse encourages the woman tobreastfeed her newborn. Theprimary purpose of this activity is to:a.facilitate maternal-newborninteraction.b.stimulate the uterus to contract.c.prevent neonatal hypoglycemia.d.initiate the lactation cycle.ANS: BStimulation of the nipples through breastfeeding or manual stimulationcauses the release of oxytocin and prevents maternal hemorrhage.Breastfeeding facilitates maternal-newborn interaction, but it is not theprimary reason a woman is encouraged to breastfeed after anemergency birth. The primary intervention for preventing neonatalhypoglycemia is thermoregulation. Cold stress can result inhypoglycemia. The woman is encouraged to breastfeed after anemergency birth to stimulate the release of oxytocin, which preventshemorrhage. Breastfeeding is encouraged to initiate the lactation cycle,but it is not the primary reason for this activity after an emergency birth.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity17. A pregnant woman is in her thirdtrimester. She asks the nurse toexplain how she can tell true laborfrom false labor. The nurse wouldexplain that "true" laborcontractions:a.increase with activity such asambulation.b.decrease with activity.c.are always accompanied by therupture of the bag of waters.d.alternate between a regular and anirregular pattern.ANS: ATrue labor contractions become more intense with walking. False laborcontractions often stop with walking or position changes. Rupture ofmembranes may occur before or during labor. True labor contractionsare regular.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenancefml
18. A woman who is 39 weekspregnant expresses fear about herimpending labor and how she willmanage. The nurse's best responseis:a."Don't worry about it. You'll do fine."b."It's normal to be anxious aboutlabor. Let's discuss what makes youafraid."c."Labor is scary to think about, butthe actual experience isn't."d."You can have an epidural. You won'tfeel anything."ANS: B"It's normal to be anxious about labor. Let's discuss what makes youafraid" allows the woman to share her concerns with the nurse and is atherapeutic communication tool. "Don't worry about it. You'll do fine"negates the woman's fears and is not therapeutic. "Labor is scary to thinkabout, but the actual experience isn't" negates the woman's fears andoffers a false sense of security. It is not true that every woman may havean epidural. A number of criteria must be met for use of an epidural.Furthermore, many women still experience the feeling of pressure withan epidural.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: PlanningMSC: Client Needs: Psychosocial Integrity19. For the labor nurse, care of theexpectant mother begins with any orall of these situations, with theexception of:a.the onset of progressive, regularcontractions.b.the bloody, or pink, show.c.the spontaneous rupture ofmembranes.d.formulation of the woman's plan ofcare for labor.ANS: DLabor care begins when progressive, regular contractions begin; theblood-tinged mucoid vaginal discharge appears; or fluid is dischargedfrom the vagina. The woman and nurse can formulate their plan of carebefore labor or during treatment.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
20. Nurses can help their patients bykeeping them informed about thedistinctive stages of labor. Whichdescription of the phases of the firststage of labor is accurate?a.Latent: Mild, regular contractions; nodilation; bloody show; duration of 2to 4 hoursb.Active: Moderate, regularcontractions; 4- to 7-cm dilation;duration of 3 to 6 hoursc.Lull: No contractions; dilation stable;duration of 20 to 60 minutesd.Transition: Very strong but irregularcontractions; 8- to 10-cm dilation;duration of 1 to 2 hoursANS: BThe active phase is characterized by moderate, regular contractions; 4-to 7-cm dilation; and a duration of 3 to 6 hours. The latent phase ischaracterized by mild-to-moderate, irregular contractions; dilation up to3 cm; brownish-to-pale pink mucus, and a duration of 6 to 8 hours. Noofficial "lull" phase exists in the first stage. The transition phase ischaracterized by strong to very strong, regular contractions; 8- to 10-cmdilation; and a duration of 20 to 40 minutes.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenancefml
21. It is paramount for the obstetricnurse to understand the regulatoryprocedures and criteria foradmitting a woman to the hospitallabor unit. Which guideline is animportant legal requirement ofmaternity care?a.The patient is not considered to bein true labor (according to theEmergency Medical Treatment andActive Labor Act [EMTALA]) until aqualified health care provider saysshe is.b.The woman can have only her malepartner or predesignated "doula"with her at assessment.c.The patient's weight gain iscalculated to determine whethershe is at greater risk forcephalopelvic disproportion (CPD)and cesarean birth.d.The nurse may exchangeinformation about the patient withfamily members.ANS: CAccording to EMTALA, a woman is entitled to active labor care and ispresumed to be in "true" labor until a qualified health care providercertifies otherwise. A woman can have anyone she wishes present forher support. The risk for CPD is especially great for petite women orthose who have gained 16 kg or more. All patients should have theirweight and BMI calculated on admission. This is part of standard nursingcare on a maternity unit and not a regulatory concern. According to theHealth Insurance Portability and Accountability Act (HIPAA), the patientmust give consent for others to receive any information related to hercondition.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenance22. Leopold maneuvers would be aninappropriate method of assessmentto determine:a.gender of the fetus.b.number of fetuses.c.fetal lie and attitude.d.degree of the presenting part'sdescent into the pelvis.ANS: ALeopold maneuvers help identify the number of fetuses, the fetal lie andattitude, and the degree of descent of the presenting part into thepelvis. The gender of the fetus is not a goal of the examination at thistime.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
23. In documenting laborexperiences, nurses should knowthat a uterine contraction isdescribed according to all thesecharacteristics except:a.frequency (how often contractionsoccur).b.intensity (the strength of thecontraction at its peak).c.resting tone (the tension in theuterine muscle).d.appearance (shape and height).ANS: DUterine contractions are described in terms of frequency, intensity,duration, and resting tone.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenance24. Because the risk for childbirthcomplications may be revealed,nurses should know that the point ofmaximal intensity (PMI) of the fetalheart tone (FHT) is:a.usually directly over the fetalabdomen.b.in a vertex position heard above themother's umbilicus.c.heard lower and closer to themidline of the mother's abdomen asthe fetus descends and rotatesinternally.d.in a breech position heard belowthe mother's umbilicus.ANS: CNurses should be prepared for the shift. The PMI of the FHT usually isdirectly over the fetal back. In a vertex position it is heard below themother's umbilicus. In a breech position it is heard above the mother'sumbilicus.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
25. With regard to a woman's intakeand output during labor, nursesshould be aware that:a.the tradition of restricting thelaboring woman to clear liquids andice chips is being challengedbecause regional anesthesia is usedmore often than general anesthesia.b.intravenous (IV) fluids usually arenecessary to ensure that thelaboring woman stays hydrated.c.routine use of an enema empties therectum and is very helpful forproducing a clean, clear delivery.d.when a nulliparous womanexperiences the urge to defecate, itoften means birth will follow quickly.ANS: AWomen are awake with regional anesthesia and are able to protect theirown airway, which reduces the worry over aspiration. Routine IV fluidsduring labor are unlikely to be beneficial and may be harmful. Routineuse of an enema is at best ineffective and may be harmful. A multiparouswoman may feel the urge to defecate and it may mean birth will followquickly, but not for a first timer.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenance26. If a woman complains of backlabor pain, the nurse could bestsuggest that she:a.lie on her back for a while with herknees bent.b.do less walking around.c.take some deep, cleansing breaths.d.lean over a birth ball with her kneeson the floor.ANS: DThe hands-and-knees position, with or without the aid of a birth ball,should help with the back pain. The supine position should bediscouraged. Walking generally is encouraged.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
27. Which description of the phasesof the second stage of labor isaccurate?a.Latent phase: Feeling sleepy, fetalstation 2+ to 4+, duration 30 to 45minutesb.Active phase: Overwhelminglystrong contractions, Ferguson refluxactivated, duration 5 to 15 minutesc.Descent phase: Significant increasein contractions, Ferguson refluxactivated, average duration variedd.Transitional phase: Woman "laboringdown," fetal station 0, duration 15minutesANS: CThe descent phase begins with a significant increase in contractions; theFerguson reflex is activated, and the duration varies, depending on anumber of factors. The latent phase is the lull, or "laboring down,"period at the beginning of the second stage. It lasts 10 to 30 minutes onaverage. The second stage of labor has no active phase. The transitionphase is the final phase in the second stage of labor; contractions arestrong and painful.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance28. Nurses alert to signs of the onsetof the second stage of labor can becertain that this stage has begunwhen:a.the woman has a sudden episode ofvomiting.b.the nurse is unable to feel the cervixduring a vaginal examination.c.bloody show increases.d.the woman involuntarily bears down.ANS: BThe only certain objective sign that the second stage has begun is theinability to feel the cervix because it is fully dilated and effaced.Vomiting, an increase in bloody show, and involuntary bearing down areonly suggestions of second-stage labor.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance29. A means of controlling the birthof the fetal head with a vertexpresentation is:a.the Ritgen maneuver.b.fundal pressure.c.the lithotomy position.d.the De Lee apparatus.ANS: AThe Ritgen maneuver extends the head during the actual birth andprotects the perineum. Gentle, steady pressure against the fundus of theuterus facilitates vaginal birth. The lithotomy position has beencommonly used in Western cultures, partly because it is convenient forthe health care provider. The De Lee apparatus is used to suction fluidfrom the infant's mouth.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
30. Which collection of risk factorsmost likely would result in damaginglacerations (including episiotomies)?a.A dark-skinned woman who has hadmore than one pregnancy, who isgoing through prolonged second-stage labor, and who is attended bya midwife.b.A reddish-haired mother of two whois going through a breech birth.c.A dark-skinned, first-time motherwho is going through a long labor.d.A first-time mother with reddish hairwhose rapid labor was overseen byan obstetrician.ANS: DReddish-haired women have tissue that is less distensible than that ofdarker-skinned women and therefore may have less efficient healing.First time mothers are also more at risk, especially with breech births,long second-stage labors, or rapid labors in which there is insufficienttime for the perineum to stretch. The rate of episiotomies is higher whenobstetricians rather than midwives attend births.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: DiagnosisMSC: Client Needs: Physiologic Integrity31. Concerning the third stage oflabor, nurses should be aware that:a.the placenta eventually detachesitself from a flaccid uterus.b.an expectant or active approach tomanaging this stage of laborreduces the risk of complications.c.it is important that the dark,roughened maternal surface of theplacenta appear before the shinyfetal surface.d.the major risk for women during thethird stage is a rapid heart rate.ANS: BActive management facilitates placental separation and expulsion, thusreducing the risk of complications. The placenta cannot detach itselffrom a flaccid (relaxed) uterus. Which surface of the placenta comes outfirst is not clinically important. The major risk for women during the thirdstage of labor is after birth hemorrhage.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Planning, ImplementationMSC: Client Needs: Physiologic Integrityfml
32. For women who have a history ofsexual abuse, a number of traumaticmemories may be triggered duringlabor. The woman may fight thelabor process and react with pain oranger. Alternately, she may becomea passive player and emotionallyabsent herself from the process. Thenurse is in a unique position of beingable to assist the patient toassociate the sensations of laborwith the process of childbirth andnot the past abuse. The nurse canimplement a number of caremeasures to help the patient viewthe childbirth experience in apositive manner. Which interventionwould be key for the nurse to usewhile providing care?a.Telling the patient to relax and that itwon't hurt much.b.Limiting the number of proceduresthat invade her body.c.Reassuring the patient that as thenurse you know what is best.d.Allowing unlimited care providers tobe with the patient.ANS: BThe number of invasive procedures such as vaginal examinations,internal monitoring, and intravenous therapy should be limited as muchas possible. The nurse should always avoid words and phrases that mayresult in the patient's recalling the phrases of her abuser (e.g., "Relax, thiswon't hurt" or "Just open your legs.") The woman's sense of controlshould be maintained at all times. The nurse should explain proceduresat the patient's pace and wait for permission to proceed. Protecting thepatient's environment by providing privacy and limiting the number ofstaff who observe the patient will help to make her feel safe.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: PsychosocialIntegrityfml
33. As the United States and Canadacontinue to become more culturallydiverse, it is increasingly importantfor the nursing staff to recognize awide range of varying culturalbeliefs and practices. Nurses needto develop respect for theseculturally diverse practices andlearn to incorporate these into amutually agreed on plan of care.Although it is common practice inthe United States for the father ofthe baby to be present at the birth,in many societies this is not the case.When implementing care, the nursewould anticipate that a woman fromwhich country would have the fatherof the baby in attendance?a.Mexicob.Chinac.Irand.IndiaANS: AA woman from Mexico may be stoic about discomfort until the secondstage, at which time she will request pain relief. Fathers and femalerelatives are usually in attendance during the second stage of labor. Thefather of the baby is expected to provide encouragement, support, andreassurance that all will be well. Fathers are usually not present in China.The Iranian father will not be present. Female support persons andfemale care providers are preferred. For many, a male caregiver isunacceptable. The father is usually not present in India, but femalerelatives are usually present. Natural childbirth methods are preferred.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: PlanningMSC: Client Needs: Psychosocial Integrity34. A patient whose cervix is dilatedto 5 cm is considered to be in whichphase of labor?a.Latent phaseb.Active phasec.Second staged.Third stageANS: BThe latent phase is from the beginning of true labor until 3 cm ofcervical dilation. The active phase of labor is characterized by cervicaldilation of 4 to 7 cm. The second stage of labor begins when the cervixis completely dilated until the birth of the baby. The third stage of laboris from the birth of the baby until the expulsion of the placenta. Thispatient is in the active phase of labor.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
35. The primary difference betweenthe labor of a nullipara and that of amultipara is the:a.amount of cervical dilation.b.total duration of labor.c.level of pain experienced.d.sequence of labor mechanisms.ANS: BMultiparas usually labor more quickly than nulliparas, thus making thetotal duration of their labor shorter. Cervical dilation is the same for alllabors. The level of pain is individual to the woman, not to the number oflabors she has experienced. The sequence of labor mechanisms remainsthe same with all labors.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance36. A woman who is gravida 3 para 2enters the intrapartum unit. The mostimportant nursing assessments are:a.contraction pattern, amount ofdiscomfort, and pregnancy history.b.fetal heart rate, maternal vital signs,and the woman's nearness to birth.c.identification of rupturedmembranes, the woman's gravidaand para, and her support person.d.last food intake, when labor began,and cultural practices the coupledesires.ANS: BAll options describe relevant intrapartum nursing assessments; however,this focused assessment has priority. If the maternal and fetal conditionsare normal and birth is not imminent, other assessments can beperformed in an unhurried manner. This includes: gravida, para, supportperson, pregnancy history, pain assessment, last food intake, andcultural practices.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
37. A primigravida at 39 weeks ofgestation is observed for 2 hours inthe intrapartum unit. The fetal heartrate has been normal. Contractionsare 5 to 9 minutes apart, 20 to 30seconds in duration, and of mildintensity. Cervical dilation is 1 to 2cm and uneffaced (unchanged fromadmission). Membranes are intact.The nurse should expect the womanto be:a.admitted and prepared for acesarean birth.b.admitted for extended observation.c.discharged home with a sedative.d.discharged home to await the onsetof true labor.ANS: DThis situation describes a woman with normal assessments who isprobably in false labor and will likely not deliver rapidly once true laborbegins. There is no indication that further assessments or observationsare indicated; therefore, the patient will be discharged along withinstructions to return when contractions increase in intensity andfrequency. Neither a cesarean birth nor a sedative is required at thistime.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: AssessmentMSC: Client Needs: Safe and Effective Care Environment38. A laboring woman is lying in thesupine position. The mostappropriate nursing action at thistime is to:a.ask her to turn to one side.b.elevate her feet and legs.c.take her blood pressure.d.determine whether fetal tachycardiais present.ANS: AThe woman's supine position may cause the heavy uterus to compressher inferior vena cava, thus reducing blood return to her heart andreducing placental blood flow. Elevating her legs will not relieve thepressure from the inferior vena cava. If the woman is allowed to stay inthe supine position and blood flow to the placental is reducedsignificantly, fetal tachycardia may occur. The most appropriate nursingaction is to prevent this from occurring by turning the woman to herside. Blood pressure readings may be obtained when the patient is inthe appropriate and safest position.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrityfml
39. Which nursing assessmentindicates that a woman who is insecond-stage labor is almost readyto give birth?a.The fetal head is felt at 0 stationduring vaginal examination.b.Bloody mucus discharge increases.c.The vulva bulges and encircles thefetal head.d.The membranes rupture during acontraction.ANS: CA bulging vulva that encircles the fetal head describes crowning, whichoccurs shortly before birth. Birth of the head occurs when the station is+4. A 0 station indicates engagement. Bloody show occurs throughoutthe labor process and is not an indication of an imminent birth. Ruptureof membranes can occur at any time during the labor process and doesnot indicate an imminent birth.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance40. At 1 minute after birth, the nurseassesses the newborn to assign anApgar score. The apical heart rate is110 bpm, and the infant is cryingvigorously with the limbs flexed. Theinfant's trunk is pink, but the handsand feet are blue. What is thecorrect Apgar score for this infant?a.7b.8c.9d.10ANS: CThe Apgar score is 9 because 1 point is deducted from the total score of10 for the infant's blue hands and feet. The baby received 2 points foreach of the categories except color. Because the infant's hands and feetwere blue, this category is given a grade of 1.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance41. The nurse thoroughly dries theinfant immediately after birthprimarily to:a.stimulate crying and lung expansion.b.remove maternal blood from theskin surface.c.reduce heat loss from evaporation.d.increase blood supply to the handsand feet.ANS: CInfants are wet with amniotic fluid and blood at birth, and thisaccelerates evaporative heat loss. The primary purpose of drying theinfant is to prevent heat loss. Rubbing the infant does stimulate crying;however, it is not the main reason for drying the infant. This processdoes not remove all the maternal blood.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrityfml
The vaginal examination is anessential component of laborassessment. It reveals whether thepatient is in true labor and enablesthe examiner to determine whethermembranes have ruptured. Thisexamination is often stressful anduncomfortable for the patient andshould be performed only whenindicated. Please match the correctstep number, from 1 to 7, with eachcomponent of a vaginal examinationof the laboring woman.a. After obtaining permission, gentlyinsert the index and middle fingersinto the vagina.b. Explain findings to the patient.c. Position the woman to preventsupine hypotension.d. Use sterile gloves and soluble gelfor lubrication.e. Document findings and report tothe provider.f. Cleanse the perineum and vulva ifnecessary.g. Determine dilation, presentingpart, status of membranes, andcharacteristics of amniotic fluid.1. Step 12. Step 23. Step 34. Step 45. Step 56. Step 67. Ste1. ANS: D2. ANS: C3. ANS: F4. ANS: A5. ANS: G6. ANS: B7. ANS: Efml
1. While evaluating an externalmonitor tracing of a woman in activelabor, the nurse notes that the fetalheart rate (FHR) for five sequentialcontractions begins to deceleratelate in the contraction, with the nadirof the decelerations occurring afterthe peak of the contraction. Thenurse's first priority is to:a.change the woman's position.b.notify the care provider.c.assist with amnioinfusion.d.insert a scalp electrode.ANS: ALate decelerations may be caused by maternal supine hypotensionsyndrome. They usually are corrected when the woman turns on herside to displace the weight of the gravid uterus from the vena cava. Ifthe fetus does not respond to primary nursing interventions for latedecelerations, the nurse would continue with subsequent intrauterineresuscitation measures, including notifying the care provider. Anamnioinfusion may be used to relieve pressure on an umbilical cord thathas not prolapsed. The FHR pattern associated with this situation mostlikely reveals variable deceleration. A fetal scalp electrode wouldprovide accurate data for evaluating the well-being of the fetus;however, this is not a nursing intervention that would alleviate latedecelerations, nor is it the nurse's first priority.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity2. The nurse caring for the laboringwoman should understand that earlydecelerations are caused by:a.altered fetal cerebral blood flow.b.umbilical cord compression.c.uteroplacental insufficiency.d.spontaneous rupture of membranes.ANS: AEarly decelerations are the fetus's response to fetal head compression.Variable decelerations are associated with umbilical cord compression.Late decelerations are associated with uteroplacental insufficiency.Spontaneous rupture of membranes has no bearing on the fetal heartrate unless the umbilical cord prolapses, which would result in variableor prolonged bradycardia.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity3. The nurse providing care for thelaboring woman comprehends thataccelerations with fetal movement:a.are reassuring.b.are caused by umbilical cordcompression.c.warrant close observation.d.are caused by uteroplacentalinsufficiency.ANS: AEpisodic accelerations in the fetal heart rate (FHR) occur during fetalmovement and are indications of fetal well-being. Umbilical cordcompression results in variable decelerations in the FHR. Accelerationsin the FHR are an indication of fetal well-being and do not warrant closeobservation. Uteroplacental insufficiency would result in latedecelerations in the FHR.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrityfml
4. The nurse providing care for thelaboring woman realizes thatvariable fetal heart rate (FHR)decelerations are caused by:a.altered fetal cerebral blood flow.b.umbilical cord compression.c.uteroplacental insufficiency.d.fetal hypoxemia.ANS: BVariable decelerations can occur any time during the uterinecontracting phase and are caused by compression of the umbilical cord.Altered fetal cerebral blood flow would result in early decelerations inthe FHR. Uteroplacental insufficiency would result in late decelerationsin the FHR. Fetal hypoxemia would result in tachycardia initially and thenbradycardia if hypoxia continues.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity5. The nurse providing care for thelaboring woman should understandthat late fetal heart rate (FHR)decelerations are the result of:a.altered cerebral blood flow.b.umbilical cord compression.c.uteroplacental insufficiency.d.meconium fluid.ANS: CUteroplacental insufficiency would result in late decelerations in theFHR. Altered fetal cerebral blood flow would result in earlydecelerations in the FHR. Umbilical cord compression would result invariable decelerations in the FHR. Meconium-stained fluid may or maynot produce changes in the fetal heart rate, depending on thegestational age of the fetus and whether other causative factorsassociated with fetal distress are present.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity6. The nurse providing care for thelaboring woman should understandthat amnioinfusion is used to treat:a.variable decelerations.b.late decelerations.c.fetal bradycardia.d.fetal tachycardia.ANS: AAmnioinfusion is used during labor either to dilute meconium-stainedamniotic fluid or to supplement the amount of amniotic fluid to reducethe severity of variable decelerations caused by cord compression.Amnioinfusion has no bearing on late decelerations, fetal bradycardia,or fetal tachycardia alterations in fetal heart rate (FHR) tracings.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
7. The nurse caring for the woman inlabor should understand thatmaternal hypotension can result in:a.early decelerations.b.fetal dysrhythmias.c.uteroplacental insufficiency.d.spontaneous rupture of membranes.ANS: CLow maternal blood pressure reduces placental blood flow duringuterine contractions and results in fetal hypoxemia. Maternalhypotension is not associated with early decelerations, fetaldysrhythmias, or spontaneous rupture of membranes.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance8. The nurse caring for a laboringwoman is aware that maternalcardiac output can be increased by:a.change in position.b.oxytocin administration.c.regional anesthesia.d.intravenous analgesic.ANS: AMaternal supine hypotension syndrome is caused by the weight andpressure of the gravid uterus on the ascending vena cava when thewoman is in a supine position. This reduces venous return to thewoman's heart, as well as cardiac output, and subsequently reduces herblood pressure. The nurse can encourage the woman to changepositions and avoid the supine position. Oxytocin administration,regional anesthesia, and intravenous analgesic may reduce maternalcardiac output.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: PhysiologicIntegrity9. While evaluating an externalmonitor tracing of a woman in activelabor whose labor is being induced,the nurse notes that the fetal heartrate (FHR) begins to decelerate atthe onset of several contractionsand returns to baseline before eachcontraction ends. The nurse should:a.change the woman's position.b.discontinue the oxytocin infusion.c.insert an internal monitor.d.document the finding in the patient'srecord.ANS: DThe FHR indicates early decelerations, which are not an ominous signand do not require any intervention. The nurse should simply documentthese findings.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
10. Which fetal heart rate (FHR)finding would concern the nurseduring labor?a.Accelerations with fetal movementb.Early decelerationsc.An average FHR of 126 beats/mind.Late decelerationsANS: DLate decelerations are caused by uteroplacental insufficiency and areassociated with fetal hypoxemia. They are considered ominous ifpersistent and uncorrected. Accelerations in the FHR are an indicationof fetal well-being. Early decelerations in the FHR are associated withhead compression as the fetus descends into the maternal pelvic outlet;they generally are not a concern during normal labor.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance11. The most common cause ofdecreased variability in the fetalheart rate (FHR) that lasts 30minutes or less is:a.altered cerebral blood flow.b.fetal hypoxemia.c.umbilical cord compression.d.fetal sleep cycles.ANS: DA temporary decrease in variability can occur when the fetus is in asleep state. These sleep states do not usually last longer than 30minutes. Altered fetal cerebral blood flow would result in earlydecelerations in the FHR. Fetal hypoxemia would be evidenced bytachycardia initially and then bradycardia. A persistent decrease or lossof FHR variability may be seen. Umbilical cord compression would resultin variable decelerations in the FHR.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance12. Fetal well-being during labor isassessed by:a.the response of the fetal heart rate(FHR) to uterine contractions (UCs).b.maternal pain control.c.accelerations in the FHR.d.an FHR above 110 beats/min.ANS: AFetal well-being during labor can be measured by the response of theFHR to UCs. In general, reassuring FHR patterns are characterized by anFHR baseline in the range of 110 to 160 beats/min with no periodicchanges, a moderate baseline variability, and accelerations with fetalmovement. Maternal pain control is not the measure used to determinefetal well-being in labor. Although FHR accelerations are a reassuringpattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR above 110 beats/min may bereassuring, it is only one component of the criteria by which fetal well-being is assessed. More information would be needed to determinefetal well-being.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrityfml
13. You are evaluating the fetalmonitor tracing of your patient, whois in active labor. Suddenly you seethe fetal heart rate (FHR) drop fromits baseline of 125 beats/min downto 80 beats/min. You reposition themother, provide oxygen, increaseintravenous (IV) fluid, and perform avaginal examination. The cervix hasnot changed. Five minutes havepassed, and the fetal heart rateremains in the 80s. What additionalnursing measures should you take?a.Call for staff assistance.b.Insert a Foley catheter.c.Start Pitocin.d.Notify the care providerimmediately.ANS: DTo relieve an FHR deceleration, the nurse can reposition the mother,increase IV fluid, and provide oxygen. If oxytocin is infusing, it shouldbe discontinued. If the FHR does not resolve, the primary care providershould be notified immediately. Inserting a Foley catheter is aninappropriate nursing action. If the FHR were to continue in anonreassuring pattern, a cesarean section could be warranted, whichwould require a Foley catheter. However, the physician must make thatdetermination. Pitocin may place additional stress on the fetus.PTS: 1 DIF: Cognitive Level: EvaluationOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenance14. What three measures should thenurse implement to provideintrauterine resuscitation? Select theresponse that best indicates thepriority of actions that should betaken.a.Call the provider, reposition themother, and perform a vaginalexamination.b.Reposition the mother, increaseintravenous (IV) fluid, and provideoxygen via face mask.c.Administer oxygen to the mother,increase IV fluid, and notify the careprovider.d.Perform a vaginal examination,reposition the mother, and provideoxygen via face mask.ANS: BRepositioning the mother, increasing intravenous (IV) fluid, andproviding oxygen via face mask are correct nursing actions forintrauterine resuscitation. The nurse should initiate intrauterineresuscitation in an ABC manner, similar to basic life support. The firstpriority is to open the maternal and fetal vascular systems byrepositioning the mother for improved perfusion. The second priority isto increase blood volume by increasing the IV fluid. The third priority isto optimize oxygenation of the circulatory volume by providing oxygenvia face mask. If these interventions do not resolve the fetal heart rateissue quickly, the primary provider should be notified immediately.PTS: 1 DIF: Cognitive Level: EvaluationOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
