Ch 1 , Ch 2 , CH 12 OB Process of birth, ch 13 pain OB, Ch 14 OB Intrapartum Fetal Surv, ch 15 Nursing Care During Labor

A patient is prescribed spinal anesthesia in preparation for a cesarean birth. The primary health care provider instructs the nurse to administer a preanesthetic fluid bolus. What is the purpose of this prescription? 1 To prevent maternal hypotension 2 To potentiate effect of anesthesia 3 To maintain fluid balance 4 To prevent neonatal hypoglycemia

1 Spinal anesthesia may cause sympathetic blockade and increase the patient's risk for hypotension. Therefore, the primary health care provider prescribes a preanesthetic fluid bolus 15 to 30 minutes before administering anesthesia. This will prevent hypotension in the patient. There is no need to potentiate the effect of anesthesia, because the prescribed dose has optimum effect on the patient. The nurse can maintain fluid balance by providing enough fluids to the patient. There is a risk for neonatal hypoglycemia if the fluid bolus contains dextrose.

What is another name for human sex trafficking? 1 Sex games 2 Licensed sexual act 3 Modern-day slavery 4 Prostitution

3 Human sex trafficking has been referred to as "modern-day slavery" according to current literature. Sex games refer playing during the course of sexual activity. Human sex trafficking is performed under coercion and the aspect of "licensure" does not apply to this term. Prostitution refers to the trade whereby an individual provides sexual activity for monetary remuneration.

The nurse is monitoring the fetal heart rate of a pregnant patient. Which fetal heart rate is indicative of adequate fetal oxygen supply? 1 Fetal heart rate is 90 beats/minute. 2 Fetal heart rate is 100 beats/minute. 3 Fetal heart rate is 130 beats/minute. 4 Fetal heart rate is 170 beats/minute.

3 The fetal heart rate needs to be at a certain level to ensure a sufficient oxygen supply to the infant from the maternal blood. An insufficient supply of oxygen leads to hypoxia in the fetus. If the fetal heart rate is from 110 beats/minute to 160 beats/minute, it indicates that the fetus has adequate circulation and is obtaining a sufficient amount of oxygen from the maternal blood. The fetus with a heart rate of 130 beats/minute is normal. Fetal heart rates of 90 beats/minute or 100 beats/minute are indications of fetal bradycardia. A heart rate of 170 beats/minute in a fetus indicates tachycardia. Both conditions indicate impaired cardiac activity in the fetus

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe what? 1 Weight gain of 1 to 3 lb 2 Quickening 3 Fatigue and lethargy 4 Bloody show

4 Passage of the mucus plug (operculum), also termed pink/bloody show, occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lb. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.

The nurse is using auscultation to determine the fetal heart rate (FHR) during the first stage of labor. What measures can the nurse use to reassure the mother if it takes considerable time to locate and count the heartbeats? 1 Ask the health care provider to locate the heartbeat. 2 Let the mother know the sounds are muffled. 3 Use internal monitoring to locate the heartbeat. 4 Allow the mother to listen to the heartbeat.

4 The patient may become anxious if the nurse takes considerable time to locate and count the fetal heartbeats. The nurse can reassure the mother by allowing the mother to listen to the heartbeat after it is located. The nurse may seek assistance if necessary to identify the fetal heartbeat; however, the nurse is usually capable of locating the heartbeat with patience, and escalating the intervention to a health care provider can sometimes increase anxiety in the patient. The nurse must let the mother know that it takes time to identify the spot with the loudest and clearest heartbeats that can be counted. The nurse need not tell the mother that the sounds are muffled. The nurse must use an ultrasound to locate the heartbeat during the first stage of labor. Internal monitoring is possible only when the cervix is dilated sufficiently and the membranes are ruptured.

The nurse is monitoring the fetal heart rate (FHR) of a patient. When would the nurse observe early decelerations? 1 During uterine contractions 2 When external sound is applied 3 When the abdomen is palpated 4 During regular fetal movement

1 Compression of the fetal head during uterine contraction can cause early decelerations. Fetal heart rate accelerations occur in response to applying external sounds. Palpation of the abdomen also causes FHR accelerations, but not decelerations. Spontaneous and regular fetal movement indicates fetal well-being and results in FHR accelerations.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is what? 1 Counterpressure against the sacrum 2 Pant-blow (breaths and puffs) breathing techniques 3 Effleurage 4 Biofeedback

1 Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

From the nurse's perspective, what measure should be the focus of the health care system to reduce further the rate of infant mortality? 1 Implementing programs to ensure women's early participation in ongoing prenatal care 2 Increasing the length of stay in a hospital after vaginal birth from 2 to 3 days 3 Expanding the number of neonatal intensive care units (NICUs) 4 Mandating that all pregnant women receive care from an obstetrician

1 Early prenatal care allows for early diagnosis and appropriate interventions to reduce the rate of infant mortality. An increased length of stay has been shown to foster improved self-care and parental education. However, it does not prevent the incidence of leading causes of infant mortality rates, such as low birth weight. Early prevention and diagnosis reduce the rate of infant mortality. NICUs offer care to high risk infants after they are born. Expanding the number of NICUs offers better access for high-risk care, but this is not the primary focus for further reduction of infant mortality rates. A mandate that all pregnant women receive obstetric care would be nearly impossible to enforce. Furthermore, certified nurse-midwives (CNMs) have demonstrated reliable, safe care for pregnant women

What does the nurse providing care for a laboring woman understand about accelerations in fetal movement? 1 They are reassuring. 2 They are caused by umbilical cord compression. 3 They warrant close observation. 4 They are caused by uteroplacental insufficiency.

1 Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR.

A pregnant patient who is nearing her due date informs the nurse that she would like a vaginal delivery. The nurse observes in the medical records that the presenting part is the sacrum. What does the nurse tell the patient? 1 "Vaginal delivery may not be possible." 2 "There will be no complications during labor." 3 "You may have to lose weight for a safe delivery." 4 "The infant may have congenital physical defects

1 If the presenting part of the fetus is the sacrum, it indicates a breech presentation. Vaginal delivery of a fetus in breech position carries increased risks and it is more likely that the patient will have to have a caesarean delivery. It is inaccurate to inform the patient that there will be no complications during the birth, because this is not something that the nurse can predict. A breech presentation does not indicate that the patient needs to lose weight. Environmental and biologic factors are associated with congenital defects.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun is what? 1 Progressive uterine contractions with cervical change 2 Lightening 3 Rupture of membranes 4 Passage of the mucus plug (operculum

1 Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucus plug is a premonitory sign indicating that the onset of labor is getting closer.

Nurses should be aware of the difference experience can make in labor pain, such as what? 1 Sensory pain for nulliparous women often is greater than for multiparous women during early labor. 2 Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. 3 Women with a history of substance abuse experience more pain during labor. 4 Multiparous women have more fatigue from labor and therefore experience more pain.