15. Perinatal nurses are legallyresponsible for:a.correctly interpreting fetal heartrate (FHR) patterns, initiatingappropriate nursing interventions,and documenting the outcomes.b.greeting the patient on arrival,assessing her, and starting anintravenous line.c.applying the external fetal monitorand notifying the care provider.d.making sure that the woman iscomfortable.ANS: ANurses who care for women during childbirth are legally responsible forcorrectly interpreting FHR patterns, initiating appropriate nursinginterventions based on those patterns, and documenting the outcomesof those interventions. Greeting the patient, assessing her, and startingan IV; applying the external fetal monitor and notifying the careprovider; and making sure the woman is comfortable may be activitiesthat a nurse performs, but they are not activities for which the nurse islegally responsible.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment, Planning, ImplementationMSC: Client Needs: Safe and Effective Care Environment16. As a perinatal nurse you realizethat a fetal heart rate that istachycardic, is bradycardic, or haslate decelerations or loss ofvariability is nonreassuring and isassociated with:a.hypotension.b.cord compression.c.maternal drug use.d.hypoxemia.ANS: DNonreassuring heart rate patterns are associated with fetal hypoxemia.Fetal bradycardia may be associated with maternal hypotension. Fetalvariable decelerations are associated with cord compression. Maternaldrug use is associated with fetal tachycardia.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
17. A new patient and her partnerarrive in the labor, delivery,recovery, and after birth unit for thebirth of their first child. You applythe electronic fetal monitor (EFM) tothe woman. Her partner asks you toexplain what is printing on thegraph, referring to the EFM strip. Hewants to know what the baby's heartrate should be. Your best responseis:a."Don't worry about that machine;that's my job."b."The top line graphs the baby's heartrate. Generally the heart rate isbetween 110 and 160. The heart ratewill fluctuate in response to what ishappening during labor."c."The top line graphs the baby's heartrate, and the bottom line lets meknow how strong the contractionsare."d."Your doctor will explain all of thatlater."ANS: B"The top line graphs the baby's heart rate. Generally the heart rate isbetween 110 and 160. The heart rate will fluctuate in response to what ishappening during labor" educates the partner about fetal monitoringand provides support and information to alleviate his fears. "Don't worryabout that machine; that's my job" discredits the partner's feelings anddoes not provide the teaching he is requesting. "The top line graphs thebaby's heart rate, and the bottom line lets me know how strong thecontractions are" provides inaccurate information and does not addressthe partner's concerns about the fetal heart rate. The EFM graphs thefrequency and duration of the contractions, not the intensity. Nursesshould take every opportunity to provide patient and family teaching,especially when information is requested.PTS: 1 DIF: Cognitive Level: Application OBJ: Nursing Process: PlanningMSC: Client Needs: Psychosocial Integrity18. A normal uterine activity patternin labor is characterized by:a.contractions every 2 to 5 minutes.b.contractions lasting about 2 minutes.c.contractions about 1 minute apart.d.a contraction intensity of about 1000mm Hg with relaxation at 50 mm Hg.ANS: AContractions normally occur every 2 to 5 minutes and last less than 90seconds (intensity 800 mm Hg) with about 30 seconds in between (20mm Hg or less).PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
19. According to standardprofessional thinking, nurses shouldauscultate the fetal heart rate (FHR):a.every 15 minutes in the active phaseof the first stage of labor in theabsence of risk factors.b.every 20 minutes in the secondstage, regardless of whether riskfactors are present.c.before and after ambulation andrupture of membranes.d.more often in a woman's firstpregnancy.ANS: CThe FHR should be auscultated before and after administration ofmedications and induction of anesthesia. In the active phase of the firststage of labor, the FHR should be auscultated every 30 minutes if no riskfactors are involved; with risk factors it should be auscultated every 15minutes. In the second stage of labor the FHR should be auscultatedevery 15 minutes if no risk factors are involved; with risk factors it shouldbe auscultated every 5 minutes. The fetus of a first-time mother isautomatically at greater risk.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenance20. When using intermittentauscultation (IA) for fetal heart rate,nurses should be aware that:a.they can be expected to cover onlytwo or three patients when IA is theprimary method of fetal assessment.b.the best course is to use thedescriptive terms associated withelectronic fetal monitoring (EFM)when documenting results.c.if the heartbeat cannot be foundimmediately, a shift must be made toEFM.d.ultrasound can be used to find thefetal heartbeat and reassure themother if initial difficulty was afactor.ANS: DLocating fetal heartbeats often takes time. Mothers can be reassuredverbally and by the ultrasound pictures if ultrasound is used to helplocate the heartbeat. When used as the primary method of fetalassessment, auscultation requires a nurse-to-patient ratio of one to one.Documentation should use only terms that can be numerically defined;the usual visual descriptions of EFM are inappropriate.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment, PlanningMSC: Client Needs: Health Promotion and Maintenancefml
21. When using intermittentauscultation (IA) to assess uterineactivity, the nurse should becognizant that:a.the examiner's hand should beplaced over the fundus before,during, and after contractions.b.the frequency and duration ofcontractions is measured in secondsfor consistency.c.contraction intensity is given ajudgment number of 1 to 7 by thenurse and patient together.d.the resting tone betweencontractions is described as eitherplacid or turbulent.ANS: AThe assessment is done by palpation; duration, frequency, intensity, andresting tone must be assessed. The duration of contractions is measuredin seconds; the frequency is measured in minutes. The intensity ofcontractions usually is described as mild, moderate, or strong. Theresting tone usually is characterized as soft or relaxed.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenance22. What is an advantage of externalelectronic fetal monitoring?a.The ultrasound transducer canaccurately measure short-termvariability and beat-to-beat changesin the fetal heart rate.b.The tocotransducer can measureand record the frequency, regularity,intensity, and approximate durationof uterine contractions (UCs).c.The tocotransducer is especiallyvaluable for measuring uterineactivity during the first stage oflabor.d.Once correctly applied by thenurse, the transducer need not berepositioned even when the womanchanges positions.ANS: CThe tocotransducer is especially valuable for measuring uterine activityduring the first stage of labor, particularly when the membranes areintact. Short-term changes cannot be measured with this technology.The tocotransducer cannot measure and record the intensity of UCs.The transducer must be repositioned when the woman or fetus changesposition.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
23. When assessing the relativeadvantages and disadvantages ofinternal and external electronic fetalmonitoring, nurses comprehend thatboth:a.can be used when membranes areintact.b.measure the frequency, duration,and intensity of uterine contractions.c.may need to rely on the woman toindicate when uterine activity (UA) isoccurring.d.can be used during the antepartumand intrapartum periods.ANS: DExternal monitoring can be used in both periods; internal monitoringcan be used only in the intrapartum period. For internal monitoring themembranes must have ruptured, and the cervix must be sufficientlydilated. Internal monitoring measures the intensity of contractions;external monitoring cannot do this. With external monitoring, thewoman may need to alert the nurse that UA is occurring; internalmonitoring does not require this.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Health Promotion and Maintenance24. During labor a fetus with anaverage heart rate of 135 beats/minover a 10-minute period would beconsidered to have:a.bradycardia.b.a normal baseline heart rate.c.tachycardia.d.hypoxia.ANS: BThe baseline heart rate is measured over 10 minutes; a normal range is110 to 160 beats/min. Bradycardia is a fetal heart rate (FHR) below 110beats/min for 10 minutes or longer. Tachycardia is an FHR over 160beats/min for 10 minutes or longer. Hypoxia is an inadequate supply ofoxygen; no indication of this condition exists with a baseline heart ratein the normal range.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity25. The nurse caring for the womanin labor should understand thatincreased variability of the fetalheart rate may be caused by:a.narcotics.b.barbiturates.c.methamphetamines.d.tranquilizers.ANS: CNarcotics, barbiturates, and tranquilizers may be causes of decreasedvariability; methamphetamines may cause increased variability.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment MSC: Client Needs: HealthPromotion and Maintenancefml
26. Which deceleration of the fetalheart rate would not require thenurse to change the maternalposition?a.Early decelerationsb.Late decelerationsc.Variable decelerationsd.It is always a good idea to changethe woman's position.ANS: AEarly decelerations (and accelerations) generally do not need anynursing intervention. Late decelerations suggest that the nurse shouldchange the maternal position (lateral); variable decelerations alsorequire a maternal position change (side to side). Although changingpositions throughout labor is recommended, it is not required inresponse to early decelerations.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment, PlanningMSC: Client Needs: Physiologic Integrity27. What correctly matches the typeof deceleration with its likely cause?a.Early deceleration—umbilical cordcompressionb.Late deceleration—uteroplacentalinefficiencyc.Variable deceleration—headcompressiond.Prolonged deceleration—causeunknownANS: BLate deceleration is caused by uteroplacental inefficiency. Earlydeceleration is caused by head compression. Variable deceleration iscaused by umbilical cord compression. Prolonged deceleration has avariety of either benign or critical causes.PTS: 1 DIF: Cognitive Level: KnowledgeOBJ: Nursing Process: Assessment MSC: Client Needs: PhysiologicIntegrity28. A nurse may be called on tostimulate the fetal scalp:a.as part of fetal scalp bloodsampling.b.in response to tocolysis.c.in preparation for fetal oxygensaturation monitoring.d.to elicit an acceleration in the fetalheart rate (FHR).ANS: DThe scalp can be stimulated using digital pressure during a vaginalexamination. Fetal scalp blood sampling involves swabbing the scalpwith disinfectant before a sample is collected. The nurse would stimulatethe fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxationof the uterus. Fetal oxygen saturation monitoring involves the insertionof a sensor.PTS: 1 DIF: Cognitive Level: ApplicationOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
29. In assisting with the two factorsthat have an effect on fetal status(i.e., pushing and positioning), nursesshould:a.encourage the woman's cooperationin avoiding the supine position.b.advise the woman to avoid the semi-Fowler position.c.encourage the woman to hold herbreath and tighten her abdominalmuscles to produce a vaginalresponse.d.instruct the woman to open hermouth and close her glottis, lettingair escape after the push.ANS: AThe woman should maintain a side-lying position. The semi-Fowlerposition is the recommended side-lying position with a lateral tilt to theuterus. The Valsalva maneuver, which encourages the woman to holdher breath and tighten her abdominal muscles, should be avoided. Boththe mouth and glottis should be open, letting air escape during thepush.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenance30. Which maternal condition isconsidered a contraindication forthe application of internalmonitoring devices?a.Unruptured membranesb.Cervix dilated to 4 cmc.External monitors in current used.Fetus with a known heart defectANS: AIn order to apply internal monitoring devices, the membranes must beruptured. Cervical dilation of 4 cm permits the insertion of fetal scalpelectrodes and intrauterine catheter. The external monitor can bediscontinued after the internal ones are applied. A compromised fetusshould be monitored with the most accurate monitoring devices.PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process:PlanningMSC: Client Needs: Physiologic Integrity31. The nurse knows that properplacement of the tocotransducer forelectronic fetal monitoring islocated:a.over the uterine fundus.b.on the fetal scalp.c.inside the uterus.d.over the mother's lower abdomen.ANS: AThe tocotransducer monitors uterine activity and should be placed overthe fundus, where the most intensive uterine contractions occur. Thetocotransducer is for external use.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Implementation MSC: Client Needs: HealthPromotion and Maintenancefml
1. A tiered system of categorizingFHR has been recommended byregulatory agencies. Nurses,midwives, and physicians who carefor women in labor must have aworking knowledge of fetalmonitoring standards andunderstand the significance of eachcategory. These categories include:(Select all that apply.)a.reassuring.b.Category I.c.Category II.d.nonreassuring.e.Category III.ANS: B, C, EThe three tiered system of FHR tracings include Category I, II, and III.Category I is a normal tracing requiring no action. Category II FHRtracings are indeterminate. This category includes tracings that do notmeet Category I or III criteria. Category III tracings are abnormal andrequire immediate intervention.PTS: 1 DIF: Cognitive Level: ComprehensionOBJ: Nursing Process: Assessment, PlanningMSC: Client Needs: Physiologic Integrity2. The baseline fetal heart rate (FHR)is the average rate during a 10-minute segment. Changes in FHR arecategorized as periodic or episodic.These patterns include bothaccelerations and decelerations. Thelabor nurse is evaluating thepatient's most recent 10-minutesegment on the monitor strip andnotes a late deceleration. This islikely to be caused by whichphysiologic alteration? (Select allthat apply.)a.Spontaneous fetal movementb.Compression of the fetal headc.Placental abruptiond.Cord around the baby's necke.Maternal supine hypotensionANS: C, ELate decelerations are almost always caused by uteroplacentalinsufficiency. Insufficiency is caused by uterine tachysystole, maternalhypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection,or placental abruption. Spontaneous fetal movement, vaginalexamination, fetal scalp stimulation, fetal reaction to external sounds,uterine contractions, fundal pressure and abdominal palpation are alllikely to cause accelerations of the FHR. Early decelerations are mostoften the result of fetal head compression and may be caused byuterine contractions, fundal pressure, vaginal examination, andplacement of an internal electrode. A variable deceleration is likelycaused by umbilical cord compression. This may happen when theumbilical cord is around the baby's neck, arm, leg, or other body part orwhen there is a short cord, a knot in the cord, or a prolapsed cord.PTS: 1 DIF: Cognitive Level: AnalysisOBJ: Nursing Process: Assessment, DiagnosisMSC: Client Needs: Physiologic Integrityfml
Fetal well-being in labor can bemeasured by the response of theFHR to uterine contractions. Pleasematch the characteristic of normaluterine activity during labor with thecorrect description.a.Frequencyb.Durationc.Strengthd.Resting tonee.Relaxation time1. Commonly 45 seconds or more inthe second stage of labor.2. Generally ranging from two to fivecontractions per 10 minutes of labor.3. Average of 10 mm Hg.4. Peaking at 40 to 70 mm Hg in thefirst stage of labor.5. Remaining fairly stablethroughout the first and secondstages.1. ANS: E2. ANS: A3. ANS: D4. ANS: C5. ANS: BHow would the nurse best analyzethe results from a client's sonogramthat shows the fetal shoulder as thepresenting part?1. Breech, transverse2. Breech, longitudinal3. Breech, frank4. Vertex, transverseAnswer: 1Explanation: 1. A shoulder presentation is one type of breechpresentation, and is also called a transverse lie.fml
A clinic nurse is preparing diagramsof pelvic shapes. Which pelvicshapes are considered leastadequate for vaginal childbirth?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Android2. Anthropoid3. Gynecoid4. Platypelloid5. Lambdoidal sutureAnswer: 1, 4Explanation: 1. In the android and platypelloid types, the pelvicdiameters are diminished. Labor is more likely to be difficult (longer) anda cesarean birth is more likely.4. In the android and platypelloid types, the pelvic diameters arediminished. Labor is more likely to be difficult (longer) and a cesareanbirth is more likely.The nurse is caring for laboringclients. Which women areexperiencing problems related to acritical factor of labor?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Woman at 7 cm, fetus in generalflexion2. Woman at 3 cm, fetus inlongitudinal lie3. Woman at 4 cm, fetus withtransverse lie4. Woman at 6 cm, fetus at -2 station,mild contractions5. Woman at 5 cm, fetal presentingpart is right shoulderAnswer: 3, 4, 5Explanation: 3. A transverse lie occurs when the cephalocaudal axis ofthe fetal spine is at a right angle to the woman's spine and is associatedwith a shoulder presentation and can lead to complications in the laterstages of labor.4. Station refers to the relationship of the presenting part to animaginary line drawn between the ischial spines of the maternal pelvis. Ifthe presenting part is higher than the ischial spines, a negative number isassigned, noting centimeters above zero station. A -2 station is high inthe pelvis. Contractions should be strong to cause fetal descent. Mildcontractions will not move the baby down or open the cervix. This clientis experiencing a problem between the maternal pelvis and thepresenting part.5. When the fetal shoulder is the presenting part, the fetus is in atransverse lie and the acromion process of the scapula is the landmark.This type of presentation occurs less than 1% of the time. This client isexperiencing a problem between the maternal pelvis and thepresenting part.fml
The charge nurse has received theshift change report. Which clientrequires immediate intervention?1. Woman at 6 cm undergoinginduction of labor, strongcontractions every 3 minutes2. Woman at 4 cm whose fetus is in alongitudinal lie with a cephalicpresentation3. Woman at 10 cm and fetus at +2station experiencing a strongexpulsion urge4. Woman at 3 cm screaming in fearbecause her mother died duringchildbirthAnswer: 4Explanation: 4. This client is most likely fearful that she will die duringlabor because her mother died during childbirth. This client requireseducation and a great deal of support, and is therefore the top priority.Premonitory signs of labor includewhich of the following?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Braxton Hicks contractions2. Cervical softening andeffacement3. Weight gain4. Rupture of membranes5. Sudden loss of energyAnswer: 1, 2, 4Explanation: 1. A premonitory sign of labor includes Braxton Hickscontractions.2. A premonitory sign of labor includes cervical softening andeffacement.4. A premonitory sign of labor includes rupture of membranes.A client arrives in the labor anddelivery unit and describes hercontractions as occurring every 10-12 minutes, lasting 30 seconds. Sheis smiling and very excited about thepossibility of being in labor. Onexam, her cervix is dilated 2 cm,100% effaced, and -2 station. Whatbest describes this labor?1. Second phase2. Latent phase3. Active phase4. Transition phaseAnswer: 2Explanation: 2. In the early or latent phase of the first stage of labor,contractions are usually mild. The woman feels able to cope with thediscomfort. The woman is often talkative and smiling and is eager to talkabout herself and answer questions.fml
The client has asked the nurse whyher cervix has only changed from 1to 2 cm in 3 hours of contractionsoccurring every 5 minutes. What isthe nurse's best response to theclient?1. "Your cervix has also effaced, orthinned out, and that change in thecervix is also labor progress."2. "When your perineal body thinsout, your cervix will begin to dilatemuch faster than it is now."3. "What did you expect? You'veonly had contractions for a fewhours. Labor takes time."4. "The hormones that cause laborto begin are just getting to be atlevels that will change your cervix."Answer: 1Explanation: 1. With each contraction, the muscles of the upper uterinesegment shorten and exert a longitudinal traction on the cervix, causingeffacement. Effacement is the taking up (or drawing up) of the internalos and the cervical canal into the uterine side walls.A woman who is 40 weeks pregnantcalls the labor suite to ask whethershe should be evaluated. Whichstatements by the client indicate sheis likely in labor?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. "The contractions are 5-20 minutesapart."2. "I had pink discharge on the toiletpaper."3. "I have had cramping for the past3-4 hours."4. "The contractions start in my backand then go to my abdomen andare very intense."5. "The contractions hurt more whenI walk."Answer: 4, 5Explanation: 4. This is a sign of true labor. The contractions increase induration and intensity and begin in the back and radiate around to theabdomen.5. It is a sign of true labor when the client is unable to walk during thecontraction.fml
To identify the duration of acontraction, the nurse would dowhich of the following?1. Start timing from the beginning ofone contraction to the completionof the same contraction.2. Time between the beginning ofone contraction and the beginningof the next contraction.3. Palpate for the strength of thecontraction at its peak.4. Time from the beginning of thecontraction to the peak of the samecontraction.Answer: 1Explanation: 1. The duration of each contraction is measured from thebeginning of the contraction to the completion of the contraction.The client at 40 weeks' gestationreports to the nurse that she has hadincreased pelvic pressure andincreased urinary frequency. Whichresponse by the nurse is best?1. "Unless you have pain withurination, we don't need to worryabout it."2. "These symptoms usually meanthe baby's head has descendedfurther."3. "Come in for an appointmenttoday and we'll check everythingout."4. "This might indicate that the babyis no longer in a head-downposition."Answer: 2Explanation: 2. This is the best response because it most directlyaddresses what the client has reported.fml
The client at 39 weeks' gestationcalls the clinic and reportsincreased bladder pressure buteasier breathing and irregular, mildcontractions. She also states thatshe just cleaned the entire house.Which statement should the nursemake?1. "You shouldn't work so much atthis point in pregnancy."2. "What you are describing is notcommonly experienced in the lastweeks."3. "Your body may be telling you it isgoing into labor soon."4. "If the bladder pressurecontinues, come in to the clinictomorrow."Answer: 3Explanation: 3. One of the premonitory signs of labor is lightening: Thefetus begins to settle into the pelvic inlet (engagement). With fetaldescent, the uterus moves downward, and the fundus no longer presseson the diaphragm, which eases breathing.A client calls the labor and deliveryunit and tells the nurse that she is 39weeks pregnant and that over thelast 4 or 5 days, she has noticed thatalthough her breathing has becomeeasier, she is having leg cramps, aslight amount of edema in her lowerlegs, and an increased amount ofvaginal secretions. The nurse tellsthe client that she has experiencedwhich of the following?1. Engagement2. Lightening3. Molding4. Braxton Hicks contractionsAnswer: 2Explanation: 2. Lightening describes the effect occurring when the fetusbegins to settle into the pelvic inlet.fml
A client who is having false labormost likely would have which of thefollowing?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Contractions that do not intensifywhile walking2. An increase in the intensity andfrequency of contractions3. Progressive cervical effacementand dilatation4. Pain in the abdomen that does notradiate5. Contractions that lessen with restand warm tub bathsAnswer: 1, 4, 5Explanation: 1. True labor contractions intensify while walking.4. True labor results in progressive dilation, increased intensity andfrequency of contractions, and pain in the back that radiates to theabdomen.5. In true labor, contractions do not lessen with rest and warm tub baths.The nurse is preparing a clienteducation handout on thedifferences between false labor andtrue labor. What information is mostimportant for the nurse to include?1. True labor contractions begin inthe back and sweep toward thefront.2. False labor often feels likeabdominal tightening, or "ballingup."3. True labor can be diagnosed onlyif cervical change occurs.4. False labor contractions do notincrease in intensity or duration.Answer: 3Explanation: 3. Cervical change is the only factor that actuallydistinguishes false from true labor. The contractions of true laborproduce progressive dilatation and effacement of the cervix. Thecontractions of false labor do not produce progressive cervicaleffacement and dilatation.fml
The nurse is teaching a prenatalclass about false labor. The nurseshould teach clients that false labormost likely will include which of thefollowing?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Contractions that do not intensifywhile walking2. An increase in the intensity andfrequency of contractions3. Progressive cervical effacementand dilatation4. Pain in the abdomen that does notradiate5. Contractions are at regularintervalsAnswer: 1, 4Explanation: 1. True labor contractions intensify while walking.4. The discomfort of true labor contractions usually starts in the backand radiates around to the abdomen.A client is admitted to the labor anddelivery unit with contractions thatare 2 minutes apart, lasting 60seconds. She reports that she hadbloody show earlier that morning. Avaginal exam reveals that her cervixis 100 percent effaced and 8 cmdilated. The nurse knows that theclient is in which phase of labor?1. Active2. Latent3. Transition4. FourthAnswer: 3Explanation: 3. The transition phase begins with 8 cm to 10 cm ofdilatation, and contractions become more frequent, are longer induration, and increase in intensity.A client is admitted to the labor unitwith contractions 1-2 minutes apartlasting 60-90 seconds. The client isapprehensive and irritable. Thisclient is most likely in what phase oflabor?1. Active2. Transition3. Latent4. SecondAnswer: 2Explanation: 2. During transition, contractions have a frequency of 1 1/2to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity.When the woman enters the transition phase, she may demonstratesignificant anxiety.fml
The client in early labor asks thenurse what the contractions are likeas labor progresses. What would thenurse respond?1. "In normal labor, as the uterinecontractions become stronger, theyusually also become less frequent."2. "In normal labor, as the uterinecontractions become stronger, theyusually also become less painful."3. "In normal labor, as the uterinecontractions become stronger, theyusually also become longer induration."4. "In normal labor, as the uterinecontractions become stronger, theyusually also become shorter induration."Answer: 3Explanation: 3. During the active and transition phases, contractionsbecome more frequent, are longer in duration, and increase in intensity.Four minutes after the birth of ababy, there is a sudden gush ofblood from the mother's vagina, andabout 8 inches of umbilical cordslides out. What action should thenurse take first?1. Place the client in McRobertsposition.2. Watch for the emergence of theplacenta.3. Prepare for the delivery of anundiagnosed twin.4. Place the client in a supineposition.Answer: 2Explanation: 2. Signs of placental separation usually appear around 5minutes after birth of the infant, but can take up to 30 minutes tomanifest. These signs are (1) a globular-shaped uterus, (2) a rise of thefundus in the abdomen, (3) a sudden gush or trickle of blood, and (4)further protrusion of the umbilical cord out of the vagina.fml
A nurse needs to evaluate theprogress of a woman's labor. Thenurse obtains the following data:cervical dilatation 6 cm; contractionsmild in intensity, occurring every 5minutes, with a duration of 30-40seconds. Which clue in this datadoes not fit the pattern suggestedby the rest of the clues?1. Cervical dilatation 6 cm2. Mild contraction intensity3. Contraction frequency every 5minutes4. Contraction duration 30-40secondsAnswer: 1Explanation: 1. Cervical dilatation of 6 cm indicates the active phase oflabor. During this phase the cervix dilates from about 4 to 7 cm andcontractions and pain intensify.The nurse is caring for a client inlabor. Which signs and symptomswould indicate the client isprogressing into the second stageof labor?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Bulging perineum2. Increased bloody show3. Spontaneous rupture of themembranes4. Uncontrollable urge to push5. Inability to breathe throughcontractionsAnswer: 1, 2, 4Explanation: 1. As the fetal head continues its descent, the perineumbegins to bulge, flatten, and move anteriorly.2. Bloody show increases as a woman enters the second stage of labor.4. As the fetal head descends, the woman has the urge to push becauseof pressure of the fetal head on the sacral and obturator nerves.The labor nurse would notencourage a mother to bear downuntil the cervix is completely dilated,to prevent which of the following?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Maternal exhaustion2. Cervical edema3. Tearing and bruising of the cervix4. Enhanced perineal thinning5. Having to perform an episiotomyAnswer: 1, 2, 3Explanation: 1. If the cervix is not completely dilated, maternalexhaustion can occur.2. If the cervix is not completely dilated, cervical edema can occur.3. If the cervix is not completely dilated, tearing and bruising of thecervix can occur.fml
The nurse is caring for a laboringclient. A cervical exam indicates 8cm dilation. The client is restless,frequently changing position in anattempt to get comfortable. Whichnursing action is most important?1. Leave the client alone so she canrest.2. Ask the family to take a coffee-and-snack break.3. Encourage the client to have anepidural for pain.4. Reassure the client that she willnot be left alone.Answer: 4Explanation: 4. Because the client is in the transitional phase of the firststage of labor, she will not want to be left alone; staying with the clientand reassuring her that she will not be alone are the highest priorities atthis time.During the fourth stage of labor, theclient's assessment includes a BP of110/60, pulse 90, and the fundus isfirm midline and halfway betweenthe symphysis pubis and theumbilicus. What is the priority actionof the nurse?1. Turn the client onto her left side.2. Place the bed in Trendelenburgposition.3. Massage the fundus.4. Continue to monitor.Answer: 4Explanation: 4. The client's assessment data are normal for the fourthstage of labor, so monitoring is the only action necessary. During thefourth stage of labor, the mother experiences a moderate drop in bothsystolic and diastolic blood pressure, increased pulse pressure, andmoderate tachycardia.The nurse has just palpated alaboring woman's contractions. Theuterus cannot be indented during acontraction. What would theintensity of these contractions bestbe characterized as?1. Weak2. Mild3. Moderate4. StrongAnswer: 4Explanation: 4. Strong intensity exists when the uterine wall cannot beindented.fml
The labor and delivery nurse isreviewing charts. The nurse shouldinform the supervisor about whichclient?1. Client at 5 cm requesting laborepidural analgesia2. Client whose cervix remains at 6cm for 4 hours3. Client who has developed nauseaand vomiting4. Client requesting her partner tostay with herAnswer: 2Explanation: 2. Average cervical change in the active phase of the firststage of labor is 1.2 cm/hour; thus, this client's lack of cervical change isunexpected, and should be reported to the supervisor.Which client requires immediateintervention by the labor anddelivery nurse?1. Client at 8 cm, systolic bloodpressure has increased 35 mm Hg2. Client who delivered 1 hour agowith WBC of 50,0003. Client at 5 cm with a respiratoryrate of 22 between contractions4. Client in active labor with polyuria: 2Explanation: 2. The white blood cell (WBC) count increases to25,000/mm3 to 30,000/mm3 during labor and early postpartum. Thiscount is abnormally high, and requires further assessment and providernotification.The labor and delivery nurse ispreparing a prenatal class aboutfacilitating the progress of labor.Which of the following frequentresponses to pain should the nurseindicate is most likely to impedeprogress in labor?1. Increased pulse2. Elevated blood pressure3. Muscle tension4. Increased respirationsAnswer: 3Explanation: 3. It is important for the woman to relax each part of herbody. Be alert for signs of muscle tension and tightening. Dissociativerelaxation, controlled muscle relaxation, and specified breathingpatterns are used to promote birth as a normal process.fml
While caring for a client in labor, thenurse notices during a vaginal examthat the fetus's head has rotatedinternally. What would the nurseexpect the next set of cardinalmovements for a fetus in a vertexpresentation to be?1. Flexion, extension, restitution,external rotation, and expulsion2. Expulsion, external rotation, andrestitution3. Restitution, flexion, externalrotation, and expulsion4. Extension, restitution, externalrotation, and expulsionAnswer: 4Explanation: 4. The fetus changes position in the following order:descent, flexion, internal rotation, extension, restitution, externalrotation, and expulsion.When comparing the anterior andposterior fontanelles of a newborn,the nurse knows that both are what?1. Both are approximately the samesize2. Both close within 12 months ofbirth3. Both are used in labor to identifystation4. Both allow for assessing the statusof the newborn after birthAnswer: 4Explanation: 4. The anterior and posterior fontanelles are clinicallyuseful in identifying the position of the fetal head in the pelvis and inassessing the status of the newborn after birth.The nurse is aware that labor andbirth will most likely proceednormally when the fetus is in whatposition?1. Right-acromion-dorsal-anterior2. Right-sacrum-transverse3. Occiput anterior4. Posterior positionAnswer: 3Explanation: 3. The most common fetal position is occiput anterior.When this position occurs, labor and birth are likely to proceednormally.The midwife performs a vaginalexam and determines that the fetalhead is at a -2 station. What doesthis indicate to the nurse about thebirth?1. The birth is imminent.2. The birth is likely to occur in 1-2hours.3. The birth will occur later in theshift.4. The birth is difficult to predict.Answer: 4Explanation: 4. A -2 station means that the fetus is 2 cm above the ischialspines. The ischial spines as a landmark have been designated as zerostation. If the presenting part is higher than the ischial spines, a negativenumber is assigned, noting centimeters above zero station. With thefetus's head that high in the pelvis, it is difficult to predict when birth willoccur.fml
Childbirth preparation offers severaladvantages including which of thefollowing?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. It helps a pregnant woman andher support person understand thechoices in the birth setting.2. It promotes awareness ofavailable options.3. It provides tools for a pregnantwoman and her support person touse during labor and birth.4. Women who receive continuoussupport during labor require moreanalgesia, and have more cesareanand instrument births.5. Each method has been shown toshorten labor.Answer: 1, 2, 3, 5Explanation: 1. Childbirth preparation offers several advantages. It helpsa pregnant woman and her support person understand the choices inthe birth setting, promotes awareness of available options, and providestools for them to use during labor and birth.2. Childbirth preparation offers several advantages. It helps a pregnantwoman and her support person understand the choices in the birthsetting, promotes awareness of available options, and provides tools forthem to use during labor and birth.3. Childbirth preparation offers several advantages. It helps a pregnantwoman and her support person understand the choices in the birthsetting, promotes awareness of available options, and provides tools forthem to use during labor and birth.5. Childbirth preparation offers several advantages. Each method hasbeen shown to shorten labor.The nurse determines that a client iscarrying her fetus in the vertical(longitudinal) lie. The nurse'sjudgment should be questioned ifthe fetal presenting part is which ofthe following?Note: Credit will be given only forall correct choices and no incorrectchoices.Select all that apply.1. Sacrum2. Left arm3. Mentum4. Left scapula5. Right scapulaAnswer: 2, 4, 5Explanation: 2. A fetus with an arm presenting is likely in a horizontal lie.4. A fetus with a left scapula presenting is in a horizontal lie.5. A fetus with a right scapula presenting is in a horizontal lie.fml
The nurse is admitting a client to thebirthing unit. What question shouldthe nurse ask to gain a betterunderstanding of the client'spsychosocial status?1. "How did you decide to have yourbaby at this hospital?"2. "Who will be your labor supportperson?"3. "Have you chosen names for yourbaby yet?"4. "What feeding method will youuse for your baby?"Answer: 2Explanation: 2. The expectant mother's partner or support person is animportant member of the birthing team, and assessments of the couple'scoping, interactions, and teamwork are integral to the nurse'sknowledge base. The nurse's physical presence with the laboringwoman provides the best opportunity for ongoing assessment.The nurse is admitting a client to thelabor and delivery unit. Whichaspect of the client's history requiresnotifying the physician?1. Blood pressure 120/882. Father a carrier of sickle-cell trait3. Dark red vaginal bleeding4. History of domestic abuseAnswer: 3Explanation: 3. Third-trimester bleeding is caused by either placentaprevia or abruptio placentae. Dark red bleeding usually indicatesabruptio placentae, which is life-threatening to both mother and fetus.The nurse is working with a pregnantadolescent. The client asks the nursehow the baby's condition isdetermined during labor. The nurse'sbest response is that during labor,the nurse will do which of thefollowing?1. Check the client's cervix by doinga pelvic exam every 2 hours.2. Assess the fetus's heart rate withan electronic fetal monitor.3. Look at the color and amount ofbloody show that the client has.4. Verify that the client's contractionsare strong but not too closetogether.Answer: 2Explanation: 2. This statement best answers the question the client hasasked.fml
During the initial intrapartalassessment of a client in early labor,the nurse performs a vaginalexamination. The client's partnerasks why this pelvic exam needs tobe done. The nurse should explainthat the purpose of the vaginalexam is to obtain information aboutwhich of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Uterine contraction pattern2. Fetal position3. Presence of the mucous plug4. Cervical dilation and effacement5. Presenting partAnswer: 4, 5Explanation: 4. The vaginal examination of a laboring client obtainsinformation about the station of the presenting part and the dilation andeffacement of the cervix.5. The vaginal examination of a laboring client obtains information aboutthe fetal presenting part.A client has just arrived in thebirthing unit. What steps would bemost important for the nurse toperform to gain an understanding ofthe physical status of the client andher fetus?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Check for ruptured membranesand apply a fetal scalp electrode.2. Auscultate the fetal heart ratebetween and during contractions.3. Palpate contractions and restinguterine tone.4. Assess the blood pressure,temperature, respiratory rate, andpulse rate.5. Perform a vaginal exam forcervical dilation, and performLeopold maneuvers.Answer: 2, 3Explanation: 2. Fetal heart rate auscultation gives information about thephysical status of the fetus.3. Contraction palpation provides information about the frequency,duration, and intensity of the contractions.fml
The nurse is preparing to assess alaboring client who has just arrivedin the labor and birth unit. Whichstatement by the client indicates thatadditional education is needed?1. "You are going to do a vaginalexam to see how dilated my cervixis."2. "The reason for a pelvic exam is todetermine how low in the pelvis mybaby is."3. "When you check my cervix, youwill find out how thinned out it is."4. "After you assess my pelvis, youwill be able to tell when I willdeliver."Answer: 4Explanation: 4. An experienced labor and birth nurse can estimate thetime of delivery based on the cervix, fetal position, station, andcontraction pattern. However, during a pelvic exam, no information isobtained about contractions. The nurse will not have enoughinformation following the cervical exam to estimate time of birth.The client has been pushing for 3hours, and the fetus is making a slowdescent. The partner asks the nursewhether pushing for this long isnormal. How should the nurserespond?1. "Your baby is taking a little longerthan average, but is makingprogress."2. "First babies take a long time tobe born. The next baby will beeasier."3. "The birth would go faster if youhad taken prenatal classes andpracticed."4. "Every baby is different; therereally are no norms for labor andbirth."Answer: 1Explanation: 1. Establishing rapport and a trusting relationship andproviding information that is true is best response.During a maternal assessment, thenurse determines the fetus to be in aleft occiput anterior (LOA) position.Auscultation of the fetal heart rateshould begin in what quadrant?1. Right upper quadrant2. Left upper quadrant3. Right lower quadrant4. Left lower quadrantAnswer: 4Explanation: 4. The fetal heart rate (FHR) is heard most clearly at thefetal back. Thus, in a cephalic presentation, the FHR is best heard in thelower quadrant of the maternal abdomen.fml
A laboring client asks the nurse,"Why does the physician want to usean intrauterine pressure catheter(IUPC) during my labor?" The nursewould accurately explain that thebest rationale for using an IUPC iswhich of the following?1. The IUPC can be used throughoutthe birth process.2. A tocodynamometer is invasive.3. The IUPC provides more accuratedata than does thetocodynamometer.4. The tocodynamometer can beused only after the cervix is dilated 2cm.Answer: 3Explanation: 3. The IUPC has several benefits over an externaltocotransducer or palpation. Because the IUPC is inserted directly intothe uterus, it provides near-exact pressure measurements forcontraction intensity and uterine resting tone. The increased sensitivityof the IUPC allows for very accurate timing of uterine contractions(UCs).The charge nurse is looking at thecharts of laboring clients. Whichclient is in greatest need of furtherintervention?1. Woman at 7 cm, fetal heart tonesauscultated every 90 minutes2. Woman at 10 cm and pushing,external fetal monitor applied3. Woman with meconium-stainedfluid, internal fetal scalp electrode inuse4. Woman in preterm labor, externalmonitor in place: 1Explanation: 1. During active labor, the fetal heart tones should beauscultated every 30 minutes; every 90 minutes is not frequent enough.The laboring client with meconium-stained amniotic fluid asks the nursewhy the fetal monitor is necessary,as she finds the belt uncomfortable.Which response by the nurse is mostimportant?1. "The monitor is necessary so wecan see how your labor isprogressing."2. "The monitor will preventcomplications from the meconium inyour fluid."3. "The monitor helps us to see howthe baby is tolerating labor."4. "The monitor can be removed,and oxygen given instead."Answer: 3Explanation: 3. Electronic fetal monitoring (EFM) provides a continuoustracing of the fetal heart rate (FHR), allowing characteristics of the FHRto be observed and evaluated.fml
The nurse has just palpatedcontractions and compares theconsistency to that of the foreheadto estimate the firmness of thefundus. What would the intensity ofthese contractions be identified as?1. Mild2. Moderate3. Strong4. WeakAnswer: 3Explanation: 3. The consistency of strong contractions is similar to that ofthe forehead.Before performing Leopoldmaneuvers, what would the nursedo?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Have the client empty her bladder.2. Place the client in Trendelenburgposition.3. Have the client lie on her backwith her feet on the bed and kneesbent.4. Turn the client to her left side.5. Have the client lie flat with herankles crossed.Answer: 1, 3Explanation: 1. The woman should have recently emptied her bladderbefore performing Leopold maneuvers.3. The woman should lie on her back with her abdomen uncovered. Toaid in relaxation of the abdominal wall, the shoulders should be raisedslightly on a pillow and the knees drawn up a little.The student nurse is to performLeopold maneuvers on a laboringclient. Which assessment requiresintervention by the staff nurse?1. The client is assisted into supineposition, and the position of thefetus is assessed.2. The upper portion of the uterus ispalpated, then the middle section.3. After determining where the backis located, the cervix is assessed.4. Following voiding, the client'sabdomen is palpated from top tobottom.Answer: 3Explanation: 3. The cervical exam is not part of Leopold maneuvers.Abdominal palpation is the only technique used for Leopold maneuvers.fml
The nurse is preparing to assess thefetus of a laboring client. Whichassessment should the nurseperform first?1. Perform Leopold maneuvers todetermine fetal position.2. Count the fetal heart ratebetween, during, and for 30seconds following a uterinecontraction (UC).3. Dry the maternal abdomen beforeusing the Doppler.4. The diaphragm should be cooledbefore using the Doppler.Answer: 1Explanation: 1. Performing Leopold maneuvers is the first step.After several hours of labor, theelectronic fetal monitor (EFM) showsrepetitive variable decelerations inthe fetal heart rate. The nurse wouldinterpret the decelerations to beconsistent with which of thefollowing?1. Breech presentation2. Uteroplacental insufficiency3. Compression of the fetal head4. Umbilical cord compressionAnswer: 4Explanation: 4. Variable decelerations occur when there is umbilicalcord compression.The nurse auscultates the FHR anddetermines a rate of 112 beats/min.Which action is appropriate?1. Inform the maternal client that therate is normal.2. Reassess the FHR in 5 minutesbecause the rate is low.3. Report the FHR to the doctorimmediately.4. Turn the maternal client on herside and administer oxygen.Answer: 1Explanation: 1. A fetal heart rate of 112 beats/min. falls within the normalrange of 110-160 beats/min., so there is no need to inform the doctor.fml
Upon assessing the FHR tracing, thenurse determines that there is fetaltachycardia. The fetal tachycardiawould be caused by which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Early fetalhypoxia2. Prolonged fetal stimulation3. Fetal anemia4. Fetal sleep cycle5. InfectionAnswer: 1, 2, 3, 5Explanation: 1. Early fetal hypoxia can cause fetal tachycardia.2. Prolonged fetal stimulation can cause fetal tachycardia.3. Fetal anemia can cause fetal tachycardia.5. Infection can cause fetal tachycardia.Persistent early decelerations arenoted. What would the nurse's firstaction be?1. Turn the mother on her left sideand give oxygen.2. Check for prolapsed cord.3. Do nothing. This is a benignpattern.4. Prepare for immediate forceps orcesarean delivery.Answer: 3Explanation: 3. Early decelerations are considered benign, and do notrequire any intervention.The laboring client's fetal heart ratebaseline is 120 beats per minute.Accelerations are present to 135beats/min. During contractions, thefetal heart rate gradually slows to110, and is at 120 by the end of thecontraction. What nursing action isbest?1. Document the fetal heart rate.2. Apply oxygen via mask at 10 liters.3. Prepare for imminent delivery.4. Assist the client into Fowler'sposition.Answer: 1Explanation: 1. The described fetal heart rate has a normal baseline; thepresence of accelerations indicates adequate fetal oxygenation, andearly decelerations are normal. No intervention is necessary.fml
The nurse is caring for a client whois having fetal tachycardia. The nurseknows that possible causes includewhich of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Maternal dehydration2. Maternal hyperthyroidism3. Fetal hypoxia4. Prematurity5. Anesthesia or regional analgesiaAnswer: 1, 2, 3, 4Explanation: 1. Maternal dehydration can cause fetal tachycardia.2. Maternal hyperthyroidism can cause fetal tachycardia.3. Fetal tachycardia can indicate fetal hypoxia.4. Prematurity can cause fetal tachycardia.The nurse is teaching a class onreading a fetal monitor to nursingstudents. The nurse explains thatbradycardia is a fetal heart ratebaseline below 110 and can becaused by which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Maternal hypotension2. Prolonged umbilical cordcompression3. Fetal dysrhythmia4. Central nervous systemmalformation5. Late fetal asphyxiaAnswer: 1, 2, 3, 5Explanation: 1. Maternal hypotension results in decreased blood flow tothe fetus.2. Cord compression can cause fetal bradycardia.3. This will cause fetal bradycardia if there is a fetal heart block.5. This is a depression of myocardial activity.fml
The nurse is caring for a client in thetransition phase of labor and notesthat the fetal monitor tracing showsaverage short-term and long-termvariability with a baseline of 142beats per minute. What actionsshould the nurse take in thissituation?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Provide caring labor support.2. Administer oxygen via face mask.3. Change the client's position.4. Speed up the client's intravenous.5. Reassure the client and herpartner that she is doing fine.Answer: 1, 5Explanation: 1. The tracing is normal, so the nurse can continue supportof the labor.5. The nurse can reassure the client at this time, as the tracing is normal.A woman is in labor. The fetus is invertex position. When the client'smembranes rupture, the nurse seesthat the amniotic fluid is meconium-stained. What should the nurse doimmediately?1. Change the client's position inbed.2. Notify the physician that birth isimminent.3. Administer oxygen at 2 liters perminute.4. Begin continuous fetal heart ratemonitoring.Answer: 4Explanation: 4. Meconium-stained amniotic fluid is an abnormal fetalfinding, and is an indication for continuous fetal monitoring.fml
A woman in labor asks the nurse toexplain the electronic fetal heartrate monitor strip. The fetal heartrate baseline is 150 withaccelerations to 165, variabledecelerations to 140, and moderatelong-term variability. Whichstatement indicates that the clientunderstands the nurse's teaching?1. "The most important part of fetalheart monitoring is the absence ofvariable decelerations."2. "The most important part of fetalheart monitoring is the presence ofvariability."3. "The most important part of fetalheart monitoring is the fetal heartrate baseline."4. "The most important part of fetalheart monitoring is the depth ofdecelerations."Answer: 2Explanation: 2. Baseline variability is a reliable indicator of fetal cardiacand neurologic function and well-being. The opposing "push-pull"balancing between the sympathetic nervous system and theparasympathetic nervous system directly affects the FHR.The fetal heart rate baseline is 140beats/min. When contractions begin,the fetal heart rate drops suddenlyto 120, and rapidly returns to 140before the end of the contraction.Which nursing intervention is best?1. Assist the client to changeposition.2. Apply oxygen to the client at 2liters per nasal cannula.3. Notify the operating room of theneed for a cesarean birth.4. Determine the color of theleaking amniotic fluid.Answer: 1Explanation: 1. The fetus is exhibiting variable decelerations, which arecaused by cord compression. Sometimes late or variable decelerationsare due to the supine position of the laboring woman. In this case, thedecrease in uterine blood flow to the fetus may be alleviated by raisingthe woman's upper trunk or turning her to the side to displace pressureof the gravid uterus on the inferior vena cava.fml
The nurse is caring for a client whois showing a sinusoidal fetal heartrate pattern on the monitor. Thenurse knows that possible causes forthis pattern include which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fetal anemia2. Chronic fetal bleeding3. Maternal hypotension4. Twin-to-twin transfusion5. Umbilical cord occlusionAnswer: 1, 2, 4, 5Explanation: 1. Fetal anemia can cause a sinusoidal heart rate.2. Chronic fetal bleeding can cause a sinusoidal heart rate.4. Twin-to-twin transfusion will cause a sinusoidal heart rate.5. Umbilical cord occlusion can cause a sinusoidal fetal heart rate.Fetal factors that possibly indicateelectronic fetal monitoring includewhich of the following?1. Meconium passage2. Multiple gestation3. Preeclampsia4. Grand multiparity5. Decreased fetal movementAnswer: 1, 2, 5Explanation: 1. Meconium passage is an indicator for electronic fetalmonitoring.2. Multiple gestation is an indicator for electronic fetal monitoring.5. Decreased fetal movement is an indicator for electronic fetalmonitoring.The labor and delivery nurse isassigned to four clients in earlylabor. Which electronic fetalmonitoring finding would requireimmediate intervention?1. Early decelerations with eachcontraction2. Variable decelerations thatrecover to the baseline3. Late decelerations with minimalvariability4. AccelerationsAnswer: 3Explanation: 3. Late decelerations are considered a nonreassuring fetalheart rate (FHR) pattern, and therefore require immediate intervention.The nurse is analyzing several fetalheart rate patterns. The pattern thatwould be of most concern to thenurse would be which of thefollowing?1. Moderate variability2. Early decelerations3. Late decelerations4. AccelerationsAnswer: 3Explanation: 3. Late decelerations are caused by uteroplacentalinsufficiency. The late deceleration pattern is considered anonreassuring sign.fml
After noting meconium-stainedamniotic fluid and fetal heart ratedecelerations, the physiciandiagnoses a depressed fetus. Theappropriate nursing action at thistime would be to do what?1. Increase the mother's oxygen rate.2. Turn the mother to the left lateralposition.3. Prepare the mother for a higher-risk delivery.4. Increase the intravenous infusionrate.Answer: 3Explanation: 3. Meconium-stained fluid and heart rate decelerations areindications that delivery is considered higher-risk.The nurse is aware that a fetus that isnot in any stress would respond to afetal scalp stimulation test byshowing which change on themonitor strip?1. Late decelerations2. Early decelerations3. Accelerations4. Fetal dysrhythmiaAnswer: 3Explanation: 3. A fetus that is not experiencing stress responds to scalpstimulation with an acceleration of the FHR.The client is in the second stage oflabor. The fetal heart rate baseline is170, with minimal variability present.The nurse performs fetal scalpstimulation. The client's partner askswhy the nurse did that. What is thebest response by the nurse?1. "I stimulated the top of the fetus'shead to wake him up a little."2. "I stimulated the top of the fetus'shead to try to get his heart rate toaccelerate."3. "I stimulated the top of the fetus'shead to calm the fetus down beforebirth."4. "I stimulated the top of the fetus'shead to find out whether he is indistress."Answer: 2Explanation: 2. Fetal scalp stimulation is done when there is a questionregarding fetal status. An acceleration indicates fetal well-being.fml
The primary care provider isperforming a fetal scalp stimulationtest. What result would the nursehope to observe?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Spontaneous fetal movement2. Fetal heart acceleration3. Increase in fetal heart variability4. Resolution of late decelerations5. Reactivity associated with thestimulationAnswer: 2, 5Explanation: 2. The fetal heart rate should accelerate with stimulation.5. There will be some reaction with the stimulation.The client is undergoing anemergency cesarean birth for fetalbradycardia. The client's partner hasnot been allowed into the operatingroom. What can the nurse do toalleviate the partner's emotionaldistress?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Allow the partner to wheel thebaby's crib to the newborn nursery.2. Allow the partner to be near theoperating room where thenewborn's first cry can be heard.3. Have the partner wait in theclient's postpartum room.4. Encourage the partner to be inthe nursery for the initial assessment.5. Teach the partner how to take theclient's blood pressure.Answer: 1, 2, 4Explanation: 1. Effective measures include allowing the partner to takethe baby to the nursery.2. Effective measures include allowing the partner to be in a place nearthe operating room, where the newborn's first cry can be heard.4. Effective measures include involving the partner in postpartum carein the recovery room.fml
The client tells the nurse that shehas come to the hospital so that herbaby's position can be changed. Thenurse would begin to organize thesupplies needed to perform whichprocedure?1. A version2. An amniotomy3. Leopold maneuvers4. A ballottementAnswer: 1Explanation: 1. Version, or turning the fetus, is a procedure used tochange the fetal presentation by abdominal or intrauterine manipulation.A woman has been admitted for anexternal version. She has completedan ultrasound exam and is attachedto the fetal monitor. Prior to theprocedure, why will terbutaline beadministered?1. To provide analgesia2. To relax the uterus3. To induce labor4. To prevent hemorrhageAnswer: 2Explanation: 2. Terbutaline is administered to achieve uterine relaxation.The nurse is scheduling a client foran external cephalic version (ECV).Which finding in the client's chartrequires immediate intervention?1. Previous birth by cesarean2. Frank breech ballotable3. 37 weeks, complete breech4. Failed ECV last weekAnswer: 1Explanation: 1. Any previous uterine scar is a contraindication to ECV.Prior scarring of the uterus may increase the risk of uterine tearing oruterine rupture.A woman is scheduled to have anexternal version for a breechpresentation. The nurse carefullyreviews the client's chart forcontraindications to this procedure,including which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Station -22. 38 weeks' gestation3. Abnormal fetal heart rate andtracing4. Previous cesarean section5. Rupture of membranesAnswer: 3, 4, 5Explanation: 3. An abnormal fetal heart rate or tracing would be acontraindication to performing a version. A nonreassuring FHR patternmight indicate that the fetus is already stressed and other action needsto be taken.4. A previous cesarean is a contraindication for version.5. Rupture of membranes is a contraindication for version because ofinsufficient amniotic fluid.fml
A laboring client's obstetrician hassuggested amniotomy as a methodfor inducing labor. Whichassessment(s) must be made justbefore the amniotomy isperformed?1. Maternal temperature, BP, andpulse2. Estimation of fetal birth weight3. Fetal presentation, position, andstation4. Biparietal diameterAnswer: 3Explanation: 3. Before an amniotomy is performed, the fetus is assessedfor presentation, position, station, and FHR.Amniotomy as a method of laborinduction has which of the followingadvantages?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. The danger of a prolapsed cord isdecreased.2. There is usually no risk ofhypertonus or rupture of the uterus.3. The intervention can cause adecrease in pain.4. The color and composition ofamniotic fluid can be evaluated.5. The contractions elicited aresimilar to those of spontaneouslabor.Answer: 2, 4, 5Explanation: 2. There is usually no risk of hypertonus or rupture of theuterus and this is an advantage of amniotomy.4. The color and composition of amniotic fluid can be evaluated and thisis an advantage of amniotomy.5. The contractions elicited are similar to those of spontaneous laborand this is an advantage of amniotomy.A laboring client's obstetrician hassuggested amniotomy as a methodfor creating stronger contractionsand facilitating birth. The client asks,"What are the advantages of doingthis?" What should the nurse cite inresponse?1. Contractions elicited are similar tothose of spontaneous labor.2. Amniotomy decreases thechances of a prolapsed cord.3. Amniotomy reduces the pain oflabor and makes it easier to manage.4. The client will not need anepisiotomy.Answer: 1Explanation: 1. Contractions after amniotomy are similar to those ofspontaneous labor.fml
During a visit to the obstetrician, apregnant client questions the nurseabout the potential need for anamniotomy. The nurse explains thatan amniotomy is performed to dowhich of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Stimulate the beginning of labor2. Augment labor progression3. Allow application of an internalfetal electrode4. Allow application of an externalfetal monitor5. Allow insertion of an intrauterinepressure catheterAnswer: 1, 2, 3, 5Explanation: 1. Amniotomy is the artificial rupture of the amnioticmembranes and can be used to induce labor.2. Amniotomy can be done to augment labor.3. Amniotomy allows access to the fetus in order to apply an internalfetal electrode to the fetal scalp.5. Amniotomy may be performed during labor to allow an intrauterinepressure catheter to be inserted.After inserting prostaglandin gel forcervical ripening, what should thenurse do?1. Apply an internal fetal monitor.2. Insert an indwelling catheter.3. Withhold oral intake and startintravenous fluids.4. Place the client in a supineposition with a right hip wedge.Answer: 4Explanation: 4. After the gel, intravaginal insert, or tablet is inserted, thewoman is instructed to remain lying down with a rolled blanket or hipwedge under her right hip to tip the uterus slightly to the left for the first30 to 60 minutes to maintain the cervical ripening agent in place.Under which circumstances wouldthe nurse remove prostaglandinfrom the client's cervix?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Contractions every 5 minutes2. Nausea and vomiting3. Uterine tachysystole4. Cardiac tachysystole5. Baseline fetal heart rate of 140-148Answer: 2, 3, 4Explanation: 2. A reason to remove prostaglandin from a client's cervix isthe presence of nausea and vomiting.3. A reason to remove prostaglandin from a client's cervix is uterinetachysystole.4. A reason to remove prostaglandin from a client's cervix is cardiactachysystole.fml
The nurse knows that the Bishopscoring system for cervicalreadiness includes which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fetal station2. Fetal lie3. Fetal presenting part4. Cervical effacement5. Cervical softnessAnswer: 1, 4, 5Explanation: 1. Fetal station is one of the components evaluated by theBishop scoring system.4. Cervical effacement is one of the components evaluated by theBishop scoring system.5. Cervical consistency is one of the components evaluated by theBishop scoring system.The nurse knows that acontraindication to the induction oflabor is which of the following?1. Placenta previa2. Isoimmunization3. Diabetes mellitus4. Premature rupture of membranesAnswer: 1Explanation: 1. Placenta previa is a contraindication to the induction oflabor.Induction of labor is planned for a31-year-old client at 39 weeks dueto insulin-dependent diabetes.Which nursing action is mostimportant?1. Administer 100 mcg of misoprostol(Cytotec) vaginally every 2 hours.2. Place dinoprostone (Prepidil)vaginal gel and ambulate client for 1hour.3. Begin Pitocin (oxytocin) 4 hoursafter 50 mcg misoprostol (Cytotec).4. Prepare to induce labor afteradministering a tap water enema.Answer: 3Explanation: 3. Pitocin should not administered less than 4 hours afterthe last Cytotec dose.fml
The client presents for cervicalripening in anticipation of laborinduction tomorrow. What shouldthe nurse include in her plan of carefor this client?1. Apply an internal fetal monitor.2. Monitor the client using electronicfetal monitoring.3. Withhold oral intake and startintravenous fluids.4. Place the client in a upright,sitting position.Answer: 2Explanation: 2. The client should be monitored using electronic fetalmonitoring for at least 30 minutes and up to 2 hours after placement toassess the contraction pattern and the fetal status.The nurse is explaining induction oflabor to a client. The client asks whatthe indications for labor inductionare. Which of the following shouldthe nurse include when answeringthe client?1. Suspected placenta previa2. Breech presentation3. Prolapsed umbilical cord4. HypertensionAnswer: 4Explanation: 4. A client with hypertension is appropriate for laborinduction.fml
A client at 40 weeks' gestation is toundergo stripping of themembranes. The nurse provides theclient with information about theprocedure. Which information isaccurate?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Intravenous administration ofoxytocin will be used to initiatecontractions.2. The physician/CNM will insert agloved finger into the cervical osand rotate the finger 360 degrees.3. Stripping of the membranes willnot cause discomfort, and is usuallyeffective.4. Labor should begin within 24-48hours after the procedure.5. Uterine contractions, cramping,and a bloody discharge can occurafter the procedure.Answer: 2, 4, 5Explanation: 2. This motion separates the amniotic membranes that arelying against the lower uterine segment and internal os from the distalpart of the lower uterine segment.4. If labor is initiated, it typically begins within 24-48 hours.5. Uterine contractions, cramping, scant bleeding, and bloody dischargecan occur after stripping of the membranes.The client is having fetal heart ratedecelerations. An amnioinfusion hasbeen ordered for the client toalleviate the decelerations. Thenurse understands that the type ofdecelerations that will be alleviatedby amnioinfusion is which of thefollowing?1. Early decelerations2. Moderate decelerations3. Late decelerations4. Variable decelerationsAnswer: 4Explanation: 4. When cord compression is suspected, amnioinfusion (AI)may be considered. AI helps to prevent the possibility of variabledecelerations by increasing the volume of amniotic fluid.fml
In which clinical situations would itbe appropriate for an obstetrician toorder a labor nurse to performamnioinfusion?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Placental abruption2. Meconium-stained fluid3. Polyhydramnios4. Variable decelerations5. Early decelerationsAnswer: 2, 4Explanation: 2. The physician may order amnioinfusion for meconium-stained fluid.4. Amnioinfusion is sometimes done to prevent the possibility of variabledecelerations.The nurse is monitoring a client whois receiving an amnioinfusion. Whichassessments must the nurse performto prevent a serious complication?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Color of amniotic fluid2. Maternal blood pressure3. Cervical effacement4. Uterine resting tone5. Fluid leaking from the vaginaAnswer: 2, 4, 5Explanation: 2. Blood pressure should be monitored along with othervital signs.4. The nurse should monitor contraction status (frequency, duration,intensity, resting tone, and associated maternal discomfort).5. The nurse should continually check to make sure the infused fluid isbeing expelled from the vagina.The nurse is completing dischargeteaching for a client who delivered 2days ago. Which statement by theclient indicates that furtherinformation is required?1. "Because I have a midlineepisiotomy, I should keep myperineum clean."2. "I can use an ice pack to relievesome the pain from the episiotomy."3. "I can take ibuprofen (Motrin)when my perineum starts to hurt."4. "The tear I have through myrectum is unrelated to myepisiotomy."Answer: 4Explanation: 4. This statement is incorrect. The major disadvantage is thata tear of the midline incision may extend through the anal sphincter andrectum.fml