1 Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

The nurse is caring for a patient who is at 23 weeks of gestation. The patient states, "I feel so unhappy and depressed. I don't know what is wrong with me." The nurse, suspecting that the patient may be a victim of domestic violence, will assess the patient for which additional vague somatic complaint? 1 Sleeplessness 2 Facial grimacing 3 Abdominal tenderness 4 Absence of facial response

1 Sleeplessness is a vague somatic complaint that may be indicative of domestic violence. Cues indicating violence against women include nonverbal cues, injuries, vague somatic complaints, and discrepancies between the history and type of injuries. Facial grimacing, abdominal tenderness, and absence of facial response are examples of nonverbal cues.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? 1 The fetal presenting part is 1 cm above the ischial spines. 2 Effacement is 4 cm from completion. 3 Dilation is 50% completed. 4 The fetus has achieved passage through the ischial spines.

1 Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

While monitoring the fetal heart rate (FHR) of a patient, the nurse notes tachycardia. What is a probable cause for this condition? 1 Early signs of fetal distress 2 Maternal hypothermia 3 Maternal hypoglycemia 4 Atrioventricular dissociation

1 Tachycardia is a baseline FHR greater than 160 beats/minute that lasts for 10 minutes or longer. It may be considered an early sign of fetal distress or even fetal hypoxemia, especially when associated with late decelerations and minimal or absent variability. It can result from maternal or fetal infection. Bradycardia is a baseline FHR less than 110 beats/minute that lasts for 10 minutes or longer. Maternal hypothermia or maternal hypoglycemia may cause bradycardia. Bradycardia, not tachycardia, is often caused by some type of fetal cardiac problem. These may include structural defects involving the conduction system, as in atrioventricular dissociation.

The nurse is monitoring the fetal heart rate (FHR) of a patient who is in labor at full term. What measure does the nurse take to obtain the most accurate baseline fetal heart rate? 1 Record or monitor a 10-minute segment of tracing. 2 Include periods of marked variability in the segment. 3 Include episodic changes in the segment of tracing. 4 Obtain at least 5 minutes of interpretable data in the segment.

1 The baseline fetal heart rate is the average rate during a 10-minute segment, and that is why the nurse must obtain a 10-minute segment of tracing to determine the baseline FHR. In order to determine a baseline heart rate, the 10-minute segment must not include periods of marked variability or periodic or episodic changes. The nurse must ensure there are at least 2 minutes of interpretable baseline data in a 10-minute segment of tracing.

The nurse is teaching pain relief techniques to a group of expectant patients. What does the nurse teach the patients about the gate-control theory of pain? 1 Distractions block the nerve pathways. 2 Neuromuscular activity can increase pain. 3 All sensations travel together to the brain. 4 Motor activity during labor intensifies pain. 00:00:09 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

1 The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetical gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain.

The nurse is working in a community center. Which intervention implemented by the nurse would help to achieve the objectives of Healthy People 2020? 1 Conducting awareness programs to reduce low birth weight in the infants 2 Promoting formula feeding for infants of mothers who work outside the home 3 Suggesting that clients avoid taking folate supplements during pregnancy 4 Suggesting that clients get regular exercise to avoid weight gain during pregnancy

1 The nurse should conduct awareness programs to prevent low birth weight in newborns. This helps in preventing mortality and cerebral palsy in newborns. Inadequate maternal weight gain during pregnancy may cause complications that could result in fetal and maternal death. Therefore, the nurse should not suggest that the clients avoid weight gain altogether, and instead the nurse may focus on healthy weight gain during pregnancy. Folate supplements prevent anemia in pregnant clients and neural tube defects in the newborn; therefore, the nurse should suggest that the clients take folate supplements. Breast milk helps enhance immunity and fetal growth and development. Therefore, the nurse should make suggestions for how to breastfeed newborns in work environments, rather than suggesting that the clients use alternative feeding methods such as formula.

The nurse is assessing a patient in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? 1 Latent phase 2 Active phase 3 Transition phase 4 Descent phase

1 The patient is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase or active pushing phase occurs in the second stage of labor. In this phase, the patient has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.

During a sterile vaginal examination, the nurse finds that the fetal position is ROA. What is the presenting part of the fetus? 1 Occiput 2 Sacrum 3 Scapula 4 Mentum

1 The presenting part of the fetus is the part that appears first during the labor. The fetal position refers to the presenting part in relation to the mother's pelvis. The position is denoted by a three-part abbreviation. In this case, the letters ROA stand for right, occiput, and anterior. It means that the occiput is the presenting part and is located in the right anterior quandrant of the maternal pelvis. Sacrum will be denoted by the letter S. Scapula (shoulder) is denoted by Sc. Mentum (chin) is denoted by the letter M.

With regard to primary and secondary powers, the maternity nurse should understand what? 1 That primary powers are responsible for effacement and dilation of the cervix 2 That effacement generally is well ahead of dilation in women giving birth for the first time; they are less together in subsequent pregnancies 3 That scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation 4 That pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs

1 The 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-time mothers; they are more concurrent in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

When is the best time to determine the station of the presenting part in a pregnant patient? 1 When the labor begins 2 A week before the labor 3 During the fourth stage of labor 4 At the end of the third stage of labor

1 The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The best time to determine the station is when the labor begins, because it helps to accurately determine the rate of fetal descent. Birth is imminent when the presenting part is at +4 cm to +5 cm below the spine. A week before the labor is too early to determine the station because fetal descent has usually not begun. The delivery of the placenta occurs in the fourth stage of labor. Therefore, the birth process is already complete by this stage. The third stage involves the birth of the infant and ends with the expulsion of the placenta. Therefore, it is ineffective to determine the station at that point.

Which statement made by the nurse indicates that he or she is practicing appropriate family-centered care techniques? 1 The nurse encourages the mother and father to make choices whenever possible. 2 The nurse updates the family about what is going to happen but instructs the woman's sister that she cannot be present in the room during the birth. 3 The nurse believes that he or she is acting in the best interest of the woman and commands her what to do throughout labor. 4 The father is discouraged from accompanying his wife during a cesarean birth.

1 With family-centered maternity care (FCMC) it is important to allow for choices for the couple and to include the partner in the care process. Unless there is an institutional policy prohibiting the number of attendees at a birth, the woman should be allowed to have whomever she desires with her (unless the birth is emergent and guests may be requested to leave). FCMC involves collaboration between the health care team and the woman. In a family-centered care model, the partner or even a grandparent may be present for a cesarean birth

A single pregnant woman in labor has a trained support person providing emotional support to her during the labor process at no cost. What is the term for this trained support person? 1 Doula 2 Lamaze coach 3 Nurse practitioner (NP) 4 Certified nurse midwife (CNM)

1 A doula is a trained labor support person who provides physical and emotional support through labor and, at times, through the postpartum period. Lamaze is a term for a method of childbirth that allows the mother to control her fear, ultimately controlling her pain during labor. An NP is a health care provider who a patient may select to provide medical care during pregnancy. A CNM cares for women who are at low risk for complications and refers them to a backup physician if problems develop.

Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1 A return of urinary frequency as a result of increased bladder pressure 2 Persistent low backache from relaxed pelvic joints 3 Stronger and more frequent uterine (Braxton Hicks) contractions 4 A decline in energy as the body stores up for labor 5 Uterus sinking downward and forward in first-time pregnancies

1,2,3,5 After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term

The nurse is assessing a pregnant patient who is due in 2 weeks. Which signs and symptoms preceding labor may the nurse expect to see in the patient? Select all that apply. 1 Loss of weight 2 Pain in the groin 3 Persistent low backache 4 Loss of energy 5 Blood-tinged cervical mucus

1,2,3,5, The pregnant patient may have a weight loss of 0.5 to 1.5 kg in the days preceding labor, due to water loss from electrolyte shifts, caused by changes in estrogen and progesterone levels. Pain in the groin and persistent low backache may occur due to the relaxation of the pelvic joints. The extreme congestion of the vaginal mucous membranes may cause blood-tinged cervical mucus. A surge of energy is a common phenomenon in a pregnant patient preceding labor

Many nurses complete advanced programs of education and obtain licensure as an advanced practice nurse, allowing them to provide primary care to girls and women before, during, and after their childbearing years. What are the roles of the nurse in the care of these patients? Select all that apply. 1 Teacher 2 Manager 3 Advocate 4 Distributor 5 Collaborator 6 Communicator

1,2,3,5,6 The roles of the nurse providing primary care to girls and women before, during, and after their childbearing years include acting as teacher, manager, advocate, collaborator, and communicator. Distributor is not a role of the nurse.

Which are the factors that affect the onset of labor? Select all that apply. 1 Increasing intrauterine pressure 2 Increasing estrogen levels 3 Decreasing oxytocin levels 4 Decreasing progesterone levels 5 Decreasing prostaglandin levels

1,2,4 Increasing intrauterine pressure, increasing estrogen levels, and decreasing progesterone levels affect the onset of labor. Increasing intrauterine pressure is associated with increasing myometrial irritability. This is caused by increasing concentrations of estrogen and decreasing progesterone levels. Oxytocin and prostaglandin levels are known to increase during the onset of labor.

Which fetal attitude is seen in general flexion? Select all that apply. 1 The chin is flexed on the chest. 2 The legs are flexed at the knees. 3 The fetal head is extended. 4 The thighs are flexed on the abdomen. 5 The arms are crossed over the thorax.

1,2,4,5 Attitude or posture refers to the relation of the fetal body parts to one another. The attitude of general flexion is seen in most pregnancies. The chin is flexed on the chest, as the back of the fetus is rounded. As a result, the legs are flexed at the knees, and the thighs are flexed on the abdomen. The arms are crossed over the thorax, and the umbilical cord lies between the arms and legs. An extended fetal head indicates a deviation from the normal attitude that may cause difficulties during childbirth.

The nurse teaches the patient nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Select all that apply. 1 Biofeedback 2 Massage and touch 3 Patterned breathing 4 Controlled relaxation 5 Slow-paced breathing

1,3,4 Patterned breathing, controlled relaxation, and biofeedback techniques must be practiced to obtain best results. Patterned breathing and controlled relaxations help to manage pain during labor. Biofeedback is effective when the patient is able to focus and control body responses during labor. The nurse assisting the laboring patient can use methods such as massage and touch and slow-paced breathing successfully without the patient having any prior knowledge about it.

Which factors contribute to the improvement of infant and maternal mortality rates in the United States? Select all that apply. 1 Increased prenatal care 2 Reduction of antibiotic use 3 Decreased need for sanitation 4 Improved health of the population 5 Improvements in public health facilities

1,4,5 Infant and maternal mortality rates began to fall with increased prenatal care, improved health of the general population, and improvements in public health facilities. Reduction in antibiotic use does not contribute to the reduction in maternal and infant mortality rates; however, an increase in the availability of antibiotics does contribute to the decreased mortality rate. The application of basic principles of sanitation contributes to the fall in maternal and infant mortality rates.

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. 1 Imagine breathing in light and energy. 2 Maintain clenched fists to drive out pain. 3 Engage in dance or rhythmic movements. 4 Imagine walking through a restful garden. 5 Envisage breathing out worries and tension.

1,4,5 Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.

A patient has just vaginally delivered a 6-lb baby girl and the placenta. What does the fourth stage of labor entail? Select all that apply. 1 It is a crucial time for mother and newborn. 2 The fourth stage of labor is delivery of the fetus. 3 The fourth stage of labor includes delivery of the placenta. 4 The fourth stage of labor includes the first 1 to 4 hours after birth. 5 During this time, maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. 6 Mother and baby are not only recovering from the physical process of birth, but also becoming acquainted with each other and additional family members.

1,4,5,6 The fourth stage of labor is a crucial time for the mother and the newborn; it includes the first 1 to 2 hours after birth. During this time maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. The mother and baby are not only recovering from the physical process of birth, but are also becoming acquainted with each other and additional family members. The second (not fourth) stage of labor is delivery of the fetus. The third (not fourth) stage of labor includes delivery of the placenta.

After change-of-shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, what should the nurse understand about this type of pain? 1 It is visceral. 2 It is referred. 3 It is somatic. 4 It is afterpain.

2 As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and the thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

Which of the following FHR tracing characteristics are considered reassuring or normal (category I)? 1 Bradycardia not accompanied by baseline variability 2 Early decelerations, either present or absent 3 Sinusoidal pattern 4 Tachycardia

2 Early decelerations, the absence of late decelerations, and the presence of accelerations indicate a normal category I tracing. Bradycardia not accompanied by variability is a category II tracing. A sinusoidal pattern is considered an ominous sign and is definitely an abnormal category III tracing. Fetal tachycardia is a category II tracing and not considered normal

The health care team is administering naloxone hydrochloride (Narcan) to a pregnant patient in labor to counter the adverse effects of opioids. What does the nurse inform the patient? 1 "Naloxone will cause a more rapid birth." 2 "Naloxone will reverse the pain relief provided by the opioid." 3 "Naloxone is likely to cause nausea and vomiting." 4 "Naloxone may cause prolonged neonatal sedation."

2 Naloxone hydrochloride (Narcan) is an opioid antagonist that will cause the pain that was relieved with opioids to resume. Naloxone does not cause a more rapid birth. Nausea and vomiting are the side effects of opioids but will not be caused by naloxone itself. Meperidine hydrochloride (Demerol) causes prolonged neonatal sedation because it crosses the placenta.

The diagnostic test reports of a pregnant patient reveal a baseline fetal heart rate of 175 beats/minute. What does this finding indicate to the nurse? 1 The fetus has ischemia. 2 The fetus has tachycardia. 3 The fetus has bradycardia. 4 The fetus has hypotension.

2 Normal baseline fetal heart rate ranges from 110 to 160 beats/minute. If the fetal heart rate is more than 160 beats/minute, then tachycardia in the fetus is indicated. Ischemia is a condition in which there is a reduced blood supply to the fetal tissues. Baseline heart rate below 110 beats/minute indicates bradycardia in fetus. Hypotension indicates a blood pressure level below 120/80 mm Hg, which is a life-threatening condition for the fetus.

What is sexual assault considered to be? 1 Limited to rape 2 An act of force in which an unwanted and uncomfortable sexual act occurs 3 A legal term for sexual violence 4 An act of violence in which the partner is unknown

2 Sexual assault encompasses a wide range of sexual victimization, including unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual acts. It may include but is not limited to rape. Sexual violence is a term for rape, not for sexual assault, which includes a broader range of activities. A sexual act of violence, or rape, may be categorized as sexual assault. Statistically, the victim knows the assailant.

When assessing a patient for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? 1 It is the part above the brim of the bony pelvis. 2 It is movable in the latter part of the pregnancy. 3 It has three planes: the inlet, midpelvis, and outlet. 4 It is ovoid and bound by pubic arch anteriorly

2 The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly

In the early 1950s, consumers began to insist on the right to be involved in their own health care. There was an increased focus on family-centered care surrounding childbirth. What is the goal of family-centered care? 1 To allow for birth without pharmacologic intervention 2 To promote family unity while maintaining physical safety 3 To decrease mortality rates among mothers and newborns 4 To provide funds for state-managed programs for mothers and children

2 The goal of family-centered care is to foster family unity while maintaining physical safety. In the early 1950s, Dr. Grantly Dick-Read proposed a method of childbirth that allowed the mother to control her fear. This allowed the mother to choose birth without pharmacologic intervention, though it does not guarantee the mother's pain is controlled. Decreasing mortality rates is not the goal of family-centered care. The Sheppard-Towner Act of 1921, the first federally sponsored program, provided funds for state-managed programs for mothers and children.

The nurse is assisting the health care provider with a patient in labor. The nurse concludes that the placental blood flow is reduced. What assessment finding would lead the nurse to conclude this? 1 Increased maternal blood pressure 2 Prolonged contractions 3 Impaired fetal respiratory movement 4 Slow decrease in progesterone levels

2 The nurse is assisting the health care provider with a patient in labor. The nurse concludes that the placental blood flow is reduced. What assessment finding would lead the nurse to conclude this? 1 Increased maternal blood pressure 2 Prolonged contractions 3 Impaired fetal respiratory movement 4 Slow decrease in progesterone levels

A pregnant patient is anxious about the pain that she may experience during labor. What does the nurse include in the prenatal teaching to relieve anxiety in this patient? 1 Avoids discussing any negative feelings 2 Explores different relaxation techniques 3 Discusses the different stages of labor 4 Explains that pain is part of the birthing process

2 The nurse should encourage the woman to explore different relaxation techniques that can be used to relieve pain during labor. The nurse should also encourage the patient to express any negative feelings to relieve her anxiety. Providing factual information regarding the different stages of labor makes the patient aware of the entire process but does not help relieve anxiety. Telling the patient that pain is a part of the birthing process does not help relieve anxiety. Instead, the nurse should discuss the different pharmacologic and nonpharmacologic pain relief measures.

The nurse is assisting a patient in labor. What neurologic changes does the nurse expect in the laboring patient? 1 Decreased pain threshold 2 Amnesia and sedation 3 Increased perception of pain 4 Patient elated between contractions

2 The patient experiences amnesia between contractions in the second stage of labor. Endogenous endorphins produced by the body cause sedation. This also raises the pain threshold. Pressure of the presenting part causes physiologic anesthesia of the perineal tissues. This decreases the perception of pain. At the start of labor, the patient may be euphoric. Euphoria first gives way to increased seriousness. Second, it gives way to amnesia between contractions. Finally, it leads to elation or fatigue after giving birth.

The nurse is assisting a patient who is prepared to use the paced breathing method. What does the nurse remind the patient to do at the beginning of the breathing pattern? 1 Exhale a deep breath. 2 Take a deep relaxing breath. 3 Take 32 breaths per minute. 4 Take three breaths per minute.

2 The patient must remember that all breathing patterns begin with a deep, relaxing "cleansing breath" to "greet the contraction." The patient must then exhale a deep breath to "blow the contraction away." These deep breaths ensure adequate oxygen for the mother and the baby and signal that a contraction is beginning or has ended. The patient must take six to eight breaths per minute when performing slow-paced breathing. As contractions increase in frequency and intensity, the patient takes shallow, fast breaths, about 32 to 40 per minute.

The nurse is assisting a pregnant patient in labor. What instructions should the nurse give to the patient to promote comfort? Select all that apply. 1 "You should cough frequently." 2 "Breathe with your mouth open." 3 "Lie down in the lateral position." 4 "Lie in the supine position in bed." 5 "Lie in the semi-Fowler's position."

2,3,5 The nurse helps the pregnant patient during labor. This includes teaching the patient relaxation techniques. The nurse teaches the patient to keep the mouth open during exhalation to allow air to easily leave the lungs. Placing the patient in a semi-Fowler's or lateral position is helpful during labor. Therefore the nurse should instruct the patient to maintain the lateral or semi-Fowler's position with a lateral tilt. Asking the patient to cough frequently would increase the intraabdominal pressure of the patient and would make the patient uncomfortable. Having the patient lie down in a supine position during labor may cause orthostatic hypotension. Therefore the nurse should instruct the patient to lie down in a position other than supine.

In an effort to promote safety and quality in maternity and women's health, The Joint Commission (TJC) developed five perinatal core measures for best practice in perinatal care. Which core measures are reported by health care organizations to TJC? Select all that apply. 1 Increasing the rate of cesarean births 2 Decreasing the rate of elective deliveries 3 Decreasing the rate of exclusive breastfeeding 4 Decreasing the rate of newborns with bacteremia 5 Decreasing the rate of antenatal administration of steroids in preterm labor

2,4 The TJC core measures in perinatal care include decreasing the rate of elective deliveries and decreasing the rate of newborns with bacteremia. Other core measures include decreasing the rate of cesarean births, increasing the rate of exclusive breastfeeding, and increasing the rate of antenatal administration of steroids in preterm labor.

A nurse in a public women's clinic conducts an assessment of the use of complementary and alternative medicine (CAM) in the community among pregnant women and women of childbearing age. The nurse is surprised by the large number of women who use CAM and asks why they have never discussed CAM with their health care providers. What are the reasons patients often do not discuss CAM with their providers? Select all that apply. 1 "There are no risks with CAM." 2 "My physician never asked." 3 "My health care provider does not care." 4 "I did not know it was important to discuss CAM." 5 "There was not enough time during the office visit."