The client requires vacuumextraction assistance. To provideeasier access to the fetal head, thephysician cuts a mediolateralepisiotomy. After delivery, the clientasks the nurse to describe theepisiotomy. What does the nurserespond?1. "The episiotomy goes straightback toward your rectum."2. "The episiotomy is from yourvagina toward the urethra."3. "The episiotomy is cut diagonallyaway from your vagina."4. "The episiotomy extends fromyour vagina into your rectum."Answer: 3Explanation: 3. A mediolateral episiotomy is angled from the vaginalopening toward the buttock. It begins in the midline of the posteriorfourchette and extends at a 45-degree angle downward to the right orleft.The client is recovering from adelivery that included a midlineepisiotomy. Her perineum is swollenand sore. Ten minutes after an icepack is applied, the client asks foranother. What is the best responsefrom the nurse?1. "I'll get you one right away."2. "You only need to use one icepack."3. "You need to leave it off for atleast 20 minutes and then reapply."4. "I'll bring you an extra so that youcan change it when you are ready."Answer: 3Explanation: 3. For optimal effect, the ice pack should be applied for 20to 30 minutes and removed for at least 20 minutes before beingreapplied.Major perineal trauma (extension toor through the anal sphincter) ismore likely to occur if what type ofepisiotomy is performed?1. Mediolateral2. Episiorrhaphy3. Midline4. MedicalAnswer: 3Explanation: 3. Major perineal trauma is more likely to occur if a midlineepisiotomy is performed. The major disadvantage is that a tear of themidline incision may extend through the anal sphincter and rectum.fml
A client attending a prenatal classasks why episiotomies areperformed. The nurse explains thatrisk factors that predispose womento episiotomies include which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Large or macrosomic fetus2. Use of forceps3. Shoulder dystocia4. Maternal health5. Shorter second stageAnswer: 1, 2, 3Explanation: 1. A large fetus places a woman at risk for an episiotomy toprevent lacerations.2. Use of forceps or vacuum extractor is a risk factor that predisposeswomen to episiotomies.3. Shoulder dystocia is a risk factor that predisposes women toepisiotomies.The nurse is training a nurse new tothe labor and delivery unit. They arecaring for a laboring client who willhave a forceps delivery. Whichaction or assessment findingrequires intervention?1. Regional anesthesia isadministered via pudendal block.2. The client is instructed to pushbetween contractions.3. Fetal heart tones are consistentlybetween 110 and 115.4. The client's bladder is emptiedusing a straight catheter.Answer: 2Explanation: 2. During the contraction, as the forceps are applied, thewoman should avoid pushing.The need for forceps has beendetermined. The client's cervix isdilated to 10 cm, and the fetus is at+2 station. What category of forcepsapplication would the nurseanticipate?1. Input2. Low3. Mid4. OutletAnswer: 2Explanation: 2. Low forceps are applied when the leading edge of thefetal head is at +2 station.fml
What type of forceps are designedto be used with a breechpresentation?1. Midforceps2. Piper3. Low4. HighAnswer: 2Explanation: 2. Piper forceps are designed to be used with a breechpresentation. They are applied after the birth of the body, when the fetalhead is still in the birth canal and assistance is needed.The physician has determined theneed for forceps. The nurse shouldexplain to the client that the use offorceps is indicated because ofwhich of the following?1. Her support person is exhausted2. Premature placental separation3. To shorten the first stage of labor4. To prevent fetal distressAnswer: 2Explanation: 2. Fetal conditions indicating the need for forceps includepremature placental separation, prolapsed umbilical cord, andnonreassuring fetal status.The physicians/CNM opts to use avacuum extractor for a delivery.What does the nurse understand?1. There is little risk with vacuumextraction devices.2. There should be further fetaldescent with the first two "pop-offs."3. Traction is applied betweencontractions.4. The woman often feels increaseddiscomfort during the procedure.Answer: 2Explanation: 2. If more than three "pop-offs" occur (the suction cuppops off the fetal head), the procedure should be discontinued.Page Ref: 641The client has been pushing for 2hours and is exhausted. Thephysician is performing a vacuumextraction to assist the birth. Whichfinding is expected and normal?1. The head is delivered after eight"pop-offs" during contractions.2. A cephalohematoma is present onthe fetal scalp.3. The location of the vacuum isapparent on the fetal scalp afterbirth.4. Positive pressure is applied by thevacuum extraction duringcontractions.Answer: 3Explanation: 3. The parents need to be informed that the caput(chignon) on the baby's head will disappear within 2 to 3 days.fml
The client has been pushing for twohours, and is exhausted. The fetalhead is visible betweencontractions. The physician informsthe client that a vacuum extractorcould be used to facilitate thedelivery. Which statement indicatesthat the client needs additionalinformation about vacuumextraction assistance?1. "A small cup will be put onto thebaby's head, and a gentle suctionwill be applied."2. "I can stop pushing and just rest ifthe vacuum extractor is used."3. "The baby's head might havesome swelling from the vacuumcup."4. "The vacuum will be applied for atotal of ten minutes or less."Answer: 2Explanation: 2. Vacuum extraction is an assistive delivery. Thephysician/CNM applies traction in coordination with uterinecontractions.The laboring client participated inchildbirth preparation classes thatstrongly discouraged the use ofmedications and intervention duringlabor. The client has been pushingfor two hours, and is exhausted. Thephysician requests that a vacuumextractor be used to facilitate thebirth. The client first states that shewants the birth to be normal, thenallows the vacuum extraction.Following this, what should thenurse assess the client for after thebirth?1. Elation, euphoria, andtalkativeness2. A sense of failure and loss3. Questions about whether or notto circumcise4. Uncertainty surrounding thebaby's nameAnswer: 2Explanation: 2. Clients who participate in childbirth classes that stressthe normalcy of birth may feel a sense of loss or failure if an interventionis used during their labor or birth.fml
The nurse is reviewing charts ofclients who underwent cesareanbirths by request in the last twoyears. The hospital is attempting todecrease costs of maternity care.What findings contribute toincreased health care costs inclients undergoing cesarean birthby request?1. Increased abnormal placentaimplantation in subsequentpregnancies2. Decreased use of generalanesthesia with greater use ofepidural anesthesia3. Prolonged anemia, requiringblood transfusions every fewmonths4. Coordination of career projects ofboth partners leading to increasedincomeAnswer: 1Explanation: 1. Repeat cesarean births are associated with greater risksincluding increased incidence of abnormal placentation in subsequentpregnancies and the increased risk of mortality secondary to surgery,which would contribute to increased health care costs.After being in labor for severalhours with no progress, a client isdiagnosed with CPD (cephalopelvicdisproportion), and must have acesarean section. The client isworried that she will not be able tohave any future children vaginally.After sharing this information withher care provider, the nurse wouldanticipate that the client wouldreceive what type of incision?1. Transverse2. Infraumbilical midline3. Classic4. VerticalAnswer: 1Explanation: 1. The transverse incision is made across the lowest andnarrowest part of the abdomen and is the most common lower uterinesegment incision.fml
The client demonstratesunderstanding of the implicationsfor future pregnancies secondary toher classic uterine incision when shestates which of the following?1. "The next time I have a baby, I cantry to deliver vaginally."2. "The risk of rupturing my uterus istoo high for me to have any morebabies."3. "Every time I have a baby, I willhave to have a cesarean delivery."4. "I can only have one more baby."Answer: 3Explanation: 3. A classic uterine incision is made in the upper uterinesegment and is associated with an increased risk of rupture insubsequent pregnancy, labor, and birth. Therefore, subsequentdeliveries will be done by cesarean.In the operating room, a client isbeing prepped for a cesareandelivery. The doctor is present. Whatis the last assessment the nurseshould make just before the client isdraped for surgery?1. Maternal temperature2. Maternal urine output3. Vaginal exam4. Fetal heart tonesAnswer: 4Explanation: 4. Ascertain fetal heart rate (FHR) before surgery andduring preparation because fetal hypoxia can result from aortocavalcompression.A prenatal client asks the nurseabout conditions that wouldnecessitate a cesarean delivery. Thenurse explains that cesareandelivery generally is performed inthe presence of which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Complete placenta previa2. Placental abruption3. Umbilical cord prolapse4. Precipitous labor5. Failure to progressAnswer: 1, 2, 3, 5Explanation: 1. When the placenta completely covers the uterineopening, a cesarean is performed.2. Premature separation of the placenta from the uterine wall requires animmediate cesarean.3. A prolapsed cord is an emergency requiring an immediate cesarean.5. Failure to progress in labor can necessitate a cesarean birth.fml
A client is consulting a certifiednurse-midwife because she ishoping for a vaginal birth aftercesarean (VBAC) with thispregnancy. Which statementindicates that the client requiresmore information about VBAC?1. "I can try a vaginal birth becausemy uterine incision is a low segmenttransverse incision."2. "The vertical scar on my skindoesn't mean that the scar on myuterus goes in the same direction."3. "There is about a 90% chance ofgiving birth vaginally after acesarean."4. "Because my hospital has asurgery staff on call 24 hours a day, Ican try a VBAC there."Answer: 3Explanation: 3. Women whose previous cesarean was performedbecause of nonrecurring indications have been reported to haveapproximately a 60% to 80% chance of success with VBAC.The nurse is teaching a class onvaginal birth after cesarean (VBAC).Which statement by a participantindicates that additional informationis needed?1. "Because the scar on my bellygoes down from my navel, I am nota candidate for a VBAC."2. "My first baby was in a breechposition, so for this pregnancy, I cantry a VBAC if the baby is head-down."3. "Because my hospital is so smalland in a rural area, they won't let meattempt a VBAC."4. "The rate of complications fromVBAC is lower than the rate ofcomplications from a cesarean."Answer: 1Explanation: 1. Skin incision is not indicative of uterine incision. Only theuterine incision is a factor in deciding whether VBAC is advisable. Theclassic vertical incision was commonly done in the past and isassociated with increased risk of uterine rupture in subsequentpregnancies and labor.fml
The nurse has admitted a womanwith cervical insufficiency. The nurseis aware that causes of this conditioninclude which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Congenital factors2. Intercourse during pregnancy3. Infection4. Increased uterine volume5. Past cervical surgeriesAnswer: 1, 3, 4, 5Explanation: 1. Congenitally incompetent cervix may be found in womenexposed to diethylstilbestrol (DES) or those with a bicornuate uterus.3. Infection or trauma can cause acquired cervical incompetence.4. Cervical insufficiency can occur in multiple-gestation pregnancies.5. Previous elective abortion or cervical manipulation can lead tocervical insufficiency.The nurse is admitting a client for acerclage procedure. The client asksfor information about theprocedure. What is the nurse's mostaccurate response?1. "A stitch is placed in the cervix toprevent a spontaneous abortion orpremature birth."2. "The procedure is done during thethird trimester."3. "Cerclage is always placed afterthe cervix has dilated and effaced."4. "An uncomplicated electivecerclage may is done on inpatientbasis."Answer: 1Explanation: 1. This is the correct description of cerclage.A client is admitted to the labor anddelivery unit with a history ofruptured membranes for 2 hours.This is her sixth delivery; she is 40years old, and smells of alcohol andcigarettes. What is this client at riskfor?1. Gestational diabetes2. Placenta previa3. Abruptio placentae4. Placenta accretaAnswer: 3Explanation: 3. Abruptio placentae is more frequent in pregnanciescomplicated by smoking, premature rupture of membranes, multiplegestation, advanced maternal age, cocaine use, chorioamnionitis, andhypertension.fml
The nurse is caring for a client at 30weeks' gestation who isexperiencing preterm prematurerupture of membranes (PPROM).Which statement indicates that theclient needs additional teaching?1. "If I were having a singletonpregnancy instead of twins, mymembranes would probably nothave ruptured."2. "If I develop a urinary tractinfection in my next pregnancy, Imight rupture membranes earlyagain."3. "If I want to become pregnantagain, I will have to plan on beingon bed rest for the wholepregnancy."4. "If I have aminocentesis, I mightrupture the membranes again."Answer: 3Explanation: 3. There is no evidence that bed rest in a subsequentpregnancy decreases the risk for PPROM.A client was admitted to the laborarea at 5 cm with rupturedmembranes about 14 hours ago.What assessment data would bemost beneficial for the nurse tocollect?1. Blood pressure2. Temperature3. Pulse4. RespirationAnswer: 2Explanation: 2. Rupture of membranes places the mother at risk forinfection. The temperature is the primary and often the first indication ofa problem.The nurse admits into the labor areaa client who is in preterm labor.What assessment finding wouldconstitute a diagnosis of pretermlabor?1. Cervical effacement of 30% ormore2. Cervical change of 0.5 cm perhour3. 2 contractions in 30 minutes4. 8 contractions in 1 hourAnswer: 4Explanation: 4. 8 contractions in a 60 minute period does define adiagnosis of preterm labor.fml
During the nursing assessment of awoman with ruptured membranes,the nurse suspects a prolapsedumbilical cord. What would thenurse's priority action be?1. To help the fetal head descendfaster2. To use gravity and manipulation torelieve compression on the cord3. To facilitate dilation of the cervixwith prostaglandin gel4. To prevent head compressionAnswer: 2Explanation: 2. The top priority is to relieve compression on the umbilicalcord to allow blood flow to reach the fetus. It is because some obstetricmaneuvers to relieve cord compression are complicated that cesareanbirth is sometimes necessary.A client is admitted to the birthsetting in early labor. She is 3 cmdilated, -2 station, with intactmembranes, and FHR of 150 bpm.Her membranes rupturespontaneously, and the FHR dropsto 90 bpm with variabledecelerations. What would thenurse's initial response be?1. Perform a vaginal exam2. Notify the physician3. Place the client in a left lateralposition4. Administer oxygen at 2 L per nasalcannulaAnswer: 1Explanation: 1. Prolapsed umbilical cord can occur when the membranesrupture. The fetus is more likely to experience variable decelerationsbecause the amniotic fluid is insufficient to keep pressure off theumbilical cord. A vaginal exam is the best way to confirm.fml
The nurse has received end-of-shiftreports in the high-risk maternityunit. Which client should the nursesee first?1. The client at 26 weeks' gestationwith placenta previa experiencingblood on toilet tissue after a bowelmovement2. The client at 30 weeks' gestationwith placenta previa whose fetalmonitor strip shows latedecelerations3. The client at 35 weeks' gestationwith grade I abruptio placentae inlabor who has a strong urge to push4. The client at 37 weeks' gestationwith pregnancy-inducedhypertension whose membranesruptured spontaneouslyAnswer: 1Explanation: 1. Assessment of the woman with placenta previa must beongoing to prevent or treat complications that are potentially lethal tothe mother and fetus. Painless, bright red vaginal bleeding is the bestdiagnostic sign of placenta previa. This client is the highest priority.The nurse is presenting a class onpreterm labor, its causes, andtreatments to a group of newlypregnant couples. Which statementsregarding preterm labor are true?Note: Credit will be given only of allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Antepartum hemorrhage cancause preterm labor.2. Trauma can cause preterm labor.3. Infection can cause pretermlabor.4. Magnesium sulfate is a drug usedto stop contractions.5. Sedatives and narcotics may begiven to stop labor.Answer: 1, 2, 3, 4Explanation: 1. Hemorrhage from placenta previa or abruption cancause preterm labor.2. Trauma to the abdomen or uterus can cause preterm labor.3. Infections such as urinary tract infections can cause preterm labor.4. Magnesium sulfate acts as a CNS depressant by decreasing thequantity of acetylcholine released by motor nerve impulses and therebyblocking neuromuscular transmission.fml
A client in her second trimester iscomplaining of spotting. Causes forspotting in the second trimester arediagnosed primarily through the useof which of the following?1. A nonstress test2. A vibroacoustic stimulation test3. An ultrasound4. A contraction stress testAnswer: 3Explanation: 3. Indirect diagnosis is made by localizing the placenta viatests that require no vaginal examination. The most commonly employeddiagnostic test is the transabdominal ultrasound scan.A client at 32 weeks' gestation isadmitted with painless vaginalbleeding. Placenta previa has beenconfirmed by ultrasound. Whatshould be included in the nursingplan?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. No vaginal exams2. Encouraging activity3. No intravenous access until laborbegins4. Evaluating fetal heart rate with anexternal monitor5. Monitoring blood loss, pain, anduterine contractilityAnswer: 1, 4, 5Explanation: 1. Expectant management of placenta previa is made bylocalizing the placenta via tests that require no vaginal examination.4. Expectant management of placenta previa, when the client is at lessthan 37 weeks' gestation, includes evaluating FHR with an externalmonitor.5. Expectant management of placenta previa, when the client is at lessthan 37 weeks' gestation, includes monitoring blood loss, pain, anduterine contractility.The nurse is planning an in-serviceeducational program to talk aboutdisseminated intravascularcoagulation (DIC). The nurse shouldidentify which conditions as riskfactors for developing DIC?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Diabetes mellitus2. Abruptio placentae3. Fetal demise4. Multiparity5. Preterm laborAnswer: 2, 3Explanation: 2. As a result of the damage to the uterine wall and theretroplacental clotting with covert abruption, large amounts ofthromboplastin are released into the maternal blood supply, which inturn triggers the development of disseminated intravascular coagulation(DIC) and the resultant hypofibrinogenemia.3. Perinatal mortality associated with abruptio placentae isapproximately 25%. If fetal hypoxia progresses unchecked, irreversiblebrain damage or fetal demise may result.fml
The client at 30 weeks' gestation isadmitted with painless late vaginalbleeding. The nurse understandsthat expectant managementincludes which of the following?1. Limiting vaginal exams to only oneper 24-hour period.2. Evaluating the fetal heart rate withan internal monitor.3. Monitoring for blood loss, pain,and uterine contractibility.4. Assessing blood pressure every 2hours.Answer: 3Explanation: 3. Blood loss, pain, and uterine contractibility need to beassessed for client comfort and safety.A client is admitted to the labor anddelivery unit in active labor. Whatnursing diagnoses might apply tothe client with suspected abruptioplacentae?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fluid Volume, Deficient, Risk for,related to hypovolemia secondaryto excessive blood loss2. Tissue Perfusion: Peripheral,Ineffective, related to blood losssecondary to uterine atonyfollowing birth3. Anxiety related to concern forown personal status and the baby'ssafety4. Knowledge, Deficient related tolack of information about inheritedgenetic defects5. Alteration in Respiratory Functionrelated to blood lossAnswer: 1, 2, 3Explanation: 1. Maternal and perinatal fetal mortality are concerns dueto hypoxia.2. Maternal and perinatal fetal mortality are concerns due to blood loss.3. This mother would be anxious for herself and her baby.What is the most significant cause ofneonatal morbidity and mortality?1. Amenorrhea2. Posttraumatic stress disorder3. Prematurity4. EndometriosisAnswer: 3Explanation: 3. The most significant cause of neonatal morbidity andmortality is prematurity and its associated complications such asrespiratory distress syndrome, necrotizing enterocolitis, andintraventricular hemorrhage.fml
What is the most significant maternalrisk factor for preterm birth?1. Previous preterm birth2. Smoking3. Stress4. Substance abuseAnswer: 1Explanation: 1. The most significant maternal risk factor for preterm birthis a previous preterm birth.A pregnant client is admitted to theemergency department withbleeding. The nurse realizes that theclient might have placenta previa.Which signs would be suggestive ofplacenta previa?1. Bright red vaginal bleeding2. Sudden onset of vaginal bleeding3. Firm and hard uterus4. Change in the size of abdomenAnswer: 1Explanation: 1. As the lower uterine segment contracts and dilates, theplacental villi are torn from the uterine wall, causing bright redbleeding.The nurse educator is describing thedifferent kinds of abruptio placentaeto a group of students, explainingthat in a complete abruptioplacentae, which of the followingoccurs?1. Separation begins at the peripheryof the placenta.2. The placenta separates centrallyand blood is trapped between theplacenta and the uterine wall.3. There is massive vaginal bleedingin the presence of almost totalseparation.4. Blood passes between the fetalmembranes and the uterine wall,and escapes vaginally.Answer: 3Explanation: 3. There is massive vaginal bleeding in the presence ofalmost total separation describes a complete separation of theplacenta.The labor nurse is caring for a clientat 38 weeks' gestation who hasbeen diagnosed with symptomaticplacenta previa. Which physicianorder should the nurse question?1. Begin oxytocin drip rate at 0.5milliunits/min.2. Assess fetal heart rate every 10minutes.3. Weigh all vaginal pads.4. Assess hematocrit andhemoglobin.Answer: 1Explanation: 1. This order should be questioned, as this client is not agood candidate for labor induction.fml
The nurse is presenting a class fornursing students on multiple-gestation pregnancy. Whichstatements about multiple-gestationpregnancies are accurate?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Hypertension is a major maternalcomplication.2. Gestational diabetes occurs moreoften.3. Maternal anemia occurs.4. Pulmonary embolism is 12 timesmore likely to develop duringpregnancy with multiple gestations.5. Multiple gestations are more likelyto acquire HELLP.Answer: 1, 2, 3, 5Explanation: 1. Hypertension is a complication in multiple-gestationpregnancies.2. Gestational diabetes occurs more often in multiple gestations.3. Maternal anemia occurs because of demands of the multiplegestations.5. Multiple gestations are more likely to acquire HELLP (hemolyticanemia, elevated liver enzymes, and low platelet count) syndrome, acomplication resulting from eclampsia or preeclampsia.What can be determined based onultrasound visualization or the lackof visualization of an intertwinmembrane?1. Toxicity2. Amnionicity3. Variability4. PrematurityAnswer: 2Explanation: 2. Evidence supports the use of ultrasound for accuratelydetermining chorionicity and amnionicity in multiple pregnancies.Determination of amnionicity is based on ultrasound visualization or thelack of visualization of an intertwin membrane.What fetal factors require acesarean birth?1. Severe intrauterine growthrestriction (IUGR)2. Fetal anomalies3. Unfavorable fetal position orpresentation4. Preterm birth5. Lack of maternal attachmentAnswer: 1, 2, 3, 4Explanation: 1. Fetal factors such as severe intrauterine growthrestriction (IUGR), preterm birth, fetal anomalies, nonreassuring fetalstatus, or unfavorable fetal position or presentation require cesareanbirth.2. Fetal factors such as severe intrauterine growth restriction (IUGR),preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorablefetal position or presentation require cesarean birth.3. Fetal factors such as severe intrauterine growth restriction (IUGR),preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorablefetal position or presentation require cesarean birth.4. Fetal factors such as severe intrauterine growth restriction (IUGR),preterm birth, fetal anomalies, nonreassuring fetal status, or unfavorablefetal position or presentation require cesarean birth.fml
The home health nurse is admitting aclient at 18 weeks who is pregnantwith twins. Which nursing action ismost important?1. Teach the client about foods thatare good sources of protein.2. Assess the client's blood pressurein her upper right arm.3. Determine whether thepregnancy is the result of infertilitytreatment.4. Collect a cervicovaginal fetalfibronectin (fFN) specimen.Answer: 1Explanation: 1. A daily intake of 4000 kcal (minimum) and 135 g protein isrecommended for a woman with normal-weight twins.The client is carryingmonochorionic-monoamniotic twins.The nurse teaches the client whatthis is, and the implications of thisfinding. The nurse knows thatteaching is successful when theclient states which of the following?1. "My babies came from two eggs."2. "About two thirds of twins havethis amniotic sac formation."3. "My use of a fertility drug led tothis issue."4. "My babies have a lower chanceof surviving to term than fraternaltwins do."Answer: 4Explanation: 4. Monochorionic-monoamniotic twins are both in oneamniotic sac. There is an increased risk of umbilical cords becomingtangled or knotted and a higher incidence of fetal demise.When counseling a newly pregnantclient at 8 weeks' gestation of twins,the nurse teaches the woman aboutthe need for increased caloricintake. What would the nurse tell thewoman that the minimumrecommended intake should be?1. 2500 kcal and 120 grams protein2. 3000 kcal and 150 grams protein3. 4000 kcal and 135 grams protein4. 5000 kcal and 190 grams proteinAnswer: 3Explanation: 3. 4000 kcal and 135 grams protein is the recommendedcaloric and protein intake in a twin-gestation pregnancy.fml
Intervention to reduce preterm birthcan be divided into primaryprevention and secondaryprevention. What does secondaryprevention include?1. Diagnosis and treatment ofinfections2. Cervical cerclage3. Progesterone administration4. Antibiotic treatment and tocolysisAnswer: 4Explanation: 4. Secondary prevention strategies are antibiotic treatmentand tocolysis.The nurse is caring for a client withhydramnios. What will the nursewatch for?1. Possible intrauterine growthrestriction2. Newborn congenital anomalies3. Newborn postmaturity and renalmalformations4. Fetal adhesionsAnswer: 2Explanation: 2. Newborn congenital anomalies occur with hydramniosSlowly removing some amnioticfluid is a treatment for hydramnios.What consequence can occur withthe withdrawal of fluid?1. Preterm labor2. Prolapsed cord3. Preeclampsia4. Placenta previaAnswer: 2Explanation: 2. A needle or a fetal scalp electrode is used to make asmall puncture in the amniotic sac. There is a risk that the force of thefluid could make a larger hole in the amniotic sac, thus increasing therisk of a prolapsed cord.The nurse is admitting a client whowas diagnosed with hydramnios. Theclient asks why she has developedthis condition. The nurse shouldexplain that hydramnios issometimes associated with which ofthe following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Rh sensitization2. Postmaturity syndrome3. Renal malformation ordysfunction4. Maternal diabetes5. Large-for-gestational-age infantsAnswer: 1, 4Explanation: 1. Hydramnios is associated with Rh sensitization.4. Hydramnios is associated with maternal diabetes.fml
The nurse is admitting a client withpossible hydramnios. When ishydramnios most likely suspected?1. Hydramnios is most likelysuspected when there is lessamniotic fluid than normal forgestation.2. Hydramnios is most likelysuspected when the fundal heightincreases disproportionately to thegestation.3. Hydramnios is most likelysuspected when the woman has atwin gestation.4. Hydramnios is most likelysuspected when the quadruplescreen comes back positive.Answer: 2Explanation: 2. Hydramnios should be suspected when the fundal heightincreases out of proportion to the gestational age.If oligohydramnios occurs in the firstpart of pregnancy, the nurse knowsthat there is a danger of which of thefollowing?1. Major congenital anomalies2. Fetal adhesions3. Maternal diabetes4. Rh sensitizationAnswer: 2Explanation: 2. If oligohydramnios occurs in the first part of pregnancy,there is a danger of fetal adhesions (one part of the fetus may adhere toanother part).When caring for a laboring clientwith oligohydramnios, what shouldthe nurse be aware of?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Increased risk of cordcompression2. Decreased variability3. Labor progress is often morerapid than average4. Presence of periodicdecelerations5. During gestation, fetal skin andskeletal abnormalities can occurAnswer: 1, 2, 4, 5Explanation: 1. During the labor and birth, the lessened amounts of fluidreduce the cushioning effect for the umbilical cord, and cordcompression is more likely to occur.2. The nurse should evaluate the EFM tracing for the presence ofnonperiodic decelerations or other nonreassuring signs (such asincreasing or decreasing baseline, decreased variability, or presence ofperiodic decelerations).4. The nurse should evaluate the EFM tracing for the presence ofnonperiodic decelerations or other nonreassuring signs (such asincreasing or decreasing baseline, decreased variability, or presence ofperiodic decelerations).5. During the gestational period, fetal skin and skeletal abnormalitiesmay occur because fetal movement is impaired as a result of inadequateamniotic fluid volume.fml
The nurse knows that a baby born toa mother who had oligohydramnioscould show signs of which of thefollowing?1. Respiratory difficulty2. Hypertension3. Heart murmur4. Decreased temperatureAnswer: 1Explanation: 1. Because there is less fluid available for the fetus to useduring fetal breathing movements, pulmonary hypoplasia may develop.The client at 38 weeks' gestation hasbeen diagnosed witholigohydramnios. Which statementindicates that teaching about thecondition has been effective?1. "My gestational diabetes mighthave caused this problem todevelop."2. "When I go into labor, I shouldcome to the hospital right away."3. "This problem was diagnosed withblood and urine tests."4. "Women with this conditionusually do not have a cesareanbirth."Answer: 2Explanation: 2. The incidence of cord compression and resulting fetaldistress is high when there is an inadequate amount of amniotic fluid.The client with oligohydramnios should come to the hospital in earlylabor.The nurse is planning care for aclient with hydramnios. For whichinterventions might the nurse needto prepare the client?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Artificial rupture of themembranes2. Amnioinfusion3. Amniocentesis4. Administration of prostaglandinsynthesis inhibitor5. Administration of indomethacinAnswer: 1, 3, 4, 5Explanation: 1. Artificial rupture may be performed to remove theexcessive fluid.3. Amniocentesis may be performed to remove some excess fluid.4. A prostaglandin synthesis inhibitor is used to treat hydramnios.5. Indomethacin can decrease amniotic fluid by decreasing fetal urineoutput.fml
What would be a normal cervicaldilatation rate in a first-time mother("primip")?1. 1.5 cm per hour2. Less than 1 cm cervical dilatationper hour3. 1 cm per hour4. Less than 0.5 cm per hourAnswer: 1Explanation: 1. Dilatation in a "multip" is about 1.5 cm per hour.Dystocia encompasses manyproblems in labor. What is the mostcommon?1. Meconium-stained amniotic fluid2. Dysfunctional uterine contractions3. Cessation of contractions4. Changes in the fetal heart rateAnswer: 2Explanation: 2. The most common problem is dysfunctional (oruncoordinated) uterine contractions that result in a prolongation oflabor.Risk factors for tachysystole includewhich of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Cocaine use2. Placental abruption3. Low-dose oxytocin titrationregimens4. Uterine rupture5. SmokingAnswer: 1, 2, 4Explanation: 1. Cocaine use is a risk factor for tachysystole.2. Placental abruption is a risk factor for tachysystole.4. Uterine rupture is a risk factor for tachysystole.A woman has been havingcontractions since 4 a.m. At 8 a.m.,her cervix is dilated to 5 cm.Contractions are frequent, and mildto moderate in intensity.Cephalopelvic disproportion (CPD)has been ruled out. After giving themother some sedation so she canrest, what would the nurse anticipatepreparing for?1. Oxytocin induction of labor2. Amnioinfusion3. Increased intravenous infusion4. Cesarean sectionAnswer: 1Explanation: 1. Oxytocin is the drug of choice for labor augmentation orlabor induction and may be administered as needed for hypotonic laborpatterns.fml
Nonreassuring fetal status oftenoccurs with a tachysystolecontraction pattern. Intrauterineresuscitation measures may becomewarranted and can include which ofthe following measures?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Position the woman on her rightside.2. Apply oxygen via face mask.3. Call for anesthesia provider forsupport.4. Increase intravenous fluids by atleast 700 mL bolus.5. Call the physician/CNM to thebedside.Answer: 2, 3, 4Explanation: 2. The nurse would apply oxygen via face mask.3. The nurse would call for anesthesia provider for support.4. The nurse would increase intravenous fluids by at least 500 mL bolus.The nurse is making clientassignments for the next shift. Whichclient is most likely to experience acomplicated labor pattern?1. 34-year-old woman at 39 weeks'gestation with a large-for-gestational-age (LGA) fetus2. 22-year-old woman at 23 weeks'gestation with ruptured membranes3. 30-year-old woman at 41 weeks'gestation and estimated fetal weight7 pounds 8 ounces4. 43-year-old woman at 37 weeks'gestation with hypertensionAnswer: 1Explanation: 1. A risk factor for hypotonic uterine contraction patternsincludes a large-for-gestational-age (LGA) fetus.fml