2,4,5 The most common reasons stated by patients for not discussing CAM with their health care providers are that the physician never asked, the patients did not know it was important to discuss, and there was not enough time during the office visit. "There are no risks with CAM" is not a typical reason patients do not discuss it with their health care providers. "The health care provider does not care" is not a reason patients typically do not discuss CAM with their health care providers.

What behavior does the nurse expect in a patient who is in the transition phase during the first stage of labor? 1 The patient remains calm and silent. 2 The patient doubts her ability to control pain. 3 The patient vomits. 4 The patient's attention is directed inward.

3 A patient in the transition phase of the first stage of labor has strong uterine contractions, resulting in severe pain. The patient may hyperventilate, resulting in nausea and vomiting. The patient may remain calm and silent in the latent phase of uterine contractions, because the urge to bear down is not too strong in this phase. During the active stage of labor, the patient may become doubtful of her ability to control pain. The patient's attention is directed inward in the active phase of the first stage of labor.

When caring for pregnant women, the nurse should keep what in mind regarding violence during pregnancy? 1 Affects more than 25% of pregnant women in the United States 2 Increases a pregnant woman's risk for gestational hypertension 3 May be associated with substance abuse by both the pregnant woman and her partner 4 Has decreased in incidence as a result of better assessment techniques and record keeping

3 Alcoholism and substance abuse by the woman or her abuser are associated with violence. Approximately 8 percent of pregnant women are battered; the incidence of battering increases during pregnancy. Violence itself has no correlation with the incidence of gestational hypertension. The rates of violence have increased, possibly because of better assessment and reporting mechanisms.

What does the nurse know that occurs in the second stage of labor, the descent phase? 1 The amniotic membranes rupture. 2 The cervix cannot be felt during a vaginal examination. 3 The woman experiences a strong urge to bear down. 4 The presenting part is below the ischial spines.

3 During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation

A patient is taking fentanyl citrate (Sublimaze) for labor pain. The nurse finds that the patient has also been prescribed naloxone (Narcan) PRN. What is the purpose of naloxone? 1 To promote more rapid birth 2 To increase uterine contractions 3 To reverse the central nervous system (CNS) depressant effects 4 To relieve pain if fentanyl is ineffective

3 Fentanyl citrate (Sublimaze) is a short-acting opioid narcotic agonist analgesic that may cause CNS depression. Therefore, the nurse may need to administer naloxone (Narcan), an opioid antagonist that promptly reverses the CNS depressant effects. An opioid antagonist is helpful to relieve pain when a more rapid birth is anticipated. Opioids inhibit uterine contractions. Fentanyl citrate (Sublimaze) has a short duration of action, and more frequent dosing is required if the pain is not relieved in one dose

The nurse assesses a fetus as being in the cephalic presentation. What does the nurse mean by the term "fetal presentation"? 1 The relation of the presenting part to the mother's pelvis 2 The relation of the fetus's and mother's spine 3 The part of the fetus that enters the pelvic inlet first 4 The relation of the fetal body parts to one another

3 Fetal presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. In a cephalic presentation, the fetal head enters the pelvic inlet first. Fetal position is the relationship of the reference point on the presenting part of the fetus to the four quadrants of the mother's pelvis. The fetal lie is the relation of the long axis or spine of the fetus to the long axis or spine of the mother. The fetal attitude is the relation of the fetal body parts to one another in utero.

A patient has a stepfather and a couple of stepsons. The patient asks the nurse, "What kind of family category does my family belong to according to classification?" What is an appropriate response by the nurse? 1 "No-parent families" 2 "Married-parent families" 3 "Married-blended families" 4 "Single-parent families"

3 Married-blended families are those formed as a result of divorce and remarriage. They consist of unrelated family members such as stepparents, stepchildren, and stepsiblings. No-parent families are those in which children live independently in foster or kinship care such as living with a grandparent. Married-parent families (biologic or adoptive parents) make up the majority—about 48.4% of American families. Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults.

While assessing the fetal heart rate (FHR) of a patient in labor, what does the nurse identify as normal variability of the FHR? 1 Absent variability 2 Minimal variability 3 Moderate variability 4 Marked variabilit

3 Moderate variability is highly predictive of a normal fetal acid-base balance. It indicates that FHR regulation is not significantly affected by fetal sleep cycles, tachycardia, prematurity, congenital anomalies, preexisting neurologic injury, or central nervous system depressant medications. Absent or minimal variability is classified as either abnormal or indeterminate. It can result from fetal hypoxemia and metabolic academia. The significance of marked variability is unclear.

What physiologic change can the nurse expect to see in the patient during labor pain? 1 Reduced heart rate 2 Respiratory acidosis 3 Pallor and diaphoresis 4 Reduced blood pressure

3 Pallor and diaphoresis are commonly observed in patients during labor pain. Blood pressure tends to increase during labor. The patient consumes more oxygen, leading to hyperventilation accompanied by respiratory alkalosis. The nurse must teach the patient to perform rapid shallow breathing techniques during contractions. Intensifying pain may increase maternal heart rate during labor.

The nurse is caring for a Native American patient during labor. What does the nurse keep in mind about the patient's cultural approach to pain? 1 The patient may exhibit reactions to pain. 2 The patient may be vocal in response to pain. 3 The patient may use remedies from indigenous plants. 4 The patient may express pain vocally late in labor.

3 The Native American patient may use medications or remedies made from medicinal plants. They are often stoic in response to labor pain. Hispanic patients may be stoic until late in labor, when they may become vocal and request pain relief. Chinese patients may not exhibit reactions to pain. Arabian or Middle Eastern patients may be vocal in response to labor pain and request medication for pain relief.

Which hormone produced by the fetus is believed to initiate labor? 1 Insulin 2 Estriol 3 Cortisol 4 Thyroxine

3 The adrenal cortex is formed during the 6th week of the gestational period and produces hormones by the 8th or 9th week. The fetus produces higher amounts of cortisol as the due date gets closer. This is believed to aid in initiating labor by decreasing the maternal progesterone and stimulating prostaglandin production. Insulin, which helps regulate glucose in the fetus, is produced by the islets of Langerhans of the pancreas. Estriol is a type of estrogen hormone secreted by the placenta that stimulates uteroplacental growth. Thyroxine is a thyroid hormone produced in the fetus; thyroxine does not easily cross the placenta.

The nurse is caring for a patient who refuses a blood transfusion after a hemorrhage, citing religious reasons. Which model of ethical theory will guide the nurse's decision-making process in this situation? 1 Utilitarian 2 Deontologic 3 Human rights 4 Nonmaleficence

3 The human rights model of ethical theory will guide the nurse's decision-making process. The basis of the human rights model is the belief that each person has human rights. The patient has the right to refuse blood for religious reasons and the right to make decisions about his or her care. The utilitarian model is an approach to ethical dilemmas that analyzes the benefits and burdens of any course of action to find one that will result in the greatest amount of good. This model negates the patient's right to make his or her own decisions. The deontologic model determines what is right by applying ethical principles and moral rules; it does not vary the solution according to individual situations and is therefore inappropriate in this case. Nonmaleficence is an ethical principle, not an ethical model.

What intervention should the nurse perform to provide a relaxed environment for labor? 1 Stand at the bedside. 2 Encourage rapid birth. 3 Control sensory stimuli. 4 Demonstrate excitement.

3 The nurse must assist the patient by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the patient's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the patient for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the patient.

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? 1 Pallor 2 Nausea 3 Dizziness 4 Diaphoresis

3 The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, lightheadedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain.

During the prenatal assessment of a patient, the nurse teaches the patient about nonpharmacologic pain management. What does the nurse tell the patient about this method? 1 It is technical and expensive. 2 It requires intensive training. 3 It provides the patient with a sense of control. 4 It is used only in stage I of labor.

3 The patient makes choices about the nonpharmacologic pain management methods that are best suited. This provides the patient with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the patient may obtain best results from the practice. It can be used throughout labor.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

3 The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

A nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse verifies her understanding of the instructions when the woman makes what statement? 1 "True labor contractions will subside when I walk around." 2 "True labor contractions will cause discomfort over the top of my uterus." 3 "True labor contractions will continue and get stronger even if I relax and take a shower." 4 "True labor contractions will remain irregular but become stronger."

3 True labor contractions occur regularly, become stronger, last longer, and occur closer together. They may become intense during walking and continue despite comfort measures. Typically, true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically, the contractions often stop with walking or a change of position.

A nurse who has recently joined the agency has been asked by the primary health care provider (PHP) to prepare an intravenous (IV) access for a patient. The nurse is not clear about the steps to be taken for this procedure. What does the nurse do in this situation? 1 The nurse will ask a colleague for help. 2 The nurse will refer to the nursing textbooks. 3 The nurse will refer to the agency procedure book. 4 The nurse will ask the PHP to perform the procedure.

3 The standards of care differ from agency to agency. Therefore, if the nurse is uncertain about how to perform a procedure, the nurse should refer to the agency procedure book. The nurse should not rely on a colleague for help while performing basic nursing procedures. The guidelines given in the nursing textbooks may not be in accordance with the agency guidelines. Preparing an IV access is the nurse's role. Therefore, the nurse would not routinely ask the PHP to perform the procedure.

The nurse is teaching a group of nursing students about fetal oxygenation. The nurse questions a student, "What happens when oxytocin levels are elevated in the patient?" What would be the most appropriate answer given by the nursing student related to the patient's condition? 1 "Hemoglobin levels will decrease." 2 "Blood glucose levels will increase." 3 "Placenta lowers the blood supply." 4 "Uterine contractions (UCs) will increase."

4 An elevated level of oxytocin increases UCs during labor. Reduced hemoglobin levels lead to a decreased oxygen supply to the fetus, but are not a complication associated with an elevated oxytocin level. Oxytocin has no effect on blood glucose levels. A family history of diabetes may increase the risk of gestational diabetes in the patient. Conditions such as hypertension in the patient may lower the blood supply to the placenta, but are not associated with oxytocin levels.

Which factor is associated with the reduced pain and feelings of euphoria in a pregnant patient during labor? 1 Use of hydrotherapy 2 Use of distraction techniques 3 Increase in catecholamine levels 4 Increase in beta-endorphin levels

4 Beta-endorphins are endogenous opioids secreted by the pituitary gland and are associated with feelings of euphoria. An increase in beta-endorphin levels increases the pain threshold so that the patient is able to endure acute pain during labor. Hydrotherapy facilitates birth and can reduce labor pains, but is not associated with feelings of euphoria. Distraction techniques help reduce pain as the patient focuses on other things apart from the pain. However, they are not associated with euphoria. An increase in catecholamine levels indicates that the patient is experiencing more stress.

Which statement by the nursing student about the effect of culture on health behaviors indicates effective learning? 1 "Cultural influences determine the success of therapy." 2 "Cultural values and beliefs do not affect coping during sickness." 3 "Cultural values make the client resent Western therapies." 4 "Cultural beliefs influence a client's perception of illness."

4 Cultural values and beliefs apply to every aspect of a person's life. Therefore, cultural beliefs influence a client's perception of illness, too. Health behaviors, such as reaction to pain, expression of emotion, and patterns of interaction, are influenced by culture. Cultural influences do not determine the success of therapy. Cultural values are important during serious illness; they help nurses understand why a particular client behaves in a specific way. Clients' cultural values may create resentment, but this is not specific to only Western therapies.

Which is a reality concerning violence against women? 1 The abuser is out of control. 2 Alcohol and drugs cause abusive behavior. 3 Violence against women occurs only in lower socioeconomic classes. 4 Couples' counseling is ineffective and can be dangerous to the woman.

4 In cases of violence against women, couples' counseling is ineffective for the couple and can be dangerous for the woman. The abuser is not out of control; instead, the abuser is making a decision in choosing who, when, and where he or she abuses. Substance abuse and violence against women are two separate problems. Substance abuse is a disease, but violence is a learned behavior. Violence against women occurs across all socioeconomic classes.

Which action does the nurse take before administering meperidine hydrochloride (Demerol) to a patient to relieve labor pain? 1 Administers 1000 mL normal saline solution 2 Asks the patient to use relaxation techniques 3 Asks the patient to assume an upright position 4 Monitors maternal vital signs and fetal heart rate

4 Meperidine hydrochloride (Demerol) affects fetal oxygenation, because it decreases maternal heart and respiratory rates along with blood pressure. Therefore, the nurse needs to monitor maternal vital signs and fetal heart rate before administering the medication. The nurse administers 1000 mL normal of saline solution as a preanesthetic fluid bolus to decrease the potential for hypotension. Relaxation techniques alone are not enough in this case, because the pain has already progressed, and should be reduced through pharmacologic measures. The patient assumes an upright position after a spinal anesthetic solution has been injected so that it flows downward, and a lower level of anesthesia is obtained for vaginal birth.

The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part? 1 -1 2 +1 3 +3 4 +5

4 Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm. When the lowermost portion of the presenting part is 1 cm above the spine, it is noted as minus (-)1. When the presenting part is 1 cm below the spine, the station is said to be plus (+)1. At +3, the presenting part is still descending the birth canal. Birth is imminent when the presenting part is at +4 to +5 cm

A pregnant woman at 40 weeks of gestation asks the nurse what factor initiates labor. What is the nurse's best response? 1 "Cervical dilation is the first step in initiating the labor process." 2 "Labor begins as a result of the increased secretion of oxytocin." 3 "One factor is higher progesterone levels, which we can mimic synthetically if labor doesn't begin soon." 4 "The exact mechanisms are unknown, but we do know that the fetus plays a role in secreting hormones that contribute to the initiation of labor."