Two hours ago, a client at 39 weeks'gestation was 3 cm dilated, 40%effaced, and +1 station. Frequency ofcontractions was every 5 minuteswith duration 40 seconds andintensity 50 mmHg. The currentassessment is 4 cm dilated, 40%effaced, and +1 station. Frequency ofcontractions is now every 3 minuteswith 40-50 seconds' duration andintensity of 40 mmHg. What wouldthe priority intervention be?1. Begin oxytocin after assessing forCPD.2. Give terbutaline to stop thepreterm labor.3. Start oxygen at 8 L/min.4. Have the anesthesiologist givethe client an epidural.Answer: 1Explanation: 1. The client is having hypertonic contractions.Cephalopelvic disproportion (CPD) must be excluded. If CPD exists,oxytocin (Pitocin) augmentation should not be used. Oxytocin is thedrug of choice for labor augmentation or labor induction.What are the primary complicationsof placenta accrete?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Maternal hemorrhage2. Insomnia3. Failure of the placenta to separatefollowing birth of the infant4. Autonomic dysreflexia5. Shoulder dystociaAnswer: 1, 3Explanation: 1. The primary complications of placenta accreta arematernal hemorrhage and failure of the placenta to separate followingbirth of the infant.3. The primary complications of placenta accreta are maternalhemorrhage and failure of the placenta to separate following birth ofthe infant.) Risk factors for labor dystociainclude which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Tall maternal height2. Labor induction3. Small-for-gestational-age (SGA)fetus4. Malpresentation5. Prolonged latent phaseAnswer: 2, 4, 5Explanation: 2. Labor induction is a risk factor of dystocia.4. Malpresentation is a risk factor of dystocia.5. Prolonged latent phase is a risk factor of dystocia.fml
In succenturiate placenta, one ormore accessory lobes of fetal villihave developed on the placenta,with vascular connections of fetalorigin. What is the gravest maternaldanger?1. Cord prolapse2. Postpartum hemorrhage3. Paroxysmal hypertension4. Brachial plexus injuryAnswer: 2Explanation: 2. The gravest maternal danger is postpartum hemorrhageif this minor lobe is severed from the placenta and remains in the uterus.The nurse knows that the maternalrisks associated with posttermpregnancy include which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Polyhydramnios2. Maternal hemorrhage3. Maternal anxiety4. Forceps-assisted delivery5. Perineal damageAnswer: 2, 3, 4, 5Explanation: 2. Maternal symptoms and complications in posttermpregnancy may include maternal hemorrhage.3. Maternal symptoms and complications in postterm pregnancy mayinclude maternal anxiety.4. Maternal symptoms and complications in postterm pregnancy mayinclude an operative vaginal birth with forceps or vacuum extractor.5. Maternal symptoms and complications in postterm pregnancy mayinclude perineal trauma and damage.The client is at 42 weeks' gestation.Which order should the nursequestion?1. Obtain biophysical profile today.2. Begin nonstress test now.3. Schedule labor induction fortomorrow.4. Have the client return to the clinicin 1 week.Answer: 4Explanation: 4. Many practitioners use twice-weekly testing providingthe amniotic fluid level is normal. One week is too long a periodbetween assessments.fml
During labor, the fetus was in a browpresentation, but after a prolongedlabor, the fetus converted to facepresentation and was deliveredvaginally with forceps assist. Whatshould the nurse explain to theparents?1. The infant will need to beobserved for meconium aspiration.2. Facial edema and head moldingwill subside in a few days.3. The infant will be givenprophylactic antibiotics.4. Breastfeeding will need to bedelayed for a day or two.Answer: 2Explanation: 2. Any facial edema and head molding that result from theuse of forceps at birth will subside in a few days.The multiparous client at term hasarrived to the labor and delivery unitin active labor with intactmembranes. Leopold maneuversindicate the fetus is in a transverselie with a shoulder presentation.Which physician order is mostimportant?1. Artificially rupture membranes.2. Apply internal fetal scalpelectrode.3. Monitor maternal blood pressureevery 15 minutes.4. Alert surgical team of urgentcesarean.Answer: 4Explanation: 4. This is the highest priority because vaginal birth isimpossible with a transverse lie. Labor should not be allowed tocontinue, and a cesarean birth is done quickly.The nurse should anticipate thelabor pattern for a fetal occiputposterior position to be which of thefollowing?1. Shorter than average during thelatent phase2. Prolonged as regards the overalllength of labor3. Rapid during transition4. PrecipitousAnswer: 2Explanation: 2. Occiput posterior (OP) position of the fetus is the mostcommon fetal malposition and occurs when the head remains in thedirect OP position throughout labor. This can prolong the overall lengthof labor.fml
Maternal risks of occiput posterior(OP) malposition include which ofthe following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Blood loss greater than 1000 mL2. Postpartum infection3. Anal sphincter injury4. Higher rates of vaginal birth5. Instrument deliveryAnswer: 2, 3, 5Explanation: 2. Postpartum infection is a maternal risk of OP.3. Anal sphincter injury is a maternal risk of OP.5. Instrument delivery is a maternal risk of OP.Which of the following potentialproblems would the nurse considerwhen planning care for a client witha persistent occiput posteriorposition of the fetus?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Increased fetal mortality2. Severe perineal lacerations3. Ceasing of labor progress4. Fetus born in posterior position5. Intense back pain during laborAnswer: 2, 3, 4, 5Explanation: 2. The woman can have third- or fourth-degree perineallaceration or extension of a midline episiotomy.3. Sometimes labor progress ceases if the fetus fails to rotate to anocciput anterior position.4. Occiput posterior positions are associated with a higher incidence ofvacuum-assisted births.5. The woman usually experiences intense back pain in the small of herback throughout labor.If the physician indicates a shoulderdystociaduring the delivery of amacrosomic fetus, how would thenurse assist?1. Call a second physician to assist.2. Prepare for an immediatecesarean delivery.3. Assist the woman into McRobertsmaneuver.4. Utilize fundal pressure to push thefetus out.Answer: 3Explanation: 3. The McRoberts maneuveris thought to change thematernal pelvic angle and therefore reduce the force needed to extractthe shoulders, thereby decreasing the incidence of brachial plexusstretching and clavicular fracture.fml
The client has undergone anultrasound, which estimated fetalweight at 4500 g (9 pounds 14ounces). Which statement indicatesthat additional teaching is needed?1. "Because my baby is big, I am atrisk for excessive bleeding afterdelivery."2. "Because my baby is big, hisblood sugars could be high after heis born."3. "Because my baby is big, myperineum could experience traumaduring the birth."4. "Because my baby is big, hisshoulders could get stuck and acollarbone broken."Answer: 2Explanation: 2. Hypoglycemia, not hyperglycemia, is a potentialcomplication experienced by a macrosomic fetus.The client vaginally delivers an infantthat weighs 4750 g. Moderateshoulder dystocia occurred duringthe birth. During the initialassessment of this infant, whatshould the nurse look for?1. Bell's palsy2. Bradycardia3. Erb palsy4. PetechiaeAnswer: 3Explanation: 3. Macrosomic newborns should be inspected forcephalhematoma, Erb palsy, and fractured clavicles.The nurse caring for a client in laboranticipates fetal macrosomia andshoulder dystocia. Appropriatemanagement of shoulder dystocia isessential in order to prevent whichfetal complications?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Brachial plexus injury2. Fractured clavicle3. Asphyxia4. Neurological damage5. Puerperal infectionAnswer: 1, 2, 3, 4Explanation: 1. Brachial plexus injury occurs due to improper orexcessive traction applied to the fetal head.2. Complications in macrosomia include fractured clavicles.3. Complications in macrosomia include asphyxia of the fetus.4. Neurological damage is a complication of macrosomia.fml
True postterm pregnancies arefrequently associated with placentalchanges that cause a decrease inthe uterine-placental-fetalcirculation. Complications related toalternations in placenta functioninginclude which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Increased fetal oxygenation2. Increased placental blood supply3. Reduced nutritional supply4. Macrosomia5. Risk of shoulder dystociaAnswer: 3, 4, 5Explanation: 3. Reduced nutritional supply is a complication related toalternations in placenta functioning.4. Macrosomia is a complication related to alternations in placentafunctioning.5. Risk of shoulder dystocia is a complicationThe nurse examines the client'splacenta and finds that the umbilicalcord is inserted at the placentalmargin. The client comments that theplacenta and cord look differentthan they did for her first two births.The nurse should explain that thisvariation in placenta and cord iscalled what?1. Placenta accreta2. Circumvallate placenta3. Succenturiate placenta4. Battledore placentaAnswer: 4Explanation: 4. In battledore placenta, the umbilical cord is inserted ator near the placental margin.A woman is admitted to the birthsetting in early labor. She is 3 cmdilated, -2 station, with intactmembranes and FHR of 150beats/min. Her membranes rupturespontaneously, and the FHR dropsto 90 beats/min with variabledecelerations. What would the initialresponse from the nurse be?1. Perform a vaginal exam.2. Notify the physician.3. Place the client in a left lateralposition.4. Administer oxygen at 2 L per nasalcannula.Answer: 1Explanation: 1. A drop in fetal heart rate accompanied by variabledecelerations is consistent with a prolapsed cord. The nurse wouldassess for prolapsed cord via vaginal examination.fml
The nurse is caring for a client inactive labor. The membranesspontaneously rupture, with a largeamount of clear amniotic fluid.Which nursing action is mostimportant to undertake at this time?1. Assess the odor of the amnioticfluid.2. Perform Leopold maneuvers.3. Obtain an order for painmedication.4. Complete a sterile vaginal exam.Answer: 4Explanation: 4. Checking the cervix will determine whether the cordprolapsed when the membranes ruptured. The nurse would assess forprolapsed cord via vaginal examination.During labor, the client at 4 cmsuddenly becomes short of breath,cyanotic, and hypoxic. The nursemust prepare or arrangeimmediately for which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Intravenous access2. Cesarean delivery3. Immediate vaginal delivery4. McRoberts maneuver5. A crash cartAnswer: 1, 2, 5Explanation: 1. When an amniotic fluid embolism is suspected,intravenous access is obtained as quickly as possible.2. Shortness of breath, cyanosis, and hypoxia are symptoms of anamniotic fluid embolus, which necessitates immediate cesarean delivery.5. The chances of a code are high, so the crash cart needs to beavailable.On assessment, a labor client isnoted to have cardiovascular andrespiratory collapse and isunresponsive. What should the nursesuspect?1. An amniotic fluid embolus2. Placental abruption3. Placenta accreta4. Retained placentaanswer 1Explanation: 1. Cardiovascular and respiratory collapse are symptoms ofan amniotic fluid embolus and cor pulmonale.fml
Five clients are in active labor in thelabor unit. Which women should thenurse monitor carefully for thepotential of uterine rupture?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Age 15, in active labor2. Age 22, with eclampsia3. Age 25, last delivery by cesareansection4. Age 32, first baby died duringlabor5. Age 27, last delivery 11 monthsagoAnswer: 3, 5Explanation: 3. A woman who has had a previous cesarean section is atrisk for uterine rupture.5. A woman who does not have at least 18 months between deliveries isat greater risk for uterine rupture.The nurse is caring for a client whocould be at risk for uterine rupture.The nurse is monitoring the fetusclosely for which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Late decelerations2. Bradycardia3. Loss of ability to determine fetalstation4. Tachycardia5. Early decelerationsAnswer: 1, 2, 3Explanation: 1. Late decelerations could be seen with uterine rupture.2. Bradycardia is seen if there is uterine rupture.3. The uterus is not holding the fetus in place anymore if the uterusruptures.fml
A 26-year-old client is having herinitial prenatal appointment. Theclient reports to the nurse that shesuffered a pelvic fracture in a caraccident 3 years ago. The client askswhether her pelvic fracture mightaffect her ability to have a vaginaldelivery. What response by thenurse is best?1. "It depends on how your pelvishealed."2. "You will need to have a cesareanbirth."3. "Please talk to your doctor aboutthat."4. "You will be able to deliveryvaginally."Answer: 1Explanation: 1. Women with a history of pelvic fractures may also be atrisk for cephalopelvic disproportion (CPD).) In caring for a client with a uterinerupture, the nurse determines whichnursing diagnoses to beappropriate?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Gas Exchange, Impaired2. Fear related to unknown outcome3. Coping, Ineffective4. Mobility: Physical, Impaired5. AnxietyAnswer: 1, 2, 3, 5Explanation: 1. Gas Exchange, Impaired diagnosis could apply to bothmother and fetus.2. The client would experience fear related to an unknown outcome.3. Ineffective coping would be due to emergent situation secondary touterine rupture.5. There will be anxiety related to emergency procedures and unknownfetal outcome.A fetal weight is estimated at 4490grams in a client at 38 weeks'gestation. Counseling should occurbefore labor regarding which of thefollowing?1. Mother's undiagnosed diabetes2. Likelihood of a cesarean delivery3. Effectiveness of epiduralanesthesia with a large fetus4. Need for early deliveryAnswer: 2Explanation: 2. The likelihood of a cesarean delivery with a fetus over4000 grams is high. This should be discussed with the client beforelabor.fml
A woman has been in labor for 16hours. Her cervix is dilated to 3 cmand is 80% effaced. The fetalpresenting part is not engaged. Thenurse would suspect which of thefollowing?1. Breech malpresentation2. Fetal demise3. Cephalopelvic disproportion(CPD)4. Abruptio placentaeAnswer: 3Explanation: 3. Cephalopelvic disproportion (CPD) prevents thepresenting part from becoming engaged.What is one of the most commoninitial signs of nonreassuring fetalstatus?1. Meconium-stained amniotic fluid2. Cyanosis3. Dehydration4. Arrest of descentAnswer: 1Explanation: 1. The most common initial signs of nonreassuring fetalstatus are meconium-stained amniotic fluid and changes in the fetalheart rate (FHR).The client gave birth to a 7 pound,14 ounce female 30 minutes ago.The placenta has not yet delivered.Manual removal of the placenta isplanned. What should the nurseprepare to do?1. Start an IV of lactated Ringer's.2. Apply anti-embolism stockings.3. Bottle-feed the infant.4. Send the placenta to pathology.Answer: 1Explanation: 1. In women who do not have an epidural in place,intravenous sedation may be required because of the discomfortcaused by the procedure. An IV is necessary.The client delivered 30 minutes ago.Her blood pressure and pulse arestable. Vaginal bleeding is scant. Thenurse should prepare for whichprocedure?1. Abdominal hysterectomy2. Manual removal of the placenta3. Repair of perineal lacerations4. Foley catheterizationAnswer: 2Explanation: 2. Retention of the placenta beyond 30 minutes after birthis termed retained placenta. Manual removal of the placenta is thenperformed.fml
Lacerations of the cervix or vaginamay be present when bright redvaginal bleeding persists in thepresence of a well-contracteduterus. The incidence of lacerationsis higher among which of thefollowing childbearing women?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Over the age of 352. Have not had epidural block3. Have had an episiotomy4. Have had a forceps-assisted orvacuum-assisted birth5. NulliparousAnswer: 3, 4Explanation: 3. The incidence of lacerations is higher amongchildbearing women who undergo an episiotomy.4. The incidence of lacerations is higher among childbearing womenwho undergo forceps-assisted or vacuum-assisted birth.After delivery, it is determined thatthere is a placenta accreta. Whichintervention should the nurseanticipate?1. 2 L oxygen by mask2. Intravenous antibiotics3. Intravenous oxytocin4. HysterectomyAnswer: 4Explanation: 4. The primary complication of placenta accreta is maternalhemorrhage and failure of the placenta to separate following birth ofthe infant. An abdominal hysterectomy may be the necessary treatment,depending on the amount and depth of involvement.What is required for any womenreceiving oxytocin (Pitocin)?1. CPR2. Continuous electronic fetalmonitoring3. Administering oxygen by mask4. Nonstress testAnswer: 2Explanation: 2. Continuous electronic fetal monitoring (EFM) is requiredfor any women receiving oxytocin (Pitocin).fml
The client has delivered a 4200 gfetus. The physician performed amidline episiotomy, which extendedinto a third-degree laceration. Theclient asks the nurse where she tore.Which response is best?1. "The episiotomy extended andtore through your rectal mucosa."2. "The episiotomy extended andtore up near your vaginal mucousmembrane."3. "The episiotomy extended andtore into the muscle layer."4. "The episiotomy extended andtore through your anal sphincter."Answer: 4Explanation: 4. A third degree laceration includes the anal sphincter.The nurse is caring for a client whowas just admitted to rule out ectopicpregnancy. Which orders are themost important for the nurse toperform?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Assess the client's temperature.2. Document the time of the client'slast meal.3. Obtain urine for urinalysis andculture.4. Report complaints of dizziness orweakness.5. Have the lab draw blood for B-hCG level every 48 hours.4, 5(Explanation: 4. Reporting complaints of dizziness and weakness isimportant, as it can indicate hypovolemia from internal bleeding.5. Having the lab draw blood for B-hCG levels every 48 hours isimportant, as the level rises much more slowly in ectopic pregnancythan in normal pregnancy.)fml
The nurse educator is presenting aclass on the different kinds ofmiscarriages. Miscarriages, orspontaneous abortions, areclassified clinically into which of thefollowing different categories?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Threatened abortion2. Incomplete abortion3. Complete abortion4. Missed abortion5. Acute abortion1, 2, 3, 4(Explanation: 1. Unexplained cramping, bleeding, or backache indicatesthe fetus might be in jeopardy. This is a threatened abortion.2. In an incomplete abortion, parts of the products of conception areretained, most often the placenta.3. In a complete abortion, all the products of conception are expelled.The uterus is contracted and the cervical os may be closed.4. In a missed abortion, the fetus dies in utero but is not expelled.)The nurse is presenting a class onthe pathophysiology of the differentabortions. Some of the causes arewhich of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Chromosomal abnormalities2. Insufficient or excessive hormonallevels3. Sexual intercourse in the firsttrimester4. Infections in the first trimester5. Cervical insufficiency1, 2, 4, 5(Explanation: 1. Chromosomal defects are generally seen asspontaneous abortions during weeks 4 to 8.2. Insufficient or excessive hormonal levels usually will result inspontaneous abortion by 10 weeks' gestation.4. Infectious and environmental factors may also be seen in firsttrimester pregnancy loss.5. In late spontaneous abortion, the cause is usually a maternal factor,for example, cervical insufficiency or maternal disease, and fetal deathmay not precede the onset of abortion.)A woman is hospitalized with severepreeclampsia. The nurse is meal-planning with the client andencourages a diet that is high inwhat?1. Sodium2. Carbohydrates3. Protein4. Fruits3(Explanation: 3. The client who experiences preeclampsia is losingprotein.)fml
The nurse is assessing a client whohas severe preeclampsia. Whatassessment finding should bereported to the physician?1. Excretion of less than 300 mg ofprotein in a 24-hour period2. Platelet count of less than100,000/mm33. Urine output of 50 mL per hour4. 12 respirations2(Explanation: 2. HELLP syndrome (hemolysis, elevated liver enzymes,and low platelet count) complicates 10% to 20% of severe preeclampsiacases and develops prior to 37 weeks' gestation 50% of the time.Vascular damage is associated with vasospasm, and platelets aggregateat sites of damage, resulting in low platelet count (less than100,000/mm3).)A woman is 16 weeks pregnant. Shehas had cramping, backache, andmild bleeding for the past 3 days.Her physician determines that hercervix is dilated to 2 centimeters,with 10% effacement, butmembranes are still intact. She iscrying, and says to the nurse, "Is mybaby going to be okay?" In additionto acknowledging the client's fear,what should the nurse also say?1. "Your baby will be fine. We'll startIV, and get this stopped in no timeat all."2. "Your cervix is beginning to dilate.That is a serious sign. We willcontinue to monitor you and thebaby for now."3. "You are going to miscarry. Butyou should be relieved becausemost miscarriages are the result ofabnormalities in the fetus."4. "I really can't say. However, whenyour physician comes, I'll ask her totalk to you about it."2(Explanation: 2. If bleeding persists and abortion is imminent orincomplete, the woman may be hospitalized, IV therapy or bloodtransfusions may be started to replace fluid, and dilation and curettage(D&C) or suction evacuation is performed to remove the remainder ofthe products of conception.)fml
The nurse is supervising care in theemergency department. Whichsituation most requires anintervention?1. Moderate vaginal bleeding at 36weeks' gestation; client has an IV oflactated Ringer's solution running at125 mL/hour2. Spotting of pinkish-browndischarge at 6 weeks' gestation andabdominal cramping; ultrasoundscheduled in 1 hour3. Bright red bleeding with clots at32 weeks' gestation; pulse = 110,blood pressure 90/50, respirations =204. Dark red bleeding at 30 weeks'gestation with normal vital signs;client reports an absence of fetalmovement3(Explanation: 3. Bleeding in the third trimester is usually a placentaprevia or placental abruption. Observe the woman for indications ofshock, such as pallor, clammy skin, perspiration, dyspnea, orrestlessness. Monitor vital signs, particularly blood pressure and pulse,for evidence of developing shock.)A client who is 11 weeks pregnantpresents to the emergencydepartment with complaints ofdizziness, lower abdominal pain, andright shoulder pain. Laboratory testsreveal a beta-hCG at a lower-than-expected level for this gestationalage. An adnexal mass is palpable.Ultrasound confirms no intrauterinegestation. The client is crying andasks what is happening. The nurseknows that the most likely diagnosisis an ectopic pregnancy. Whichstatement should the nurse include?1. "You're feeling dizzy because thepregnancy is compressing your venacava."2. "The pain is due to the babyputting pressure on nervesinternally."3. "The baby is in the fallopian tube;the tube has ruptured and is causingbleeding."4. "This is a minor problem. Thedoctor will be right back to explainit to you."3(Explanation: 3. The woman who experiences one-sided lowerabdominal pain or diffused lower abdominal pain, vasomotordisturbances such as fainting or dizziness, and referred right shoulderpain from blood irritating the subdiaphragmatic phrenic nerve isexperiencing an ectopic pregnancy.)fml
A client at 18 weeks' gestation hasbeen diagnosed with a hydatidiformmole. In addition to vaginalbleeding, which signs or symptomswould the nurse expect to see?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Hyperemesis gravidarum2. Diarrhea and hyperthermia3. Uterine enlargement greater thanexpected4. Polydipsia5. Vaginal bleeding1, 3, 5(Explanation: 1. This is often seen in clients with hydatidiform mole.3. This is a classic sign of hydatidiform mole.5. This is a classic symptom of hydatidiform mole.)A woman at 7 weeks' gestation isdiagnosed with hyperemesisgravidarum. Which nursing diagnosiswould receive priority?1. Fluid Volume: Deficient2. Cardiac Output, Decreased3. Injury, Risk for4. Nutrition, Imbalanced: Less thanBody Requirements1(Explanation: 1. The newly admitted client with hyperemesis gravidarumhas been experiencing excessive vomiting, and is in a fluid volume-deficit state.)The prenatal clinic nurse is caringfor a client with hyperemesisgravidarum at 14 weeks' gestation.The vital signs are: blood pressure95/48, pulse 114, respirations 24.Which order should the nurseimplement first?1. Weigh the client.2. Give 1 liter of lactated Ringer'ssolution IV.3. Administer 30 mL Maalox(magnesium hydroxide) orally.4. Encourage clear liquids orally.2(Explanation: 2. The vital signs indicate hypovolemia from dehydration,which leads to hypotension and increased pulse rate. Giving this client aliter of lactated Ringer's solution intravenously will reestablish vascularvolume and bring the blood pressure up, and the pulse and respiratoryrate down.)fml
A pregnant client has been admittedwith a diagnosis of hyperemesis.Which orders written by the primaryhealthcare provider are the highestpriorities for the nurse toimplement?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Obtain complete blood count.2. Start intravenous fluid withmultivitamins.3. Check admission weight.4. Obtain urine for urinalysis.5. Give a medication to stop thenausea and vomiting.2, 5(Explanation: 2. Starting intravenous fluid with multivitamins is a priority ifthe client has been vomiting.5. Giving a medication to stop the nausea and vomiting is a priority.)A primary herpes simplex infectionin the first trimester can increase therisk of which of the following?1. Spontaneous abortion2. Preterm labor3. Intrauterine growth restriction4. Neonatal infection1(Explanation: 1. A primary herpes simplex infection can increase the riskof spontaneous abortion when infection occurs in the first trimester.)A woman is being treated forpreterm labor with magnesiumsulfate. The nurse is concerned thatthe client is experiencing early drugtoxicity. What assessment finding bythe nurse indicates early magnesiumsulfate toxicity?1. Patellar reflexes weak or absent2. Increased appetite3. Respiratory rate of 164. Fetal heart rate of 1201(Explanation: 1. Early signs of magnesium sulfate toxicity are related to adecrease in deep tendon reflexes.)Doppler flow studies (umbilicalvelocimetry) help to assess which ofthe following?1. Placental function and sufficiency2. Fetal heart rate3. Fetal growth and fluid levels4. Maturity of the fetal lungs1(Explanation: 1. Doppler flow studies (umbilical velocimetry) help toassess placental function and sufficiency. Uteroplacental insufficiency isa risk for a woman with preeclampsia. If fetal growth restriction ispresent, Doppler velocimetry of the umbilical artery is useful for fetalsurveillance.)fml
When blood pressure and othersigns indicate that the preeclampsiais worsening, hospitalization isnecessary to monitor the woman'scondition closely. At that time, whichof the following should beassessed?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fetal heart rate2. Blood pressure3. Temperature4. Urine color5. Pulse and respirations1, 2, 3, 5(Explanation: 1. Determine the fetal heart rate along with blood pressure,or monitor continuously with the electronic fetal monitor if the situationindicates.2. Determine blood pressure every 1 to 4 hours, or more frequently ifindicated by medication or other changes in the woman's status.3. Determine temperature every 4 hours, or every 2 hours if elevated orif premature rupture of the membranes (PROM) has occurred.5. Determine pulse rate and respirations along with blood pressure.)The community nurse is workingwith a client at 32 weeks' gestationwho has been diagnosed withpreeclampsia. Which statement bythe client would indicate thatadditional information is needed?1. "I should call the doctor if Idevelop a headache or blurredvision."2. "Lying on my left side as much aspossible is good for the baby."3. "My urine could become darkerand smaller in amount each day."4. "Pain in the top of my abdomen isa sign my condition is worsening."3(Explanation: 3. Oliguria is a complication of preeclampsia. Specificgravity of urine readings over 1.040 correlate with oliguria andproteinuria and should be reported to the physician.)Infants of women with preeclampsiaduring pregnancy tend to be smallfor gestational age (SGA) becauseof which condition?1. Intrauterine growth restriction2. Oliguria3. Proteinuria4. Hypertension1(Explanation: 1. Infants of women with preeclampsia during pregnancytend to be small for gestational age (SGA) because of intrauterinegrowth restriction. The cause is related specifically to maternalvasospasm and hypovolemia, which result in fetal hypoxia andmalnutrition.)fml
A woman is experiencing pretermlabor. The client asks why she is onbetamethasone. Which is the nurse'sbest response?1. "This medication will halt the laborprocess until the baby is moremature."2. "This medication will relax thesmooth muscles in the infant's lungsso the baby can breathe."3. "This medication is effective instimulating lung development in thepreterm infant."4. "This medication is an antibioticthat will treat your urinary tractinfection, which caused pretermlabor."3(Explanation: 3. Betamethasone or dexamethasone is often administeredto the woman whose fetus has an immature lung profile to promote fetallung maturation.)A client is being admitted to thelabor area with the diagnosis ofeclampsia. Which actions by thenurse are appropriate at this time?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Tape a tongue blade to the headof the bed.2. Pad the side rails.3. Have the woman sit up.4. Provide the client with griefcounseling.5. The airway should be maintainedand oxygen administered.2, 5(Explanation: 2. Side rails should be up and padded.5. Suctioning may be necessary to keep the airway clear.)A clinic nurse is planning when toadminister Rh immune globulin(RhoGAM) to an Rh-negativepregnant client. When should thefirst dose of RhoGAM beadministered?1. After the birth of the infant2. 1 month postpartum3. During labor4. At 28 weeks' gestation4(Explanation: 4. When the woman is Rh negative and not sensitized andthe father is Rh positive or unknown, Rh immune globulin is givenprophylactically at 28 weeks' gestation.)fml
Whether sensitization is the result ofa blood transfusion or maternal-fetalhemorrhage for any reason, whattest can be performed to determinethe amount of Rh(D) positive bloodpresent in the maternal circulationand to calculate the amount of Rhimmune globulin needed?1. Indirect Coombs' test2. Nonstress test3. Kleihauer-Betke or rosette test4. Direct Coombs' test3(Explanation: 3. A Kleihauer-Betke or rosette test can be performed todetermine the amount of Rh(D) positive blood present in the maternalcirculation and to calculate the amount of Rh immune globulin needed.)Which maternal-child client shouldthe nurse see first?1. Blood type O, Rh-negative2. Indirect Coombs' test negative3. Direct Coombs' test positive4. Blood type B, Rh-positive3(Explanation: 3. Direct Coombs' test is done on the infant's blood todetect antibody-coated Rh-positive RBCs. If the mother's indirectCoombs' test is positive and her Rh-positive infant has a positive directCoombs' test, Rh immune globulin is not given; in this case, the infant iscarefully monitored for hemolytic disease.)The client with blood type A, Rh-negative, delivered yesterday. Herinfant is blood type AB, Rh-positive.Which statement indicates thatteaching has been effective?1. "I need to get RhoGAM so I don'thave problems with my nextpregnancy."2. "Because my baby is Rh-positive, Idon't need RhoGAM."3. "If my baby had the same bloodtype I do, it might causecomplications."4. "Before my next pregnancy, I willneed to have a RhoGAM shot."1(Explanation: 1. Rh-negative mothers who give birth to Rh-positiveinfants should receive Rh immune globulin (RhoGAM) to preventalloimmunization.)fml
) A client is concerned because shehas been told her blood type andher baby's are incompatible. What isthe nurse's best response?1. "This is called ABO incompatibility.It is somewhat common but rarelycauses significant hemolysis."2. "This is a serious condition, andadditional blood studies arecurrently in process to determinewhether you need a medication toprevent it from occurring with afuture pregnancy."3. "This is a condition caused by ablood incompatibility between youand your husband, but does notaffect the baby."4. "This type of condition is verycommon, and the baby can receivea medication to prevent jaundicefrom occurring."1(Explanation: 1. When blood types, not Rh, are incompatible, it is calledABO incompatibility. The incompatibility occurs as a result of thematernal antibodies present in her serum and interaction between theantigen sites on the fetal RBCs.)If the woman is Rh negative and notsensitized, she is given Rh immuneglobulin to prevent what?1. The potential for hemorrhage2. Hyperhomocysteinemia3. Antibody formation4. Tubal pregnancy3(Explanation: 3. If the woman is Rh negative and not sensitized, she isgiven Rh immune globulin to prevent antibody formation.)fml