4 The nurse's best response is, "The exact mechanisms are unknown, but we do know that the fetus plays a role in secreting hormones that contribute to the initiation of labor." Cervical dilation is not the first step in initiating the labor process. The cervix can dilate and contract throughout labor. Increased secretion of natural oxytocin appears to maintain labor once it has begun. Oxytocin alone does not appear to start labor but may play a part in labor's initiation in conjunction with other substances. The ratio of maternal estrogen to progesterone changes so that estrogen levels are higher than progesterone levels. Prostaglandins can be mimicked synthetically

During the vaginal examination of a patient in labor, the nurse identifies the presenting part as the scapula. Which fetal presentation does the nurse recognize? 1 Cephalic 2 Frank breech 3 Complete breech 4 Shoulder

4 The presenting part can be defined as that part of the fetus that lies closest to the internal os of the cervix. In the shoulder presentation, the presenting part is the scapula. In a cephalic presentation, the presenting part is usually the occiput. In a breech presentation, the presenting part is the sacrum. The sacrum is the presenting part in a frank breech presentation. The sacrum and feet are the presenting parts in a complete breech presentation.

You are evaluating the fetal monitor tracing of your patient, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? 1 Call for help. 2 Insert a Foley catheter. 3 Start oxytocin (Pitocin). 4 Notify the primary health care provider immediately.

4 To relieve an FHR deceleration the nurse can reposition the mother, increase IV fluid, and provide oxygen. In addition, if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately. Although it is always a good idea to have extra help during any unanticipated obstetric event, this is not the most important nursing measure at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section may be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus.

The nurse is caring for a patient with electronic fetal monitoring using a spiral electrode. How is the use of a spiral electrode different from the use of an ultrasound transducer? 1 It is used only during the antepartum period. 2 It is used when the cervix has not yet dilated. 3 It is applied firmly to the maternal abdomen. 4 It is used after the membranes have ruptured.

4 A spiral electrode can be used only after the membranes have ruptured. The electrode is attached securely to the presenting fetal body part to obtain a good signal. It can be used only during the intrapartum period and only if the cervix is sufficiently dilated and the membranes are ruptured. A tocotransducer is applied firmly to the maternal abdomen to monitor the frequency and duration of contractions. A spiral electrode penetrates into the presenting part by 1.5 mm.

The nurse is caring for a patient in the last trimester of pregnancy. What assessments will the patient display related to the effects of fear and anxiety during labor? 1 Increased blood flow 2 Increase in the progression of labor 3 Increased contractions 4 Increase in muscle tension

4 Fear and excessive anxiety lead to increased muscle tension. This causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus, fear and anxiety magnify the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions, leading to increased discomfort. This slows the progress of labor.

Which method has been widely implemented by nurses to prevent potential complications of a short maternity stay after delivery? 1 Home visits 2 Follow-up phone calls 3 Providing written materials 4 Teaching that begins early

4 The method most widely implemented to prevent potential complications of a short maternity stay after delivery is early teaching. Self-care during pregnancy begins at the first encounter, and more teaching occurs during pregnancy when the mother's physical needs do not interfere with her ability to comprehend the new knowledge. Home visits are also effective but are not routine practice in the United States for newly delivered mothers and newborns. Nursing phone calls after discharge are the least expensive method of follow-up care, but early education is more widely used. Written materials are a resource used for teaching.

Upon admission to the birthing unit, the nurse conducts a focused assessment including assessment of the fetal heart rate using intermittent auscultation. Which is considered a normal category I fetal heart rate finding? 1 Regular rhythm 2 Baseline rate of 180 beats/minute 3 Absence of increases from the baseline 4 Presence of decreases from the baseline

1 A regular rhythm is a normal finding under the category I fetal heart rate guidelines. A baseline rate of 180 beats/minute is higher than the normal baseline rate range of 110-160 beats/minute. Absence of increases from the baseline is not a normal finding under the category I fetal heart rate guidelines. Presence of decrease from the baseline is an abnormal finding and not part of the category I fetal heart rate guidelines.

Fetal well-being during labor is assessed by monitoring what? 1 The response of the fetal heart rate (FHR) to uterine contractions (UCs) 2 Maternal pain control 3 Accelerations in the FHR 4 An FHR greater than 110 beats/minute

1 Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/minute with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/minute may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

Which assessment findings in a patient indicate a higher chance of maternal mortality? Select all that apply. 1 Hypertensive heart disease 2 Infection 3 Cardiovascular disease 4 Migraine 5 Caucasian race

1,2,3 Hypertensive disorders and infection have been the leading causes of maternal death in the last 50 years in the United States. Maternal mortality is also more likely if the patient is younger than 20 years. Migraine is not a life-threatening disease and does not affect pregnancy. Maternal mortality rates have been higher in non-Caucasian races in the last 50 years.

The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? Select all that apply. 1 Unstable coronary artery disease 2 Previous cesarean birth 3 Placenta previa 4 Initial blood pressure of 132/87 5 History of three spontaneous abortions

1,2,3 Maternal indications for cesarean birth include: (1) specific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease); (2) specific respiratory disease (e.g., Guillain-Barré syndrome); (3) conditions associated with increased intracranial pressure; (4) mechanical obstruction of the lower uterine segment (tumors, fibroids); (5) mechanical vulvar obstruction (e.g., extensive condylomata); and (6) history of previous cesarean birth. Fetal indications for cesarean birth include: (1) abnormal fetal heart rate or pattern; (2) malpresentation (e.g., breech or transverse lie); (3) active maternal herpes lesions; (4) maternal human immunodeficiency virus with a viral load of more than 1000 copies/mL; and (5) congenital anomalies. Maternal-fetal indications include: (1) dysfunctional labor (e.g., cephalopelvic disproportion, "failure to progress" in labor); (2) placental abruption; (3) placenta previa; and (4) elective cesarean birth (cesarean on maternal request). The blood pressure can be elevated because of pain and is not necessarily a contraindication to vaginal birth until further assessment is completed. Having a history of three spontaneous abortions is not a contraindication to vaginal birth.

The nurse is caring for a patient who is receiving an epidural block. Which adverse effects does the nurse look out for after the block is administered? Select all that apply. 1 Fever 2 Pruritus 3 Hypertension 4 Bladder distention 5 Delayed respiratory depression

1,2,4,5 Fever, pruritus, bladder distention, and delayed respiratory depression are possible adverse effects of an epidural block. Hypotension, not hypertension, is an adverse effect of epidural block.