) The client presents to the clinic foran initial prenatal examination. Sheasks the nurse whether there mightbe a problem for her baby becauseshe has type B Rh-positive bloodand her husband has type O Rh-negative blood, or because hersister's baby had ABOincompatibility. What is the nurse'sbest answer?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. "Your baby would be at risk for Rhproblems if your husband were Rh-negative."2. "Rh problems only occur whenthe mother is Rh-negative and thefather is not."3. "ABO incompatibility occurs onlyafter the baby is born."4. "We don't know for sure, but wecan test for ABO incompatibility."5. "Your husband's being type B putsyou at risk for ABO incompatibility."2, 3(Explanation: 2. Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive.3. ABO incompatibility is limited to type O mothers with a type A or Bfetus and occurs after the baby is born.)A woman has a hydatidiform mole(molar pregnancy) evacuated, and isprepared for discharge. The nurseshould make certain that the clientunderstands that what is essential?1. That she not become pregnantuntil after the follow-up program iscompleted2. That she receive RhoGAM withher next pregnancy and birth3. That she has her blood pressurechecked weekly for the next 30 days4. That she seek genetic counselingwith her partner before the nextpregnancy1(Explanation: 1. Because of the risk of choriocarcinoma, the womantreated for hydatidiform mole should receive extensive follow-uptherapy. Follow-up care includes a baseline chest X-ray to detect lungmetastasis and a physical examination including a pelvic examination.The woman should avoid pregnancy during this time because theelevated hCG levels associated with pregnancy would cause confusionas to whether cancer had developed.)fml
A client at 10 weeks' gestation hasdeveloped cholecystitis. If surgery isrequired, what is the safest timeduring pregnancy?1. Immediately, before the fetus getsany bigger2. Early in the second trimester3. As close to term as possible4. The risks are too high to do itanytime in pregnancy2(Explanation: 2. The early second trimester is the best time to operatebecause there is less risk of spontaneous abortion or early labor, andthe uterus is not so large as to impinge on the abdominal field.)The nurse is presenting a class tonewly pregnant families. What formof trauma will the nurse describe asthe leading cause of fetal andmaternal death?1. Falls2. Domestic violence3. Gun accidents4. Motor vehicle accidents4(Explanation: 4. Trauma from motor vehicle accidents is the leadingcause of fetal and maternal death.)During a prenatal exam, a clientdescribes several psychosomaticsymptoms and has several vaguecomplaints. What could thesebehaviors indicate?1. Abuse2. Mental illness3. Depression4. Nothing, they are normal1(Explanation: 1. Chronic psychosomatic symptoms and vague complaintscan be indicators of abuse.)The nurse is caring for a client at 35weeks' gestation who has beencritically injured in a shooting. Whichstatement by the paramedicsbringing the woman to the hospitalwould cause the greatest concern?1. "Blood pressure 110/68, pulse 90."2. "Entrance wound present belowthe umbilicus."3. "Client is positioned in a leftlateral tilt."4. "Clear fluid is leaking from thevagina."2(Explanation: 2. Penetrating trauma includes gunshot wounds and stabwounds. The mother generally fares better than the fetus if thepenetrating trauma involves the abdomen as the enlarged uterus is likelyto protect the mother's bowel from injury.)fml
The client at 34 weeks' gestation hasbeen stabbed in the low abdomenby her boyfriend. She is brought tothe emergency department fortreatment. Which statementsindicate that the client understandsthe treatment being administered?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. "The baby needs to be monitoredto check the heart rate."2. "My bowel has probably beenlacerated by the knife."3. "I might need an ultrasound tolook at the baby."4. "The catheter in my bladder willprevent urinary complications."5. "The IV in my arm will replace theamniotic fluid if it is leaking."1, 3(Explanation: 1. Ongoing assessments of trauma include evaluation ofuterine tone, contractions and tenderness, fundal height, fetal heart rate,intake and output and other indicators of shock, normal postoperativeevaluation in those women requiring surgery, determination ofneurologic status, and assessment of mental outlook and anxiety level.3. In cases of noncatastrophic trauma, where the mother's life is notdirectly threatened, fetal monitoring for 4 hours should be sufficient ifthere is no vaginal bleeding, uterine tenderness, contractions, or leakingamniotic fluid.)A client is admitted to the laborsuite. It is essential that the nurseassess the woman's status in relationto which infectious diseases?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Chlamydia trachomatis2. Rubeola3. Varicella4. Group B streptococcus5. Acute pyelonephritis1, 4, 5(Explanation: 1. The infant may develop chlamydial pneumonia andChlamydia trachomatis may be responsible for premature labor andfetal death. Chlamydial infection should be assessed.4. Women may transmit GBS to their fetus in utero or during childbirth.GBS is a leading infectious cause of neonatal sepsis and mortality andshould be assessed.5. Acute pyelonephritis should be assessed as there is an increased riskof premature birth and intrauterine growth restriction (IUGR).)fml
The nurse knows that a mother whohas been treated for Betastreptococcus passes this risk on toher newborn. Risk factors forneonatal sepsis caused by Betastreptococcus include which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Prematurity2. Maternal intrapartum fever3. Membranes ruptured for longerthan 18 hours4. A previously infected infant withGBS disease5. An older mother having her firstbaby1, 2, 3, 4(Explanation: 1. Prematurity is a risk factor.2. Maternal intrapartum fever is a risk factor.3. Prolonged rupture of membranes is a risk factor.4. A previously infected infant increases the risk.)1) The nurse is caring for a pregnantwoman who admits to using cocaineand ecstasy on a regular basis. Theclient states, "Everybody knows thatalcohol is bad during pregnancy,but what's the big deal aboutecstasy?" What is the nurse's bestresponse?A) "Ecstasy can cause a high fever inyou and therefore cause the babyharm."B) "Ecstasy leads to deficiencies ofthiamine and folic acid, which helpthe baby develop."C) "Ecstasy produces babies withsmall heads and short bodies withbrain function alterations."D) "Ecstasy produces intrauterinegrowth restriction and meconiumaspiration."Answer: AExplanation:A) Hyperthermia (elevated temperature) is a side effect of M D M A(ecstasy).B) Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid.Folic acid helps prevent neural tube defects.C) Cocaine, not ecstasy, causes these fetal effects (small heads andshort bodies with brain function alterations).D) Heroin, not ecstasy, causes these fetal effects (intrauterine growthrestriction and meconium aspiration).Page Ref: 368fml
2) The nurse is doing preconceptioncounseling with a 28-year-oldwoman with no prior pregnancies.Which statement made by the clientindicates to the nurse that the clienthas understood the teaching?A) "I can continue to drink alcoholuntil I am diagnosed as pregnant."B) "I need to stop drinking alcoholcompletely when I start trying to getpregnant."C) "A beer once a week will notdamage the fetus."D) "I can drink alcohol whilebreastfeeding because it doesn'tpass into breast milk."Answer: BExplanation:A) The expectant woman should avoid alcohol completely.B) Women should discontinue drinking alcohol when they start toattempt to become pregnant due to possible effects of alcohol on thefetus.C) The effects of alcohol on the fetus may include a group of signsreferred to as fetal alcohol spectrum disorders (F A S D).D) Alcohol is excreted in breast milk; therefore, it should be avoided.Page Ref: 3683) A woman's history andappearance suggest drug abuse.What is the nurse's best approach?A) Ask the woman directly, "Do youuse any street drugs?"B) Ask the woman whether shewould like to talk to a counselor.C) Ask some questions about over-the-counter medications and avoidmention of illicit drugs.D) Explain how harmful drugs canbe for her baby.Answer: AExplanation:A) If drug abuse is suspected, the nurse should ask direct questions andbe matter-of-fact and nonjudgmental to elicit honest responses.B) Advising the client to seek counseling would not occur until the nurseverifies that the woman uses street drugs.C) If abuse is suspected, the nurse should ask direct questions,beginning with less threatening questions about the use of tobacco,caffeine, and over-the-counter medications, but not avoid the mentionof illicit drugs.D) When talking to clients in a therapeutic manner, it is important not tobe threatening or judgmental; an example of judgmental behaviorwould be stating that the drugs will harm the baby.Page Ref: 370fml
4) A 20-year-old woman is at 28weeks' gestation. Her prenatalhistory reveals past drug abuse, andurine screening indicates that shehas recently used heroin. The nurseshould recognize that the woman isat increased risk for whichcondition?A) Erythroblastosis fetalisB) Diabetes mellitusC) Abruptio placentaeD) Pregnancy-induced hypertensionAnswer: DExplanation:A) Erythroblastosis fetalis is secondary to physiological blood disorderssuch as R h incompatibility.B) Diabetes is an endocrine disorder that is unrelated to drug use andabuse.C) Abruptio placentae is seen more commonly with cocaine or crackuse.D) Women who use heroin are at risk for poor nutrition, anemia, andpregnancy-induced hypertension (or preeclampsia-eclampsia).Page Ref: 3695) The client has just beendiagnosed as diabetic. The nurseknows teaching was effective whenthe client makes which statement?A) "Ketones in my urine mean thatmy body is using the glucoseappropriately."B) "I should be urinating frequentlyand in large amounts to get rid ofthe extra sugar."C) "My pancreas is making enoughinsulin, but my body isn't using itcorrectly."D) "I might be hungry frequentlybecause the sugar isn't getting intothe tissues the way it should."Answer: DExplanation:A) Ketones are produced when fat is being utilized for glucose, and thisis not a desirable response.B) Frequent urination is an indication of glucose above the renalthreshold, and is not a good indicator of diabetic stability.C) Diabetes is a result of lack of insulin production. If the insulin is beingproduced, the body will utilize it.D) The client who understands the disease process is aware that if thebody is not getting the glucose it needs, the message of hunger will besent to the brain.Page Ref: 354—3566) The maternal health nurse iscaring for a pregnant client withobsessive-compulsive disorder (O CD). Which action will the nurse takewhen teaching the client, based onthe client's psychological disorder?A) Allow the client opportunity forrepetitive rituals.B) Ask the client to follow along withwritten material.C) Repeat instructions as needed.D) Provide multiple handouts withvarious photographsAnswer: CExplanation:A) Although those with O C D may have repetitive rituals, this does notpromote learning and is not the best action for the nurse.B) While written material may be helpful as a supplement to learning, itmay be difficult for the client with O C D to follow along.C) The best action for the nurse is to repeat any instructions or teachingsas needed. This allows the client more opportunity to learn.D) While multiple learning techniques and opportunities are helpful formost individuals, those with O C D have a difficult time following alongwith teaching material.Page Ref: 371fml
The client with insulin-dependenttype 2 diabetes and an HbA1c of5.0% is planning tobecome pregnant soon. Whatanticipatory guidance should thenurse provide this client?1. Insulin needs decrease in the firsttrimester and usually begin to riselate in the first trimesteras glucose use and glycogenstorage by the woman and fetusincrease.2. The risk of ketoacidosis decreasesduring the length of the pregnancy.3. Vascular disease thataccompanies diabetes slowsprogression.4. The baby is likely to have acongenital abnormality because ofthe diabetes.Answer: 1Explanation: 1. Insulin needs decrease in the first trimester and usuallybegin to rise late in thefirst trimester as glucose use and glycogen storage by the woman andfetus increase.7) A newly diagnosed insulin-dependent type 1 diabetic withgood blood sugar control is at 20weeks' gestation. She asks the nursehow her diabetes will affect herbaby. What would the bestexplanation include?A) "Your baby could be smaller thanaverage at birth."B) "Your baby will probably belarger than average at birth."C) "As long as you control yourblood sugar, your baby will not beaffected at all."D) "Your baby might have highblood sugar for several days."Answer: BExplanation:A) Characteristically, infants of mothers with diabetes are large forgestational age (L G A).B) Characteristically, infants of mothers with diabetes are large forgestational age (L G A), as a result of high levels of fetal insulinproduction stimulated by the high levels of glucose crossing theplacenta from the mother. Sustained fetal hyperinsulinism andhyperglycemia ultimately lead to excessive growth, called macrosomia,and deposition of fat.C) The demands of pregnancy will make it difficult for the best of clientsto control blood sugar on a regular basis.D) After birth, the umbilical cord is severed, and, thus, the generousmaternal blood glucose supply is eliminated.Page Ref: 355fml
8) A 26-year-old client is 28 weekspregnant. She has developedgestational diabetes. She isfollowing a program of regularexercise, which includes walking,bicycling, and swimming. Whatinstructions should be included in ateaching plan for this client?A) "Exercise either just before mealsor wait until 2 hours after a meal."B) "Carry hard candy (or othersimple sugar) when exercising."C) "If your blood sugar is 120 m g/dL, eat 20 g of carbohydrate."D) "If your blood sugar is more than120 m g/d L, drink a glass of wholemilk."Answer: BExplanation:A) It is best to exercise just after the meal, in order to utilize the glucose.B) The nurse should advise her to carry a simple sugar such as hardcandy, because of the possibility of exercise-induced hypoglycemia.C) A finger stick result of 120 m g/d L is considered to be normal.D) Such clients need no additional carbohydrate or protein intake.Page Ref: 3629) A 26-year-old client is 26 weekspregnant. Her previous birthsinclude two large-for-gestational-age babies and one unexplainedstillbirth. Which tests would thenurse anticipate as being mostdefinitive in diagnosing gestationaldiabetes?A) A 50g, 1-hour glucose screeningtestB) A single fasting glucose levelC) A 100g, 1-hour glucose tolerancetestD) A 100g, 3-hour glucose tolerancetestAnswer: DExplanation:A) All women get the initial 50 g of glucose and a 1-hour screening.B) A single fasting glucose level is not an adequate indicator of theglucose level in relation to food.C) The 100g, 1-hour tolerance test is not an adequate indicator of theglucose level in relation to food.D) Gestational diabetes is diagnosed if two or more of the followingvalues are met or exceeded after taking the 100 g, 3-hour O G T T:Fasting: 95 m g/d L; 1 hour: 180 m g/d L; 2 hours: 155 m g/d L; 3 hours:140 m g/d L.Page Ref: 356fml
10) A woman asks her nurse what shecan do before she begins trying toget pregnant to help her baby, asshe is prone to anemia. What wouldthe nurse correctly advise her todo?A) Get pregnant, then start ironsupplementation.B) Add more carbohydrates to herdiet.C) Begin taking folic acidsupplements daily.D) Have a hemoglobin baselinedone now so her progress can befollowed.Answer: CExplanation:A) Waiting until one is pregnant to add iron or evaluate a diet is notbeing proactive.B) Adding carbohydrates to her diet will not help prevent anemia.C) The common anemias of pregnancy are due to insufficienthemoglobin production related to nutritional deficiency in either iron orfolic acid during pregnancy. Folic acid deficiency during pregnancy isprevented by a daily supplement of 0.4 m g (400 micrograms) of folate.D) Having a hemoglobin baseline done will not help the patient preventanemia in pregnancy.Page Ref: 363The nurse has written the nursingdiagnosis Injury, Risk for for adiabetic pregnant client.Interventions for this diagnosisinclude which of the following?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Assessment of fetal heart tones2. Perform oxytocin challenge test,if ordered3. Refer the client to a diabetessupport group4. Assist with the biophysical profileassessment5. Develop an appropriate teachingplanAnswer: 1, 2, 4Explanation: 1. Reassuring fetal heart rate variability and accelerationsare interpreted asadequate placental oxygenation.2. The nurse would perform oxytocin challenge test (OCT)/contractionstress test (CST) and non-stress tests as determined by physician.4. The nurse assists the physician in performing a biophysical profileassessment.fml
11) Which of the following may bethe main presenting symptom ofiron deficiency anemia?A) Frequent urinationB) FatigueC) NauseaD) HeadachesAnswer: BExplanation:A) The main presenting symptom of iron deficiency anemia would notbe frequent urination.B) The main presenting symptom of iron deficiency anemia may befatigue.C) The main presenting symptom of iron deficiency anemia would notbe nausea.D) The main presenting symptom of iron deficiency anemia would notbe headaches.Page Ref: 363—36412) The client with thalassemiaintermedia has a hemoglobin levelof 9.0. The nurse is preparing aneducation session for the client.Which statement should the nurseinclude?A) "You need to increase your intakeof meat and other iron-rich foods."B) "Your low hemoglobin could putyou into preterm labor."C) "Increasing your vitamin C intakewill help your hemoglobin level."D) "You should not take ironsupplements."Answer: DExplanation:A) Iron-rich foods and supplementation should be avoided.B) Because the client's iron levels are normal, increasing dietary iron willnot affect the hemoglobin.C) Vitamin C increases iron absorption, but a client with thalassemiadoes not need additional iron.D) Folic acid supplements are indicated for women with thalassemia, butiron supplements are not.Page Ref: 366fml
13) The client at 20 weeks' gestationhas had an ultrasound that revealeda neural tube defect in her fetus. Theclient's hemoglobin level is 8.5. Thenurse should include whichstatement when discussing thesefindings with the client?A) "Your low iron intake has causedanemia, which leads to the neuraltube defect."B) "You should increase your vitaminC intake to improve your anemia."C) "You are too picky about food.Your poor diet caused your baby'sdefect."D) "You haven't had enough folicacid in your diet. You should take asupplement."Answer: DExplanation:A) Low hemoglobin does not cause neural tube defects.B) Vitamin C will increase iron absorption, but this client is deficient infolic acid.C) Therapeutic communication requires that the nurse avoid makingjudgmental statements.D) An inadequate intake of folic acid has been associated with neuraltube defects (N T Ds) (e.g., spina bifida, anencephaly,meningomyelocele) in the fetus or newborn.Page Ref: 364The clinic nurse is teaching apregnant client about her ironsupplement. Which informationis included in the teaching?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Iron does not affect thegastrointestinal tract.2. A stool softener might be needed.3. Start a low dose, and increase itgradually.4. Expect the stools to be black andbloody.5. Iron absorption is poor if takenwith meals.Answer: 2, 3, 5Explanation: 2. Constipation can be a problem when taking iron, so astool softener might beneeded.3. To prevent anemia, experts recommend that all pregnant women starton 30 mg/day of ironsupplements daily. If anemia is diagnosed, the dosage should beincreased to 60 to 120 mg perday of iron.5. Iron absorption is reduced by 40% to 50% if taken with mealsfml
14) The client at 9 weeks' gestationhas been told that her H I V test waspositive. The client is very upset, andtells the nurse, "I didn't know I had HI V! What will this do to my baby?"The nurse knows teaching has beeneffective when the client makeswhich statement?A) "I cannot take the medicationsthat control H I V during mypregnancy, because they will harmthe baby."B) "My baby can get H I V during thepregnancy and through my breastmilk."C) "The pregnancy will increase theprogression of my disease and willreduce my C D4 counts."D) "The H I V won't affect my baby,and I will have a low-risk pregnancywithout additional testing."Answer: BExplanation:A) Antiretroviral therapy is recommended to all infected pregnantwomen, regardless of whether or not they are symptomatic, to reducethe rate of perinatal transmission.B) H I V transmission can occur during pregnancy and through breastmilk; however, it is believed that the majority of all infections occurduring labor and birth.C) There is no evidence to indicate that pregnancy increases theprogression of H I V/A I D S.D) A pregnancy complicated by H I V infection, even if asymptomatic, isconsidered high risk, and the fetus is monitored closely. Weekly non-stress testing (N S T) is begun at 32 weeks' gestation.Page Ref: 372—373fml
15) During the history, the clientadmits to being H I V-positive andsays she knows that she is about 16weeks pregnant. Which statementsmade by the client indicate anunderstanding of the plan of careboth during the pregnancy andpostpartally?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.A) "During labor and delivery, I canexpect the zidovudine (Z D V) to begiven in my ."B) "After delivery, the dose ofzidovudine (Z D V) will be doubledto prevent further infection."C) "My baby will be started onzidovudine (Z D V) for six weeksfollowing the birth."D) "My baby's zidovudine (Z D V)will be given in a cream form."E) "My baby will not needzidovudine (Z D V) if I take it duringmy pregnancy."Answer: A, CExplanation:A) A R T therapy generally includes oral Zidovudine (Z D V) daily, Z DV during labor and until birth, and Z D V therapy for the infant for 6weeks following birth.B) The mother will continue with her oral dosage of zidovudine (Z D V)after delivery just as prior to delivery.C) A R T therapy generally includes oral Zidovudine (Z D V) daily, Z DV during labor and until birth, and Z D V therapy for the infant for 6weeks following birth.D) The initial treatment is zidovudine (Z D V) orally every day.E) The infant will be started on oral zidovudine (Z D V) after birth for 6weeks.Page Ref: 372—373A diabetic client goes into labor at36 weeks' gestation. Provided thattests for fetal lungmaturity are successful, the nursewill anticipate which of the followinginterventions?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Administration of tocolytic therapy2. Beta-sympathomimeticadministration3. Allowance of labor to progress4. Hourly blood glucose monitoring5. Cesarean birth may be indicated ifevidence of reassuring fetal statusexistsAnswer: 3, 4Explanation: 3. There will be no attempt to stop the labor, as this cancompromise the motherand fetus.4. To reduce incidence of congenital anomalies and other problems inthe newborn, the womanshould be euglycemic (have normal blood glucose) throughout thepregnancy.fml
16) A woman is 32 weeks pregnant.She is H I V-positive butasymptomatic. The nurse knows thatwhat would be important inmanaging her pregnancy anddelivery?A) An amniocentesis at 30 and 36weeksB) Weekly non-stress testingbeginning at 32 weeks' gestationC) Application of a fetal scalpelectrode as soon as hermembranes rupture in laborD) Administration of intravenousantibiotics during labor and deliveryAnswer: BExplanation:A) Invasive procedures such as amniocentesis are avoided whenpossible to prevent the contamination of a noninfected infant.B) Weekly non-stress testing (N S T) is begun at 32 weeks' gestation andserial ultrasounds are done to detect I U G R.C) Invasive procedures are avoided when possible to prevent thecontamination of a noninfected infant.D) Antibiotics would be ineffective for either the mother or the infantwho was H I V-positive.Page Ref: 372—37317) A pregnant woman is married toan intravenous drug user. She had anegative H I V screening test justafter missing her first menstrualperiod. What would indicate that theclient needs to be retested for H IV?A) Hemoglobin of 11 g/d L and arapid weight gainB) Elevated blood pressure andankle edemaC) Shortness of breath and frequenturinationD) Persistent candidiasisAnswer: DExplanation:A) Hemoglobin of 11 g/d L and a rapid weight gain do not indicate aneed to be retested for H I V.B) Elevated blood pressure and ankle edema do not indicate a need tobe retested for H I V.C) Shortness of breath and frequent urination do not indicate a need toretest for H I V.D) Signs and symptoms of infections include fever, weight loss, fatigue,persistent candidiasis, diarrhea, cough, and skin lesions (Kaposi'ssarcoma and hairy leukoplakia in the mouth).Page Ref: 37318) Women with H I V should beevaluated and treated for othersexually transmitted infections andfor what condition occurring morecommonly in women with H I V?A) SyphilisB) ToxoplasmosisC) GonorrheaD) HerpesAnswer: BExplanation:A) Syphilis occurs more often in men.B) Women with H I V should be evaluated and treated for other sexuallytransmitted infections and for conditions occurring more commonly inwomen with H I V, such as tuberculosis, cytomegalovirus, toxoplasmosis,and cervical dysplasia.C) Gonorrhea affects both men and women.D) Herpes affects both men and women.Page Ref: 373fml
19) A 21-year-old at 12 weeks'gestation with her first baby hasknown cardiac disease, class , as aresult of childhood rheumatic fever.During a prenatal visit, the nursereviews the signs of cardiacdecompensation with her. The nursewill know that the client understandsthese signs and symptoms if shestates that she would notify herdoctor if she had which symptom?A) "A pulse rate increase of 10 beatsper minute"B) "Breast tenderness"C) "Mild ankle edema"D) "A frequent cough"Answer: DExplanation:A) In most pregnant clients, the heart rate will increase.B) Most pregnant clients will develop breast tenderness.C) The client with rheumatic heart disease who develops congestiveheart failure would have severe ankle edema.D) The heart's signal of its decreased ability to meet the demands ofpregnancy includes frequent cough (with or without hemoptysis).Page Ref: 37820) A client is at 12 weeks' gestationwith her first baby. She has cardiacdisease, class . She states that shehad been taking sodium warfarin(Coumadin), but her physicianchanged her to heparin. She asksthe nurse why this was done. Whatshould the nurse's response be?A) "Heparin is used whencoagulation problems are resolved."B) "Heparin is safer because it doesnot cross the placenta."C) "They are the same drug, butheparin is less expensive."D) "Coumadin interferes with ironabsorption in the intestines."Answer: BExplanation:A) Heparin is used when coagulation problems develop.B) Heparin is safest for the client to take because it does not cross theplacental barrier.C) Heparin does not cost less than Coumadin.D) Coumadin does not interfere with iron absorption in the intestines.Page Ref: 378fml
21) A 21-year-old woman is at 12weeks' gestation with her first baby.She has cardiac disease, class , asa result of having had childhoodrheumatic fever. Which plannedactivity would indicate to the nursethat the client needs furtherteaching?A) "I will be sure to take a restperiod every afternoon."B) "I would like to take childbirtheducation classes in my lasttrimester."C) "I will have to cancel our trip toDisney World."D) "I am going to start my classes inwater aerobics next week."Answer: DExplanation:A) Because the heart disease is class , this client is encouraged to getadequate rest.B) Childbirth classes would be helpful for the client as long as she werecareful not to overexert herself.C) Travel during the pregnancy would be based upon the tolerance ofthe client. However, a trip to Disney World would involve a large amountof activity, which would stress the pregnancy.D) With the slightest exertion, the client's heart rate will rise, and she willbecome symptomatic. Therefore, she should not establish a newexercise program.Page Ref: 37822) Which of the followingsymptoms, if progressive, areindicative of C H F, the heart's signalof its decreased ability to meet thedemands of pregnancy?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.A) PalpitationsB) Heart murmursC) DyspneaD) Frequent urinationE) RalesAnswer: A, B, C, EExplanation:A) Palpitations are indicative of C H F.B) Heart murmurs are indicative of C H F.C) Dyspnea is indicative of C H F.D) Frequent urination is not indicative of C H F.E) Rales are indicative of C H F.Page Ref: 378—379fml
23) The prenatal clinic nurse hasreceived four phone calls. Whichclient should the nurse call backfirst?A) Pregnant woman at 28 weekswith history of asthma who isreporting difficulty breathing andshortness of breathB) Pregnant woman at 6 weeks witha seizure disorder who is inquiringwhich foods are good folic acidsources for herC) Pregnant woman at 35 weekswith a positive H B s A G who iswondering what treatment her babywill receive after birthD) Pregnant woman at 11 weeks withuntreated hyperthyroidism who isdescribing the onset of vaginalbleedingAnswer: AExplanation:A) The goal of therapy is to prevent maternal exacerbations, becauseeven a mild exacerbation can cause severe hypoxia-relatedcomplications in the fetus.B) Women with seizure disorders should be started on folic acidsupplements prior to pregnancy, and should continue throughoutpregnancy. However, this client is not the highest priority.C) A client with a positive H B s A G is contagious for hepatitis B. Within12 hours of birth, infants born to women with H B V infection shouldreceive hepatitis B immune globulin and the first dose of the H B Vvaccine series. However, this client is not the highest priority.D) Pregnant women with untreated hyperthyroidism have increasedrates of abortion, intrauterine death, and stillbirth. Vaginal bleeding at 11weeks could indicate that spontaneous abortion is taking place.However, this client is not the highest priority.Page Ref: 381A patient with gestational diabetes(G D M) is instructed to measurecapillary blood glucose levels 4times a day. If the patient eats mealsat 8 a.m., 1 p.m., and 7 p.m., at whichtimes should the nurse reinforceglucose testing to occur?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. 10 a.m.2. 12 noon3. 4 p.m.4. 3 p.m.5. 9 p.m.Answer: 1, 4, 5Explanation:Women with G D M typically measure their blood glucose four times aday - fasting and 1 to 2 hours after meals.Page Ref: 362fml
A patient in the second trimester ofpregnancy with gestational diabetesis counseled to ingest 35 calories/kg of ideal body weight. The patient'sideal weight is 154 l b s.How many calories should thepatient ingest every day?Answer: 2450 caloriesExplanation:First determine the patient's ideal body weight in kg by dividing 154 lbs.by 2.2 kg or 154/2.2 = 70 kg. Then multiply the weight in kg by thenumber of calories per kg to consume or 70 kg ×35 calories = 2450. Thepatient's daily caloric intake should be 2450 calories.Page Ref: 357A patient in the 10th week ofpregnancy is diagnosed withgestational diabetes. The dieticiandetermines that the patient's dailycaloric intake should be 2200calories and instructs the patient toingest 40% of calories fromcarbohydrates, 20% of calories fromprotein, and 40% of calories fromfats.How many calories should thepatient ingest of protein each day?Answer: 440 caloriesExplanation:To determine the number of calories of protein that should be ingestedeach day the daily caloric total is multiplied by 20% or 2200 ×20% = 440calories.Page Ref: 357During a routine prenatal visit, thenurse suspects that the patient isexperiencing undiagnoseddepression. What findings did thenurse use to make this clinicaldetermination?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Insomnia2. Headaches3. Fear of labor4. Ritualistic behavior5. Lack of interest in the pregnancyAnswer: 1, 2, 5Explanation:Manifestations of depression in the pregnant patient include withdrawnbehavior, physical fatigue due to insomnia, crying spells, sadness,hopelessness, feelings of guilt, lack of interest in the baby, thoughts ofsuicide, and headaches. Fear of labor is associated with a panic disorder.Ritualistic behavior is associated with obsessive-compulsive disorder (OC D).Page Ref: 367fml
The nurse is preparing teachingmaterial for a patient with multiplesclerosis who is in the third trimesterof pregnancy. What informationshould the nurse emphasize with thispatient?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Plan for frequent rest periods2. Breastfeeding should be avoided3. Plan to experience heightenedpain during labor4. Determine the need for childcarehelp after delivery5. Relapses may increase during thefirst 3 months after deliveryAnswer: 1, 4, 5Explanation:For the pregnant patient with multiple sclerosis, the nurse shouldemphasize that the relapse rate is reduced during the second and thirdtrimester but increased during the 3 months following birth. Exclusivebreastfeeding for the first 2 months postpartum may be independentlyassociated with decreased post-pregnancy relapse rate. Rest isimportant; help with childcare should be planned. Uterine contractionstrength is not diminished, but because sensation is frequently lessened,labor may be almost painless.Page Ref: 383The nurse is providing care to apregnant client who is diagnosedwith iron deficiency anemia. Whichteaching statement from the nurseto the client is appropriate?A) "You will need to begin ironsupplements at 30 m g/day."B) "You will need to increase yourintake of bananas."C) "You will need to increase yourintake of green leafy vegetables."D) "You will need to begin ironsupplements at 150 m g/day."Answer: CExplanation:A) Pregnant clients are prescribed 30 m g of iron daily to preventanemia. Once anemia is diagnosed, the prescribed dosage is increased.This teaching statement is not appropriate.B) Pregnant clients diagnosed with anemia should increase theirconsumption of foods that are rich in iron. Bananas are not rich in iron.This teaching statement is not appropriate.C) Pregnant clients diagnosed with anemia should increase theirconsumption of foods that are rich in iron. Green, leafy vegetables arerich in iron. This teaching statement is appropriate.D) Pregnant clients diagnosed with iron deficiency anemia will requirean increased dose of supplemental iron, typically 60 m g to 120 m g/day.Page Ref: 363fml
The nurse is providing care to aclient who would like to becomepregnant within the next year. Theclient has a history of folic aciddeficiency anemia and asks, "Whatcan I do to decrease the risk ofneural tube defects?" Whichresponse by the nurse is mostappropriate?A) "You will need to have genetictesting done to identify your risk."B) "Do you have a family history ofthese disorders?"C) "Daily consumption of orangejuice decreases your risk."D) "You will be prescribed an ironsupplement, which decreases yourrisk."Answer: CExplanation:A) Genetic testing does not identify the risk for neural tube defects. Thisresponse is not appropriate by the nurse.B) Asking the client if there is a family history of neural tube defects willnot decrease the client's risk. This response is not appropriate by thenurse.C) Daily consumption of foods rich in folic acid, such as orange juice,provides the client with the necessary amount of folic acid to decreasethe risk of neural tube defects. This response is appropriate by the nurse.D) Folic acid supplements, not iron supplements, are prescribed todecrease the risk for neural tube defects. This response is notappropriate by the nurse.Page Ref: 363The nurse is providing care to alaboring pregnant client who isdiagnosed with sickle cell disease.What will the nurse prepare forupon delivery of the client'snewborn, based on this diagnosis?A) HemorrhageB) Intrauterine growth restrictionC) Neonatal resuscitationD) Cesarean birthAnswer: BExplanation:A) A pregnant client diagnosed with sickle cell anemia is not at anincreased risk for hemorrhage.B) When providing care for a pregnant client diagnosed with sickle cellanemia, the nurse will prepare for a neonate experiencing intrauterinegrowth restriction, as this is a known consequence during pregnancy.C) The newborn of a client diagnosed with sickle cell anemia is not at anincreased risk for requiring neonatal resuscitation.D) A pregnant client diagnosed with sickle cell anemia is not at anincreased for cesarean birth.Page Ref: 363fml
The nurse is caring for a postpartumclient who is experiencing a sicklecell crisis. Which is the priorityassessment by the nurse?A) Blood pressureB) LochiaC) TemperatureD) Fundal heightAnswer: CExplanation:A) The postpartum client experiencing a sickle cell crisis is at risk forinfection. While monitoring blood pressure is important, this is not thepriority assessment.B) The postpartum client experiencing a sickle cell crisis is at risk forinfection. While monitoring lochia is important, this is not the priorityassessment.C) The postpartum client experiencing a sickle cell crisis is at risk forinfection. The priority assessment for this client is to closely monitortemperature.D) The postpartum client experiencing a sickle cell crisis is at risk forinfection. While monitoring fundal height is important, this is not thepriority assessment.Page Ref: 363The nurse is providing care to aclient in labor who admits to usingheroin throughout the pregnancy.Which will the neonate be at risk forfollowing birth?A) Seizure activityB) Congenital anomaliesC) Large for gestational ageD) Cardiac anomaliesAnswer: AExplanation:A) The neonate who has been exposed to heroin in utero is at anincreased risk for seizure activity following birth.B) The neonate who has been exposed to heroin in utero is not at anincreased risk for congenital anomalies. This is expected if the neonatewas exposed to lithium carbonate while in utero.C) The neonate who has been exposed to heroin in utero is not anincreased risk for being large for gestational age. This is expected forthe neonate who is born to a mother who is diagnosed with gestationaldiabetes mellitus.D) The neonate who has been exposed to heroin in utero is not at anincreased risk for cardiac anomalies. This is expected for the neonatewho is exposed to cocaine in utero.Page Ref: 367fml
The nurse is conducting anadmission assessment for a pregnantclient who is in labor. Which findingwould cause the nurse to expectthat the client has been abusing anillegal substance?A) The client is asking for an epiduraland rates pain as an 8 on a 0 to 10numeric scale.B) The client is diaphoretic duringthe transition stage of labor.C) The client has constricted pupilsand inflamed nasal mucosa.D) The client has a history ofprecipitous labor.Answer: CExplanation:A) The nurse would not suspect that this client has been abusing anillegal substance based on asking for an epidural and rating pain as an 8on a 0 to 10 numeric scale.B) The nurse would not suspect that this client has been abusing anillegal substance based on experiencing diaphoresis during thetransition stage of labor. This is an expected finding.C) A client who has constricted pupils and inflamed nasal mucosa wouldbe suspected of abusing illegal substances.D) A client who has a history of precipitous labor would not cause thenurse to expect substance abuse.Page Ref: 367Which of the following is a commonbarbiturate used in labor?1. Seconal2. Valium3. Phenergan4. Vistaril1. SeconalThe nurse is assessing a clientbefore administering an analgesic.What are some of the factors thenurse should consider?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. The client is willing to receivemedication after being advisedabout it.2. The client's vital signs are stable.3. The partner agrees to use of themedication.4. The client has no known allergiesto the medication.5. The client is aware of thecontraindications of the medication.Answer: 1, 2, 4, 5Explanation: 1. Medication should be explained to the client before it isadministered.2. Vital signs need to be stable before any analgesic medication isadministered.4. Ask the client about allergies before administering any medications.5. Clients should always be aware of the contraindications of themedication.fml
3) A client in labor is requesting painmedication. The nurse assesses herlabor status first, focusing on whichof the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Contraction pattern2. Amount of cervical dilatation3. When the labor began4. Whether the membranes areintact or ruptured5. Fetal presenting partAnswer: 1, 2, 5Explanation: 1. The client should have a good contraction pattern beforereceiving an analgesic.2. The nurse should evaluate the amount of cervical dilatation beforeanalgesic medication is administered.5. If normal parameters are absent or if nonreassuring maternal or fetalfactors are present, the nurse may need to complete furtherassessments with the physician/CNM.A woman in active labor is givennalbuphine hydrochloride (Nubain)14 mg IV for pain relief. Half an hourlater, her respirations are at 8 perminute. The physician would likelyorder which medication for thisclient?1. Narcan2. Reglan3. Benadryl4. VistarilAnswer: 1Explanation: 1. Narcan is useful for respiratory depression caused bynalbuphine (Nubain).An analgesic medication has beenadministered intramuscularly to aclient in labor. How would the nurseevaluate if the medication waseffective?1. The client dozes betweencontractions.2. The client is moaning duringcontractions.3. The contractions decrease inintensity.4. The contractions decrease infrequency.Answer: 1Explanation: 1. If the client dozes between contractions, the analgesic iseffective. Analgesics decrease discomfort and increase relaxation.fml
A client is having contractions thatlast 20-30 seconds and that areoccurring every 8-20 minutes. Theclient is requesting something tohelp relieve the discomfort ofcontractions. What should the nursesuggest?1. That a mild analgesic beadministered2. An epidural3. A local anesthetic block4. Nonpharmacologic methods ofpain reliefAnswer: 4Explanation: 4. For this pattern of labor, nonpharmacologic methods ofpain relief should be suggested. These can include back rubs, providingencouragement, and clean linens.Two hours after an epidural infusionhas begun, a client complains ofitching on her face and neck. Whatshould the nurse do?1. Remove the epidural catheter andapply a Band-Aid to the injectionsite.2. Offer the client a cool cloth andlet her know the itching istemporary.3. Recognize that this is a commonside effect, and follow protocol foradministration of Benadryl.4. Call the anesthesia care providerto re-dose the epidural catheter.Answer: 3Explanation: 3. Itching is a side effect of the medication used for anepidural infusion. Benadryl, an antihistamine, can be administered tomanage pruritus.fml
A client has just been admitted forlabor and delivery. She is havingmild contractions lasting 30 secondsevery 15 minutes. The client wants tohave a medication-free birth. Whendiscussing medication alternatives,the nurse should be sure the clientunderstands which of the following?1. In order to respect her wishes, nomedication will be given.2. Pain relief will allow a moreenjoyable birth experience.3. The use of medications allows theclient to rest and be less fatigued.4. Maternal pain and stress can havea more adverse effect on the fetusthan would a small amount ofanalgesia.Answer: 4Explanation: 4. The nurse can explain to the couple that, althoughpharmacologic agents do affect the fetus, so do the pain and stressexperienced by the laboring mother. If the woman's pain and anxietyare more than she can cope with, the adverse physiologic effects on thefetus may be as great as would occur with the administration of a smallamount of an analgesic agent. Once the effects are explained, however,it is still the client's choice whether to receive medication.A nurse is checking the postpartumorders. The doctor has prescribedbed rest for 6-12 hours. The nurseknows this is an appropriate order ifthe client had which type ofanesthesia?1. Spinal2. Pudendal3. General4. EpiduralAnswer: 1Explanation: 1. Following the birth, the woman may be kept flat.Although the effectiveness of the supine position to avoid headachefollowing a spinal is controversial, the physician's orders may includelying flat for 6 to 12 hours.Toward the end of the first stage oflabor, a pudendal block isadministered transvaginally. Whatwill the nurse anticipate the client'scare will include?1. Monitoring for hypotension every15 minutes2. Monitoring FHR every 15 minutes3. Monitoring for bladder distention4. No additional assessmentsAnswer: 4Explanation: 4. Because a pudendal block is done using a localanesthetic, there is no need for additional monitoring of the mother orthe fetus.fml
Narcotic analgesia is administeredto a laboring client at 10:00 a.m. Theinfant is delivered at 12:30 p.m. Whatwould the nurse anticipate that thenarcotic analgesia could do?1. Be used in place of preoperativesedation2. Result in neonatal respiratorydepression3. Prevent the need for anesthesiawith an episiotomy4. Enhance uterine contractionsAnswer: 2Explanation: 2. Analgesia given too late is of no value to the woman andmay cause neonatal respiratory depression.After nalbuphine hydrochloride(Nubain) is administered, laborprogresses rapidly, and the baby isborn less than 1 hour later. The babyshows signs of respiratorydepression. Which medicationshould the nurse be prepared toadminister to the newborn?1. Fentanyl (Sublimaze)2. Butorphanol tartrate (Stadol)3. Naloxone (Narcan)4. Pentobarbital (Nembutal)Answer: 3Explanation: 3. Narcan is useful for respiratory depression caused bynalbuphine (Nubain). Respiratory depression in the mother orfetus/newborn can be improved by the administration of naloxone(Narcan), which is a specific antagonist for this agent.The nurse has presented a sessionon pain relief options to a prenatalclass. Which statement indicates thatadditional teaching is needed?1. "An epidural can be continuous orcan be given in one dose."2. "A spinal is usually used for acesarean birth."3. "Pudendal blocks are effectivewhen a vacuum is needed."4. "Local anesthetics provide goodlabor pain relief."Answer: 4Explanation: 4. Local anesthetics are not used for labor pain relief. Theyare used prior to episiotomy and for laceration repair.What is the major adverse sideeffect of epidural anesthesia?1. Maternal hypotension2. Decrease in variability of the FHR3. Vertigo4. Decreased or absent respiratorymovementsAnswer: 1Explanation: 1. The major adverse effect of epidural anesthesia ismaternal hypotension caused by a spinal blockade, which lowersperipheral resistance, decreases venous return to the heart, andsubsequently lessens cardiac output and lowers blood pressure.fml
Prior to receiving lumbar epiduralanesthesia, the nurse wouldanticipate placing the laboringclient in which position?1. On her right side in the center ofthe bed with her back curved2. Lying prone with a pillow underher chest3. On her left side with the bottomleg straight and the top leg slightlyflexed4. Sitting on the edge of the bedAnswer: 4Explanation: 4. The woman is positioned on her left or right side, at theedge of the bed with the assistance of the nurse, with her legs slightlyflexed, or she is asked to sit on the edge of the bed.The laboring client brought awritten birth plan indicating that shewanted to avoid pain medicationsand an epidural. She is now at 6 cmand states, "I can't stand thisanymore! I need something for pain!How will an epidural affect mybaby?" What is the nurse's bestresponse?1. "The narcotic in the epidural willmake both you and the babysleepy."2. "It is unlikely that an epidural willdecrease your baby's heart rate."3. "Epidurals tend to cause lowblood pressure in babies after birth."4. "I can't get you an epidural,because of your birth plan."Answer: 2Explanation: 2. Maternal hypotension results in uteroplacentalinsufficiency in the fetus, which is manifested as late decelerations onthe fetal monitoring strip. The risk of hypotension can be minimized byhydrating the vascular system with 500 to 1000 mL of IV solution beforethe procedure and changing the woman's position and/or increasing theIV rate afterward.After administration of an epiduralanesthetic to a client in active labor,it is most important to assess themother immediately for which of thefollowing?1. Hypotension2. Headache3. Urinary retention4. BradycardiaAnswer: 1Explanation: 1. The most common complication of an epidural ismaternal hypotension.fml
A laboring client has received anorder for epidural anesthesia. Inorder to prevent the most commoncomplication associated with thisprocedure, what would the nurseexpect to do?1. Observe fetal heart rate variability2. Hydrate the vascular system with500-1000 mL of intravenous fluids3. Place the client in the semi-Fowler's position4. Teach the client appropriatebreathing techniquesAnswer: 2Explanation: 2. The risk of hypotension can be minimized by hydratingthe vascular system with 500 to 1000 mL of IV solution before theprocedure and changing the woman's position and/or increasing the IVrate afterward.The nurse knows that which of thefollowing are advantages of spinalblock?Note: Credit will be given only if allcorrect answers and no incorrectanswers are selected.Select all that apply.1. Intense blockade of sympatheticfibers2. Relative ease of administration3. Maternal compartmentalization ofthe drug4. Immediate onset of anesthesia5. Larger drug volumeAnswer: 2, 3, 4Explanation: 2. One of advantages of spinal block is the relative ease ofadministration.3. One of the advantages of spinal block is the maternalcompartmentalization of the drug.4. One of the advantages of spinal block is the immediate onset ofanesthesia.A client had an epidural inserted 2hours ago. It is functioning well, theclient is stable, and labor isprogressing. Which parts of thenurse's assessment have the highestpriority?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Assess blood pressure every hour.2. Assess the pulse rate every hour.3. Palpate the bladder.4. Auscultate the lungs.5. Assess the reflexes.Answer: 1, 3Explanation: 1. Blood pressure should be monitored every 1 to 2 minutesfor the first 10 minutes and then every 5 to 15 minutes until the blockwears off because hypotension is the most common side effect ofepidural anesthesia.3. Nursing care following an epidural block includes frequentassessment of the bladder to avoid bladder distention. Catheterizationmay be necessary, because most women are unable to void.fml
For what common side effects ofepidural anesthesia should the nursewatch?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Elevated maternal temperature2. Urinary retention3. Nausea4. Long-term back pain5. Local itchingAnswer: 1, 2, 3, 5Explanation: 1. Elevated maternal temperature is a potential side effectof epidural anesthesia.2. Urinary retention is a potential side effect of epidural anesthesia.3. Nausea is a potential side effect of epidural anesthesia.5. Pruritus may occur at any time during the epidural infusion. It usuallyappears first on the face, neck, or torso and is generally the result of theagent used in the epidural infusion. Benadryl, an antihistamine, can beadministered to manage pruritus.A client dilated to 5 cm has justreceived an epidural for pain. Shecomplains of feeling lightheadedand dizzy within 10 minutes after theprocedure. Her blood pressure was120/80 before the procedure and isnow 80/52. In addition to the bolusof fluids she has been given, whichmedication is preferred to increaseher BP?1. Epinephrine2. Terbutaline3. Ephedrine4. EpifoamAnswer: 3Explanation: 3. Ephedrine is the medication of choice to increasematernal blood pressure.A client received epidural anesthesiaduring the first stage of labor. Theepidural is discontinued immediatelyafter delivery. This client is atincreased risk for which problemduring the fourth stage of labor?1. Nausea2. Bladder distention3. Uterine atony4. HypertensionAnswer: 2Explanation: 2. Nursing care following an epidural block includesfrequent assessment of the bladder to avoid bladder distention.fml
When general anesthesia isnecessary for a cesarean delivery,what should the nurse be preparedto do?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Administer an antacid to the client.2. Place a wedge under her thigh.3. Apply cricoid pressure duringanesthesia intubation.4. Preoxygenate for 3-5 minutesbefore anesthesia.5. Place a Foley catheter in theclient's bladder.Answer: 1, 3, 4, 5Explanation: 1. Prophylactic antacid therapy is given to reduce the acidiccontent of the stomach before general anesthesia.3. During the process of rapid induction of anesthesia, the nurse appliescricoid pressure.4. The woman should be preoxygenated with 3 to 5 minutes of 100%oxygen.5. Urinary retention can be treated with the placement of an indwellingFoley catheter.The client at 39 weeks' gestation isundergoing a cesarean birth due tobreech presentation. Generalanesthesia is being used. Whichsituation requires immediateintervention?1. The baby's hands and feet are blueat 1 minute after birth.2. The fetal heart rate is 70 prior tomaking the skin incision.3. Clear fluid is obtained from thebaby's oropharynx.4. The neonate cries prior todelivery of the body.Answer: 2Explanation: 2. Fetal bradycardia occurs when the fetal heart rate fallsbelow 110 beats/minute during a 10-minute period of continuousmonitoring. When fetal bradycardia is accompanied by decreasedvariability, it is considered ominous and could be a sign of fetalcompromise.fml
The nurse is providing preoperativeteaching to a client for whom acesarean birth under generalanesthesia is scheduled for the nextday. Which statement by the clientindicates that she requires additionalinformation?1. "General anesthesia can beaccomplished with inhaled gases."2. "General anesthesia usuallyinvolves administering medicationinto my IV."3. "General anesthesia will providegood pain relief after the birth."4. "General anesthesia takes effectfaster than an epiduralAnswer: 3Explanation: 3. General anesthesia provides no pain relief after birth, asregional anesthesia does.A cesarean section is ordered for apregnant client. Because the client isto receive general anesthesia, whatis the primary danger with which thenurse is concerned?1. Fetal depression2. Vomiting3. Maternal depression4. Uterine relaxationAnswer: 1Explanation: 1. A primary danger of general anesthesia is fetaldepression. The depression in the fetus is directly proportional to thedepth and duration of the anesthesia.A cesarean section is ordered forthe laboring client with whom thenurse has worked all shift. The clientwill receive general anesthesia. Thenurse knows that potentialcomplications of general anesthesiainclude which of the following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fetal depression that is directlyproportional to the depth andduration of the anesthesia2. Poor fetal metabolism ofanesthesia, which inhibits use withpreterm infants3. Uterine relaxation4. Increased gastric motility5. Itching of the face and neckAnswer: 1, 2, 3Explanation: 1. A primary danger of general anesthesia is fetaldepression, because the medication reaches the fetus in about 2minutes. The depression is directly proportional to the depth andduration of anesthesia.2. The poor fetal metabolism of general anesthetic agents is similar tothat of analgesic agents administered during labor. General anesthesia isnot advocated when the fetus is considered to be at high risk,particularly in preterm birth.3. Most general anesthetic agents cause some degree of uterinerelaxation.fml
The client with a normal pregnancyhad an emergency cesarean birthunder general anesthesia 2 hoursago. The client now has a respiratoryrate of 30, pale blue nail beds, apulse rate of 110, and a temperatureof 102.6°F, and is complaining ofchest pain. The nurse understandsthat the client most likely isexperiencing which of thefollowing?1. Pulmonary embolus2. Pneumococcal pneumonia3. Pneumonitis4. Gastroesophageal reflux diseaseAnswer: 3Explanation: 3. Even when food and fluids have been withheld, thegastric juice produced during fasting is highly acidic and can producechemical pneumonitis if aspirated. This pneumonitis is known asMendelson syndrome. The signs and symptoms are chest pain,respiratory distress, cyanosis, fever, and tachycardia. Womenundergoing emergency cesarean births appear to be at considerablerisk for adverse events.The nurse is inducing the labor of aclient with severe preeclampsia. Aslabor progresses, fetal intoleranceof labor develops. The inductionmedication is turned off, and theclient is prepared for cesarean birth.Which statement should the nurseinclude in her preoperativeteaching?1. "Because of your preeclampsiayou are at higher risk forhypotension after an epiduralanesthesia."2. "Because of your preeclampsiayou might develop hypertensionafter a spinal anesthesia."3. "Because of your preeclampsiayour baby might have decreasedblood pressure after birth."4. "Because of your preeclampsiaAnswer: 1Explanation: 1. Pregnancies complicated by preeclampsia are high-risksituations. The woman with mild preeclampsia usually may have theanalgesia or anesthesia of choice, although the incidence ofhypotension with epidural anesthesia is increased. If hypotension occurswith the epidural block, it provides further stress on an alreadycompromised cardiovascular system.fml
An anesthesiologist informs thenurse that a client scheduled for acaesarean section will be havinggeneral anesthesia withpostoperative self-controlledanalgesia. For which clients would ageneral anesthesia berecommended?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. The client with a history ofhypertension2. The client who has had a lowerback fusion3. The client who is 13 years old4. The client who is allergic tomorphine sulfate5. The client who has had surgery forscoliosisAnswer: 2, 5Explanation: 2. Contraindications for epidural block include patients withprevious back surgery.5. Contraindications for epidural block include patients with previousback surgery.To reduce possible side effects froma cesarean section under generalanesthesia, clients are routinelygiven which type of medication?1. Antacids2. Tranquilizers3. Antihypertensives4. AnticonvulsantsAnswer: 1Explanation: 1. Antacids are routinely administered before surgery for acesarean section.The nurse is caring for a laboringclient with thrombocytopenia.During labor, it is determined thatthe client requires a cesareandelivery. The nurse is preparing theclient for surgery, and shouldinstruct the client that therecommended method ofanesthesia is which of the following?1. General anesthesia2. Epidural anesthesia3. Spinal anesthesia4. Regional anesthesiaAnswer: 1Explanation: 1. General anesthesia will be recommended. Women withthrombocytopenia should avoid regional blocks.fml
Which of the following is a majorside effect of butorphanol tartrate(Stadol)?1. Blurred vision2. Agitation3. Feelings of dysphoria4. DrowsinessAnswer: 3Explanation: 3. Feelings of dysphoria are a major side effect of Stardol.The primary physician orders anarcotic analgesic for a client inlabor. Which situations would leadthe nurse to hold the medication?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Contraction pattern every 3minutes for 60 seconds2. Fetal monitor tracing showing latedecelerations3. Client sleeping betweencontractions4. Blood pressure 150/905. Blood pressure 80/42Answer: 2, 5Explanation: 2. Maternal hypotension results in uteroplacentalinsufficiency in the fetus, which is manifested as late decelerations onthe fetal monitoring strip.5. This would be a contraindication, as a narcotic can lower the bloodpressure even more.fml
The laboring client is at 7 cm, withthe vertex at a +1 station. Her birthplan indicates that she and herpartner took Lamaze prenatalclasses, and they have planned on anatural, unmedicated birth. Hercontractions are every 3 minutesand last 60 seconds. She has usedrelaxation and breathing techniquesvery successfully in her labor untilthe last 15 minutes. Now, duringcontractions, she is writhing on thebed and screaming. Her laborpartner is rubbing the client's backand speaking to her quietly. Whichnursing diagnosis should the nurseincorporate into the plan of care forthis client?1. Fear/Anxiety related to discomfortof labor and unknown laboroutcome2. Pain, Acute, related to uterinecontractions, cervical dilatation, andfetal descent3. Coping: Family, Compromised,related to labor process4. Knowledge, Deficient, related tolack of information about normallabor process and comfortmeasuresAnswer: 2Explanation: 2. The client is exhibiting signs of acute pain, which is bothcommon and expected in the transitional phase of labor.A client is admitted to the labor anddelivery unit with contractions thatare regular, are 2 minutes apart, andlast 60 seconds. She reports that herlabor began about 6 hours ago, andshe had bloody show earlier thatmorning. A vaginal exam reveals avertex presenting, with the cervix100% effaced and 8 cm dilated. Theclient asks what part of labor she isin. The nurse should inform the clientthat she is in what phase of labor?1. Latent phase2. Active phase3. Transition phase4. Fourth stageAnswer: 3Explanation: 3. The transition phase begins with 8 cm of dilatation, and ischaracterized by contractions that are closer and more intense.fml
Usually, the family is advised toarrive at the birth setting at thebeginning of the active phase oflabor or when which of thefollowing occur?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Rupture of membranes (ROM)2. Increased fetal movement3. Decreased fetal movement4. Any vaginal bleeding5. Regular, frequent uterinecontractions (UCs)Answer: 1, 3, 4, 5Explanation: 1. The family is advised to arrive at the birth setting at thebeginning of the active phase of labor or when the membranes rupture.3. The family is advised to arrive at the birth setting at the beginning ofthe active phase of labor or when there is decreased fetal movement.4. The family is advised to arrive at the birth setting at the beginning ofthe active phase of labor or when there is any vaginal bleeding.5. The family is advised to arrive at the birth setting at the beginning ofthe active phase of labor or when there are regular, frequent uterinecontractions.The client presents to the labor anddelivery unit stating that her waterbroke 2 hours ago. Barring anyabnormalities, how often would thenurse expect to take the client'stemperature?1. Every hour2. Every 2 hours3. Every 4 hours4. Every shiftAnswer: 3Explanation: 3. Maternal temperature is taken every 4 hours unless it isabove 37.5°C. If elevated, it is taken every hour.The nurse is orienting a newgraduate nurse to the labor andbirth unit. Which statement indicatesthat teaching has been effective?1. "When a client arrives in labor, aurine specimen is obtained bycatheter to check for protein andketones."2. "When a client arrives in labor, shewill be positioned supine tofacilitate a normal blood pressure."3. "When a client arrives in labor, herprenatal record is reviewed forindications of domestic abuse."4. "When a client arrives in labor, avaginal exam is performed unlessbirth appears to be imminent."Answer: 4Explanation: 4. Unless delivery seems imminent because the client isbearing down or contractions are very close and strong, the vaginalexam is performed after the vital signs are obtained.fml
The client presents to the labor anddelivery unit stating that her waterbroke 2 hours ago. Indicators ofnormal labor include which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fetal heart rate of 130 withaverage variability2. Blood pressure of 130/803. Maternal pulse of 1604. Protein of +1 in urine5. Odorless, clear fluid onunderwearAnswer: 1, 2, 5Explanation: 1. Fetal heart rate (FHR) of 110-160 with average variability isa normal indication.2. Maternal vital sign of blood pressure below 140/90 is a normalindication.5. Fluid clear and without odor if membranes ruptured is a normalindication.The client is being admitted to thebirthing unit. As the nurse begins theassessment, the client's partner askswhy the fetus's heart rate will bemonitored. After the nurse explains,which statement by the partnerindicates a need for furtherteaching?1. "The fetus's heart rate will varybetween 110 and 160."2. "The heart rate is monitored tosee whether the fetus is toleratinglabor."3. "By listening to the heart, we cantell the gender of the fetus."4. "After listening to the heart rate,you will contact the midwife."Answer: 3Explanation: 3. Fetal heart rate is not a predictor of gender.fml
) The nurse has completed thephysical assessment of a client inearly labor, and proceeds with thesocial assessment. A social history ofthe client would include which ofthe following?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Use of drugs and alcohol2. Family violence or sexual assault3. Current living situation4. Type of insurance5. Availability of resourcesAnswer: 1, 2, 3, 5Explanation: 1. Risk factors such as the use of drugs or alcohol duringthe pregnancy can influence the labor and birth.2. It is imperative to ask the woman about domestic violence and toassess any degree of psychologic or physical harm, either potential orreal.3. A social assessment includes asking about the woman's current livingsituation. This dialog provides an opportunity for the nurse to continueto build support, to provide information when requested, and to bedirect yet supportive.5. A social assessment includes asking about resources available to thefamily.A first-time 22-year-old single laborclient, accompanied by herboyfriend, is admitted to the laborunit with ruptured membranes andmild to moderate contractions. Sheis determined to be 2 centimetersdilated. Which nursing diagnosesmight apply during the current stageof labor?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Fear/Anxiety related to discomfortof labor and unknown laboroutcome2. Knowledge, Deficient, related tolack of information about pushingmethods3. Pain, Acute, related to uterinecontractions, cervical dilatation, andfetal descent4. Pain, Acute, related to perinealtrauma5. Coping: Family, Compromised,related to labor processAnswer: 1, 3, 5Explanation: 1. A Fear/Anxiety diagnosis would apply to the first stage oflabor for a first-time labor client.3. Contractions become more regular in frequency and duration,increasing discomfort and pain.5. The woman and her boyfriend are about to undergo one of the mostmeaningful and stressful events in life together. Physical andpsychologic resources, coping mechanisms, and support systems will allbe challenged.fml
The laboring client and her partnerhave arrived at the birthing unit.Which step of the admission processshould be undertaken first?1. The sterile vaginal exam2. Welcoming the couple3. Auscultation of the fetal heart rate4. Checking for rupturedmembranesAnswer: 2Explanation: 2. It is important to establish rapport and to create anenvironment in which the family feels free to ask questions. The supportand encouragement of the nurse in maintaining a caring environmentbegin with the initial admission.An expectant father has been at thebedside of his laboring partner formore than 12 hours. An appropriatenursing intervention would be to dowhich of the following?1. Insist that he leave the room for atleast the next hour.2. Tell him he is not being aseffective as he was, and that heneeds to let someone else takeover.3. Offer to remain with his partnerwhile he takes a break.4. Suggest that the client's mothermight be of more help.Answer: 3Explanation: 3. Support persons frequently are reluctant to leave thelaboring woman to take care of their own needs. The laboring womanoften fears being alone during labor. Even though there is a supportperson available, the woman's anxiety may be decreased when thenurse remains with her while he takes a break.By inquiring about the expectationsand plans that a laboring womanand her partner have for the laborand birth, the nurse is primarilydoing which of the following?1. Recognizing the client as an activeparticipant in her own care.2. Attempting to correct anymisinformation the client might havereceived.3. Acting as an advocate for theclient.4. Establishing rapport with theclient.Answer: 1Explanation: 1. Understanding the couple's expectations and plans helpsthe nurse provide optimal nursing care and facilitate the best possiblebirth experience.fml
The labor and birth nurse isadmitting a client. The nurse'sassessment includes asking theclient whom she would like to havepresent for the labor and birth, andwhat the client would prefer to wear.The client's partner asks the nursethe reason for these questions. Whatwould the nurse's best response be?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. "These questions are asked of allwomen. It's no big deal."2. "I'd prefer that your partner askme all the questions, not you."3. "A client's preferences for herbirth are important for me tounderstand."4. "Many women have beliefs aboutchildbearing that affect thesechoices."5. "I'm gathering information that thenurses will use after the birth."Answer: 3, 4Explanation: 3. The nurse incorporates the family's expectations into theplan of care to be culturally appropriate and to facilitate the birth.4. The nurse incorporates the family's expectations into the plan of careto be culturally appropriate and to facilitate the birth.The laboring client presses the calllight and reports that her water hasjust broken. What would the nurse'sfirst action be?1. Check fetal heart tones.2. Encourage the mother to go for awalk.3. Change bed linens.4. Call the physician.Answer: 1Explanation: 1. When the membranes rupture, the nurse notes the colorand odor of the amniotic fluid and the time of rupture and immediatelyauscultates the FHR.fml
The laboring client is havingmoderately strong contractionslasting 60 seconds every 3 minutes.The fetal head is presenting at a -2station. The cervix is 6 cm and 100%effaced. The membranesspontaneously ruptured prior toadmission, and clear fluid is leaking.Fetal heart tones are in the 140s withaccelerations to 150. Which nursingaction has the highest priority?1. Encourage the husband to remainin the room.2. Keep the client on bed rest at thistime.3. Apply an internal fetal scalpelectrode.4. Obtain a clean-catch urinespecimen.Answer: 2Explanation: 2. Because the membranes are ruptured and the head ishigh in the pelvis at a -2 station, the client should be maintained on bedrest to prevent cord prolapse.The client has stated that she wantsto avoid an epidural and would likean unmedicated birth. Which nursingaction is most important for thisclient?1. Encourage the client to vocalizeduring contractions.2. Perform vaginal exams onlybetween contractions.3. Provide a CD of soft music withsounds of nature.4. Offer to teach the partner how tomassage tense muscles.Answer: 4Explanation: 4. Massage is helpful for many clients, especially duringlatent and active labor. Massage can increase relaxation and thereforedecrease tension and pain.fml
The nurse is aware of the differentbreathing techniques that are usedduring labor. Why are breathingtechniques used during labor?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. They are a form of anesthesia.2. They are a source of relaxation.3. They increase the ability to copewith contractions.4. They are a source of distraction.5. They increase a woman's painthreshold.Answer: 2, 3, 4, 5Explanation: 2. When used correctly, breathing techniques canencourage relaxation.3. When used correctly, breathing techniques can enhance the ability tocope with uterine contractions.4. When used correctly, breathing techniques provide some distractionfrom the pain.5. When used correctly, breathing techniques increase a woman's painthreshold.Two hours after delivery, a client'sfundus is boggy and has risen toabove the umbilicus. What is the firstaction the nurse would take?1. Massage the fundus until firm2. Express retained clots3. Increase the intravenous solution4. Call the physicianAnswer: 1Explanation: 1. When the uterus becomes boggy, pooling of bloodoccurs within it, resulting in the formation of clots. Anything left in theuterus prevents it from contracting effectively. Thus if it becomes boggyor appears to rise in the abdomen, the fundus should be massaged untilfirm.Why is it important for the nurse toassess the bladder regularly andencourage the laboring client tovoid frequently?1. A full bladder impedes oxygenflow to the fetus.2. Frequent voiding preventsbruising of the bladder.3. Frequent voiding encouragessphincter control.4. A full bladder can impede fetaldescent.Answer: 4Explanation: 4. The woman should be encouraged to void because a fullbladder can interfere with fetal descent. If the woman is unable to void,catheterization may be necessary.fml
The laboring client is complaining oftingling and numbness in her fingersand toes, dizziness, and spotsbefore her eyes. The nurserecognizes that these are clinicalmanifestations of which of thefollowing?1. Hyperventilation2. Seizure auras3. Imminent birth4. AnxietyAnswer: 1Explanation: 1. These symptoms all are consistent with hyperventilation.A client who wishes to have anunmedicated birth is in the transitionstage. She is very uncomfortableand turns frequently in the bed. Herpartner has stepped outmomentarily. How can the nurse bemost helpful?1. Talk to the client the entire time.2. Turn on the television to distractthe client.3. Stand next to the bed with handson the railing next to the client.4. Sit silently in the room away fromthe bed.Answer: 3Explanation: 3. Standing next to the bed is supportive without beingirritating. The laboring woman fears being alone during labor. Thewoman's anxiety may be decreased when the nurse remains with her.A full-term infant has just been born.Which interventions should thenurse perform first?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Placing the infant in a radiant-heated unit2. Suctioning the infant with a bulbsyringe3. Wrapping the infant in a blanket4. Evaluating the newborn using theApgar system5. Offering a feeding of 5% glucosewaterAnswer: 1, 2, 4Explanation: 1. If the newborn is placed in a radiant-heated unit, he orshe is dried, laid on a dry blanket, and left uncovered under the radiantheat.2. Newborns are suctioned with a bulb syringe to clear mucus from thenewborn's mouth.4. The purpose of the Apgar score is to evaluate the physical conditionof the newborn at birth.fml
The nurse administered oxytocin 20units at the time of placentaldelivery. Why was this primarilydone?1. To contract the uterus andminimize bleeding2. To decrease breast milkproduction3. To decrease maternal bloodpressure4. To increase maternal bloodpressureAnswer: 1Explanation: 1. Oxytocin is given to contract the uterus and minimizebleeding.A client delivered 30 minutes ago.Which postpartal assessment findingwould require close nursingattention?1. A soaked perineal pad since thelast 15-minute check2. An edematous perineum3. The client experiencing tremors4. A fundus located at the umbilicusAnswer: 1Explanation: 1. If the perineal pad becomes soaked in a 15-minute periodor if blood pools under the buttocks, continuous observation isnecessary. As long as the woman remains in bed during the first hour,bleeding should not exceed saturation of one pad.The neonate was born 5 minutesago. The body is bluish. The heartrate is 150. The infant is cryingstrongly. The infant cries when thesole of the foot is stimulated. Thearms and legs are flexed, and resiststraightening. What should the nurserecord as this infant's Apgar score?1. 72. 83. 94. 10Answer: 2Explanation: 2. The strong cry earns 2 points. The crying with foot solestimulation earns 2 points. The limb flexion and resistance earn 2 pointseach. Bluish color earns 0 points. The Apgar score is 8.fml
Before applying a cord clamp, thenurse assesses the umbilical cord.The mother asks why the nurse isdoing this. What should the nursereply?1. "I'm checking the blood vessels inthe cord to see whether it has oneartery and one vein."2. "I'm checking the blood vessels inthe cord to see whether it has twoarteries and one vein."3. "I'm checking the blood vessels inthe cord to see whether it has twoveins and one artery."4. "I'm checking the blood vessels inthe cord to see whether it has twoarteries and two veins."Answer: 2Explanation: 2. Two arteries and one vein are present in a normalumbilical cord.At 1 minute after birth, the infant hasa heart rate of 100 beats per minute,and is crying vigorously. The limbsare flexed, the trunk is pink, and thefeet and hands are cyanotic. Theinfant cries easily when the soles ofthe feet are stimulated. How wouldthe nurse document this infant'sApgar score?1. 72. 83. 94. 10Answer: 3Explanation: 3. Two points each are scored in each of the categories ofheart rate, respiratory effort, muscle tone, and reflex irritability. Onepoint is scored in the category of skin color. The total Apgar would be 9.Upon delivery of the newborn, whatnursing intervention most promotesparental attachment?1. Placing the newborn under theradiant warmer.2. Placing the newborn on themother's abdomen.3. Allowing the mother a chance torest immediately after delivery.4. Taking the newborn to the nurseryfor the initial assessment.Answer: 2Explanation: 2. As the baby is placed on the mother's abdomen or chest,she frequently reaches out to touch and stroke her baby. When thenewborn is placed in this position, the father or partner also has a veryclear, close view and can also reach out to touch the baby.fml
A young adolescent is transferred tothe labor and delivery unit from theemergency department. The client isin active labor, but did not know shewas pregnant. What is the mostimportant nursing action?1. Determine who might be thefather of the baby for paternitytesting.2. Ask the client what kind of birthingexperience she would like to have.3. Assess blood pressure and checkfor proteinuria.4. Obtain a Social Services referralto discuss adoption.Answer: 3Explanation: 3. Preeclampsia is more common among adolescents thanin young adults, and is potentially life-threatening to both mother andfetus. This assessment is the highest priority.As compared with admissionconsiderations for an adult womanin labor, the nurse's priority for anadolescent in labor would be whichof the following?1. Cultural background2. Plans for keeping the infant3. Support persons4. Developmental levelAnswer: 4Explanation: 4. Because her cognitive development is incomplete, theyounger adolescent may have fewer problem-solving capabilities. Thevery young woman needs someone to rely on at all times during labor.She may be more childlike and dependent than older teens.When caring for a 13-year-old clientin labor, how would the nurseprovide sensitive care?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Using simple and concreteinstructions2. Providing soothingencouragement and comfortmeasures3. Making all decisions for the clientwhen she expresses a feeling ofhelplessness4. Deciding whom the client shouldallow in the room5. Providing encouragement andsupport of the client's decisionsAnswer: 1, 2, 5Explanation: 1. A client at this developmental stage will need concreteand simplified instructions.2. Touch, soothing encouragement, and measures to promote hercomfort help her maintain control and meet her needs for dependence.5. Establishing rapport without recrimination will provide emotionalsupport and encouragement.fml
An abbreviated systematic physicalassessment of the newborn isperformed by the nurse in thebirthing area to detect anyabnormalities. Normal findingswould include which of thefollowing?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Skin color: Body blue with pinkishextremities2. Umbilical cord: two veins and oneartery3. Respiration rate of 30-60 irregular4. Temperature of above 36.5°C(97.8°F)5. Sole creases that involve the heelAnswer: 3, 4, 5Explanation: 3. Normal findings would include a respiration rate of 30-60 irregular.4. Normal findings would include temperature of above 36.5°C (97.8°F).5. Normal findings would include sole creases that involve the heel.A client's labor has progressed sorapidly that a precipitous birth isoccurring. What should the nursedo?1. Go to the nurse's station andimmediately call the physician.2. Run to the delivery room for anemergency birth pack.3. Stay with the client and askauxiliary personnel for assistance.4. Hold back the infant's headforcibly until the physician arrives forthe delivery.Answer: 3Explanation: 3. If birth is imminent, the nurse must not leave the clientalone.The pregnant 16-year-old is seeingthe nurse during a prenatal visit.Based on the client's developmentallevel, which statement would thenurse expect the client to make?1. "My friends and I all wear totallydifferent styles of clothing."2. "Having a baby will change mycollege plans."3. "I drink alcohol at parties mostweekends."4. "My mom is my best friend."Answer: 3Explanation: 3. Middle adolescence (15-17) is a time of experimentation,including drinking alcohol, using other drugs, and sex.fml
The school nurse is planning apresentation on pregnancy for 13-and 14-year-olds who are currentlypregnant. When planning thecontent of this presentation, whatshould the nurse keep in mind aboutthese teens?1. They are working onindependence and autonomy.2. They are no longer developing asense of achievement.3. They are confident in their ownidentity.4. They are in control of theirimpulses.Answer: 1Explanation: 1. The developmental tasks of adolescence includedeveloping an identity, gaining autonomy and independence,developing intimacy in a relationship, developing comfort with one'sown sexuality, and developing a sense of achievement. Teens in earlyadolescence will not have achieved all of these tasks yet.A nurse working in an adolescentclinic that deals with birth control,pregnancy, and referrals foradoption has a number of clients inearly adolescence. Clients in thatage group are how old?1. 11-16 years old2. 11-14 years old3. 14 and 15 years old4. 12-15 years oldAnswer: 2Explanation: 2. The age range for early adolescence is age 14 and under.The nurse working in an adolescentprenatal clinic knows which of thefollowing about the clients who are15-17 years old?1. They are more at ease with theirindividuality.2. They see authority as resting withparents.3. They are able to solve problemsand make decisions.4. They seek independence andidentify with their peer group.Answer: 4Explanation: 4. Teens who are in middle adolescence (15-17 years old)seek independence and identify with their peer group.fml
The nurse is working at a clinic forpregnant teens. What issues relatedto development will the nurseexpect to encounter in most of thepregnant clients?1. Peer pressure to stop usingalcohol once pregnancy isdiagnosed2. Contraception failure that resultedin this pregnancy3. The father of the baby's beingemotionally supportive to the client4. Feelings of not living up toparents' expectationsAnswer: 4Explanation: 4. Pregnant teens face risk factors based on thedevelopmental tasks of adolescence. One of these is developing anidentity. If the adolescent feels she has not lived up to parentalexpectations by becoming pregnant, she could adopt a negativeidentity.The nurse is preparing an in-servicepresentation for a group of middle-school nurses. Which statements bythe nurse would indicate that themiddle-school nurse understoodthe role of culture in adolescentpregnancy?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. "Studies show that 85% of teenmothers are middle class, and givebirth to gain adult status."2. "Teenage pregnancy is theleading reason why adolescentwomen drop out of school."3. "Teens of color are more likely tobecome pregnant."4. "Intelligence and academic abilityare positively associated withdelayed sexual activity, greater useof contraception, and lower rates ofpregnancy."5. "Over 50% of adolescents whohave had an abortion or recent birthbecome pregnant again within twoyears."Answer: 2, 3, 4Explanation: 2. An estimated 30% to 40% of female teenage dropoutsare mothers.3. In the United States, the adolescent birth rate is higher among AfricanAmerican and Hispanic teens than among white teens. To some degree,the higher teenage pregnancy rate in these groups reflects the impactof poverty because a disproportionately higher number of AfricanAmerican and Hispanic youths live in poverty.4. Teens with future goals (i.e., college or job) tend to use birth controlmore consistently compared with other teens; if they become pregnant,they are also more likely to have abortions.fml
The nurse who is counseling a groupof middle-school girls on pregnancyavoidance should include whichstatement?1. "Although sexuality is common inthe media, peer pressure to havesex is not an important factor."2. "It has become far lessacceptable to give birth during yourteenage years than it used to be."3. "Although condom use is growing,there is still an increasing rate ofSTIs among teens."4. "You have learned enough fromyour friends and families tounderstand how pregnancy occurs."Answer: 3Explanation: 3. Condom use is increasing, but the rate of STI infections,including HIV, is also rising.The nurse has given a communitypresentation on adolescentpregnancy. Which statementsindicate that further teaching isnecessary?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. "Low educational achievement ismajor risk factor for adolescentpregnancy."2. "Teens who are on a loweconomic trajectory are more likelyto become pregnant."3. "When a teen plans to attendcollege, abortion is less likely."4. "In the United States, theadolescent birth rate is higheramong white teens."5. "Teens from low-incomehouseholds are less likely tobecome pregnant."Answer: 3, 4, 5Explanation: 3. Teens with future goals (i.e., college or job) tend to usebirth control more consistently compared with other teens; if theybecome pregnant, they are also more likely to have abortions.4. In the United States, the adolescent birth rate is higher among AfricanAmerican and Hispanic teens than among white teens.5. Poverty is a major risk factor for adolescent pregnancy. As many as85% of births to unmarried teens occur to those from poor or low-income families.fml
A nurse working with adolescentsrecognizes risk factors forpregnancy include which of thefollowing?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Low socioeconomic status2. A belief in invulnerability3. A highly functional family4. Physical, emotional, or sexualabuse5. Accurate information aboutcontraceptionAnswer: 1, 2, 4Explanation: 1. Poverty is a major risk factor for adolescent pregnancy.2. The sense of invulnerability and "it won't happen to me" thinking canlead adolescents to participate in sexual activity with an overlyoptimistic view of the outcomes of the risks associated with their actions.4. Physical, emotional, or sexual abuse increases the risk of teenagepregnancy.During the initial prenatal visit, thepregnant teenager states that shedoes not know how she gotpregnant. The nurse can help toeducate her regarding anatomy bydoing what?1. Allowing her to witness a pelvicexam on another teenager2. Encouraging her to ask hermother about the physiology ofpregnancy3. Including anatomic models anddrawings in the teaching session4. Discussing the process of fetaldevelopment with the clientAnswer: 3Explanation: 3. To teach the client about anatomy and physiology, usesimple explanations and lots of audiovisuals.fml
Which statements might a pregnantteenager be likely to make at herinitial prenatal examination?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. "I didn't know I could get pregnantthe first time I had sex."2. "Several of my friends go to clinicsto get contraception."3. "It's no big deal; two of my bestfriends have babies, too."4. "I was 13 years old when I had sexthe first time."5. "My family and my boyfriend arereally happy and supportive."Answer: 1, 3, 4Explanation: 1. Many factors contribute to the high teenage pregnancyrate, and one of them is lack of knowledge about conception.3. Many factors contribute to the high teenage pregnancy rate, and oneof them is a decreased social stigma of being a young and singlemother.4. Many factors contribute to the high teenage pregnancy rate, and oneof them is a younger age at onset of sexual activity.Several adolescent female studentsare waiting to be seen by the schoolsexual health clinic nurse. Whichstudent should the nurse see first?1. 14-year-old whose 17-year-oldsister is pregnant2. 15-year-old who reports usingcondoms regularly3. 16-year-old who had chlamydiatreated 2 weeks ago4. 17-year-old with a history of childabuseAnswer: 3Explanation: 3. This client is the top priority. Teenagers 15 to 19 years oldhave a high incidence of STIs. The incidence of chlamydial infection isincreased in this age group. The presence of such infections during apregnancy greatly increases the risk to the fetus.fml
In planning a conference foradolescents, the nurse researchesthe most common socioeconomicand cultural factors that contributeto adolescent pregnancy. Whichtrue statements should be includedin this conference?Note: Credit will be given only if allcorrect choices and no incorrectchoices are selected.Select all that apply.1. Economic status has a relativelylow impact on an adolescent'ssexual activity.2. Nearly three quarters of all teensages 15-19 have had sex at leastonce.3. Poor self-esteem contributes toadolescent pregnancy.4. 38% percent of sexually activestudents use a condom.5. Sexual abuse is not an issue withteen mothers.Answer: 2, 3Explanation: 2. By 19 years of age, 70% of all teens have had intercourse.3. This is a true statement. Poor self-esteem is a major contributing factorin adolescent pregnancy.A 16-year-old is making her firstprenatal visit to the clinic in herfourth month of pregnancy. What isthe nurse's first responsibility?1. Contact the social worker.2. Develop a trusting relationship.3. Schedule the client for prenatalclasses.4. Teach the client about propernutrition.Answer: 2Explanation: 2. Developing a trusting relationship with the pregnantadolescent is essential. Honesty and respect for the individual and acaring attitude promote the client's self-esteem.fml
Which statement made by thepregnant adolescent would indicateto the nurse that she understood herincreased risk of physiologiccomplications during pregnancy?1. "It's no big deal that I startedprenatal care in my seventh month."2. "My anemia and eating mostly fastfood are not important."3. "I need to take good care ofmyself so my baby doesn't comeearly."4. "Smoking and using crack cocainewon't harm my baby."Answer: 3Explanation: 3. In the adolescent age group, prenatal care is the criticalfactor that most influences pregnancy outcome.The 19-year-old pregnant womanbegins a job to "save money for thebaby." What is the most significantdevelopmental task the nurseunderstands this statement todemonstrate?1. Striving for gaining autonomy andindependence2. Completed development of asense of identity3. Attainment of a sense ofachievement4. Having developed an intimaterelationshipAnswer: 1Explanation: 1. Having a job is how most teens develop financialindependence and autonomy.Which of the following is the mostprevalent medical complication ofpregnant adolescents?1. Constipation2. Preeclampsia-eclampsia3. Heartburn4. Rapid enlargement and sensitivityof breastsAnswer: 2Explanation: 2. Preeclampsia-eclampsia is the most prevalent medicalcomplication of pregnant adolescents and is typically characterized byhigh blood pressure, proteinuria, and edema.fml
The nurse is working with a group ofpregnant teens. Which statementindicates that teaching has beensuccessful?1. "Pregnant teens are more likely toquit school prior to graduation."2. "Because I am young, I have a lowrisk for preeclampsia."3. "My baby could come latebecause I am a teenager."4. "I am more likely to use birthcontrol after I have this baby."Answer: 1Explanation: 1. Many teenage mothers drop out of school during theirpregnancy and then are less likely to complete their schooling.The nurse is teaching a pregnant 14-year-old client who is at 10 weeks'gestation about the expected bodychanges that will occur duringpregnancy. Which client statementindicates that additional informationis needed?1. "My breasts are going to get evenbigger than they've gotten over thepast couple of years."2. "My belly will gradually get moreround, especially from the middle ofpregnancy on."3. "I will feel my baby move in about16 weeks."4. "My diet can stay the same eventhough I'm pregnant."Answer: 4Explanation: 4. Because the adolescent is at risk for anemia, she willneed education regarding the importance of iron in her diet.When working with pregnantadolescents, the nurse plans onassessing which of the following?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. High-birth-weight infants2. Pelvic measurements3. For sexually transmitted infections4. Low blood pressure readings5. Hemoglobin and hematocritAnswer: 2, 3, 5Explanation: 2. Teenagers are more likely to have cephalopelvicdisproportion.3. Teenagers are more likely to have sexually transmitted infections.5. Teenagers are more likely to be anemic, so the hemoglobin andhematocrit must be assessed.fml
The nurse seeks to involve theadolescent father in the prenatalcare of his girlfriend. What is therationale for this nursing strategy?1. Having the father more involvedwith the birth2. Avoiding conflict between theadolescent father and pregnantteenager3. Including his name of the birthcertificate4. Avoiding legal action by theadolescent father's familyAnswer: 1Explanation: 1. Many young fathers genuinely want to be involved withtheir children and would have more contact and input if they could.The nurse is working with male teenswhose partners are pregnant. Whatstatement by the father-to-berequires that the nurse intervene?1. He will be the only other personwho will be present for the birth,although his girlfriend wants hermother to be with her.2. He was very sexually active at anearlier age and he has had moresexual partners than his girlfriend.3. The pregnancy does not seemreal to him, and he is not sure whathe should do to plan for the future.4. He does not want to be married.Answer: 1Explanation: 1. Even if the adolescent father has been included in thehealth care of the client throughout the pregnancy, it is not unusual forher to want her mother as her primary support person during labor andbirth. Overriding his girlfriend's expressed desire could be an indicationthat their relationship is abusive.A 14-year-old girl is brought to theclinic by her mother. The nursedetermines that the teen is about 28weeks pregnant. The mother states,"We knew she was gaining weight,but we can't tell anyone she ispregnant." The nurse understandsthat the client's mother's behaviorexemplifies which of the following?1. Low self-esteem2. Anger3. Shame4. IgnoranceAnswer: 3Explanation: 3. In families who foster educational and career goals fortheir children, adolescent pregnancy is often a shock. Anger, shame, andsorrow are common reactions.fml
The nurse is talking with the parentsof a pregnant 15-year-old. Whichstatement by one of the parents isexpected?1. "We're very happy for her. It will beeasier to focus on education with anew baby."2. "I'm not going to get involved. Sheunderstands how her healthinsurance works."3. "Her father told her to stop datingthat boy. Now look at the troubleshe's gotten into."4. "An abortion is the best choice forher. She can deal with our Catholicpriest later."Answer: 3Explanation: 3. This statement indicates anger, which is to be expectedwhen a parent finds out about a teen daughter's pregnancy.After telling a mother that her 13-year-old daughter is pregnant, thenurse would expect the mother torespond with which statement?1. "We had such high hopes for you."2. "But you have always been ahappy child."3. "I've always liked that boy."4. "This is just one of those thingsthat happen."Answer: 1Explanation: 1. When an adolescent pregnancy is first revealed to theteen's mother, the result is often anger, shame, or sorrow. The degree ofnegative response will be determined by the age of the teen, the familyexpectations for the teen, and the presence or absence of other teenpregnancies in the family or support network.The nurse's goals for prenatalclasses may include which of thefollowing?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Increasing self-esteem2. Preparing the participants forchildrearing3. Offering information on the risksof breastfeeding4. Providing anticipatory guidanceabout pregnancy5. Helping participants developmore adaptive coping skillsAnswer: 1, 4, 5Explanation: 1. Goals for prenatal classes would include increasing self-esteem.4. Goals for prenatal class would include providing anticipatoryguidance about pregnancy.5. Goals for prenatal class would include helping participants developmore adaptive coping skills.fml
Recommendations for parents tohelp their teens avoid pregnancyinclude which of the following?1. Parents need to encouragefrequent and steady dating.2. Parents need to let their childrenset their own goals for the future.3. Parents need to have theirchildren taught about sex by schoolprograms and community resources.4. Parents should be clear abouttheir own sexual attitudes andvalues.Answer: 4Explanation: 4. This is true. Parents should be clear about their ownsexual attitudes and values in order to communicate clearly withchildren.The nurse developing a care planfor a pregnant teen knows that whatplan is best suited to pregnantteens?1. Assess menstrual history and thepresence of any food allergies.2. Inquire about family relationshipsand location of the home.3. Ask what her body image is, thencorrect her misconceptions.4. Determine whether there aresubstance abuse issues.Answer: 4Explanation: 4. Substance abuse issues are important to assess duringpregnancy of teens.The nurse is working in a teenpregnancy clinic. In order to givethe pregnant adolescent a role inher prenatal care, the nurse shouldallow the teen to do which of thefollowing?1. Choose the type of prenatalvitamin she takes2. Measure and record her weight ateach visit3. Choose the schedule of herprenatal visits4. Decide whether she wants herlabor to be inducedAnswer: 2Explanation: 2. Having the client weigh herself and record her weightprovides her the opportunity to participate in her own care plan.fml
The nurse is evaluating the expectedoutcomes of care for a pregnantadolescent. For the evaluation, thenurse will ask which of the followingquestions?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Was a trusting relationshipdeveloped?2. Did the adolescent explorefinancial options open to teenparents?3. Did the adolescent make plans forcontinuing her education?4. Can the adolescent problem-solve?5. Did the adolescent followrecommendations?Answer: 1, 4, 5Explanation: 1. A trusting relationship must be developed with theadolescent client.4. The adolescent must be able to appropriately problem-solve.5. The adolescent must follow the recommendations of the healthcareteam to deliver a healthy baby.The nurse is planning a prenatalclass for a group of pregnantadolescents. The nurse will establishwhich goals for the class?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Provide anticipatory guidance2. Prepare the participants for laborand birth3. Avoid discussion of the client'sconflicts4. Provide community resources ifasked5. Help the participants developcoping skillsAnswer: 1, 2, 5Explanation: 1. Goals for a prenatal class designed for adolescents mustinclude anticipatory guidance.2. Goals for a prenatal class designed for adolescents must includepreparing the participants for labor and the birth of their baby.5. Goals for a prenatal class designed for adolescents must includehelping the participants develop adequate coping skills.fml
The nurse discussing differentpregnancy programs explains thatwhich of the following is critical tothe success of an adolescentpregnancy-prevention program?1. Including role models from thesame cultural and racialbackgrounds2. Focusing on the adolescentfemale3. Having short-term, informalprograms available twice per year4. Focusing on the expectations ofthe adolescents' parentsAnswer: 1Explanation: 1. The National Campaign to Prevent Teen and UnplannedPregnancy's task forces found that the programs most effective atpreventing teen pregnancy include models from the same cultural andracial backgrounds as the participants.The nurse has been asked by acommunity organization to give apresentation on prevention of teenpregnancy. Which statementindicates appropriate steps towardreduction of the local teenpregnancy rate?1. Abstinence-only education will beoffered in the school and clinics.2. Classes on how to parent will bemandatory in high school.3. A low-cost reproductive healthclinic will be planned.4. Parents will be encouraged toavoid discussing sexual activity.Answer: 3Explanation: 3. Key strategies for prevention of unintended teenpregnancy and sexual health promotion include the provision ofservices that ensure accessible and high-quality reproductive healthcare; sex education programs that provide developmentallyappropriate, evidence-based curricula; and youth developmentstrategies to enhance life skills. A low-cost reproductive health clinicwould be able to provide these services.fml
The nurse is working with acommunity group to reduce teenpregnancy rates. Alternatives for thegroup to consider include which ofthe following?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Avoidance of sex education inschools2. High-quality reproductive healthservices3. Developmentally appropriate sexeducation4. Sexuality curriculum based oncommunity beliefs5. Provision of strategies to enhancelife skillsAnswer: 2, 3, 5Explanation: 2. Having access to high-quality reproductive healthservices is important in reducing adolescent pregnancy rates.3. Providing developmentally appropriate sex education is an approachthat reduces adolescent pregnancy.5. Programs that provide strategies to enhance life skills are moresuccessful in reducing adolescent pregnancy rates.In planning a program to reduceteen pregnancy rates, the nurse usesan evidence-based approach. Thenurse learns that more research isneeded for which of the following?Note: Credit will be given only if allcorrect and no incorrect choices areselected.Select all that apply.1. Teen pregnancy rate in the UnitedStates2. Use of birth control byadolescents3. Prevention of sexually transmittedinfections4. Long-active, reversiblecontraception is highly effective forteens5. Intrauterine devices are safe andeffective when used by adolescentsAnswer: 1, 2, 3Explanation: 1. The teen pregnancy rate in the United States requiresmore research.2. The use of birth control by adolescents requires more research.3. Preventing sexually transmitted infections in teenagers requires moreresearch.fml