The nurse says, "You are doing so well; do it again" to a patient during the second stage of labor. Why did the nurse say this? 1 To promote comfort and minimize distractions 2 To promote bearing-down efforts in the patient 3 To encourage the patient to feel confident 4 To promote adequate oxygen levels in the fetus

3 During the second stage of labor, the patient experiences severe pain, fear, anxiety, and confusion. The patient might scream during the active pushing stage. Therefore, the nurse encourages the patient to feel confident in her body. The nurse dims the lights during labor and speaks quietly in order to comfort the patient and to minimize distractions. Once the patient gains confidence, the bearing-down effort improves. Adequate oxygen levels in the maternal blood can be maintained by asking the patient to take rapid breaths.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? 1 The healthy newborn should be taken to the nursery for a complete assessment. 2 After drying, the infant should be wrapped in a receiving blanket and given to the mother. 3 Encourage skin-to-skin contact of mother and baby. 4 The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

3 The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. Although taking the newborn to the nursery for assessment is the practice in many facilities, it is neither evidence based nor supportive of family-centered care. Wrapping the infant in a blanket and giving him or her to the mother is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed skin to skin. The father or support person is likely anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin and breastfeeding has been initiated

The nurse notes variable fetal heart rate (FHR) decelerations while monitoring the fetal heart rate of a patient. What causes variable decelerations? 1 Uterine tachysystole 2 Maternal hypertension 3 Umbilical cord compression 4 Epidural or spinal anesthesia

3 Variable FHR decelerations are usually transient and correctable. They can occur at any time during the uterine contraction phase and are caused by umbilical cord compression. Uterine tachysystole is a condition that causes frequent uterine contractions, often more than five contractions in 10 minutes. This causes disruption of oxygen transfer from the environment to the fetus, leading to late decelerations. Maternal hypertension leads to late FHR decelerations due to reduced oxygen transfer to the fetus. Epidural or spinal anesthesia reduces blood flow through maternal vessels, causing late decelerations.

Which fetal heart rate indicates that there is normal growth and development? 1 80 beats/minute 2 100 beats/minute 3 150 beats/minute 4 180 beats/minute

3 The normal fetal heart rate is found to be 110 to 160 beats/minute. Usually, the fetal heart rate is higher than normal healthy adults in order to meet the high oxygen demand of the fetus. If the fetal heart rate is 150 beats/minute, it indicates that the fetus is healthy and is receiving sufficient oxygen, as required for fetal growth. If the fetal heart rate is less than 110 beats/minute, it indicates an insufficient supply of oxygen to the fetus. If the fetal heart rate is more than 160 beats/minute, it indicates that the fetus is at risk of hypertension.

In which culture is the father more likely to be expected to participate in the labor and delivery? 1 Asian-American 2 African-American 3 European-American 4 Hispanic

4 European-Americans expect the father to take a more active role in the labor and delivery than the other cultures. Asian-American fathers do not actively participate in labor or birth. African-American men view pregnancy as a sign of virility; however, they may be less likely to participate actively in labor or birth. Hispanic men often view labor and birth as a female affair.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. What should the nurse do? 1 Notify the woman's physician. 2 Tell the woman to slow the pace of her breathing. 3 Administer oxygen via a mask or nasal cannula. 4 Help her breathe into a paper bag

4 Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available. Notification of the physician is not necessary. Slowing the pace of her breathing will not correct the problem. Once the pattern of breathing is corrected her partner can help the woman maintain her breathing rate with visual, tactile, or auditory cues. Administration of oxygen by either route will not resolve these symptoms.

Which instruments are used to assess fetal heart rate (FHR) and rhythm? Select all that apply. 1 Fetoscope 2 Doppler ultrasound 3 Pinard stethoscope 4 Bell of adult stethoscope 5 Electrocardiogram (ECG)

Assessing FHR and rhythm is done with a fetoscope, Doppler ultrasound, and/or a Pinard stethoscope. The bell of an adult stethoscope is used to auscultate low-frequency sounds. An ECG uses electrical impulses to evaluate a cardiac rhythm after the infant is born.

The nurse is checking a patient's chart to ensure that consent has been obtained. What are the requirements of informed consent? Select all that apply. 1 Voluntary consent 2 Patient's signature 3 Patient's competence to consent 4 Full disclosure of information needed 5 Patient's understanding of information

1,3,4,5,

The nurse is monitoring the fetal heart rate (FHR) of a patient in term labor. The FHR varies between 120 and 130 beats/minute over a 10-minute period. How does the nurse record the baseline? Record your answer using a whole number. ________ beats/minute

120 + 130 /2 = 125 After 10 minutes of tracing is observed, the approximate mean rate is rounded to the closest 5 beats/minute interval, which is 125 beats/minute.

Which area does the nurse assess to hear loud, clear fetal heart sounds? 1 Fetal head 2 Fetal back 3 Fetal neck 4 Fetal abdomen

2 The nurse must locate the fetal back to listen and count the heart sounds. The heart sounds are loudest and clearest over the fetal back. It is difficult for the nurse to count the heart sounds over the fetal head, neck, or abdomen because the heart sounds are not loud and clear in these areas.

Which pregnant patient is likely to have a cesarean delivery? 1 A patient with the fetus in a transverse lie 2 A patient with the fetus in a cephalic presentation 3 A patient with the fetal biparietal diameter of 9.25 cm at term 4 A patient in whom the presenting part is 4 cm below the spines

1 A transverse lie indicates that the long axis of the fetus is at a right angle, diagonal to the long axis of the mother. As a result, a vaginal birth is not possible and the patient will need a cesarean delivery. A cephalic presentation indicates that the fetal head will lead through the birth canal during labor. This presentation facilitates vaginal delivery. A fetal biparietal diameter of 9.25 cm indicates normal head growth, which can be easily delivered vaginally. If the presenting part is 4 cm below the spines, it indicates that birth is imminent. The part is not an indicator of the type of birth.

Which infant has a higher possibility of sustaining a birth trauma? An infant who: 1 Was delivered by a vaginal birth 2 Has low glucose levels at birth 3 Has inborn errors of metabolism 4 Was born to a patient with a urinary tract infection

1 A vaginal birth increases the chance of injuries due to the use of forceps or vacuum extraction or from pressure of the fetal skull against the maternal pelvis. An infant with low glucose levels at birth is hypoglycemic. Inborn errors of metabolism refer to an inherited disease and are not a birth trauma. An infant born to a patient with a urinary tract infection has a higher chance of acquiring the infection, but this is not a birth trauma.

Which laboring patient does the nurse expect to be a likely candidate for amnioinfusion? 1 A patient with heavily meconium-stained amniotic fluid (or a low amniotic fluid index) 2 A patient with an increase in uterine activity 3 A patient with hypertension and diabetes 4 A patient with an overdistended uterine cavity

1 Amnioinfusion is the infusion of room-temperature isotonic fluid into the uterine cavity when the volume of amniotic fluid is low. Patients with premature rupture of membranes are likely to receive an amnioinfusion. The nurse should discontinue the administration of oxytocin for a patient with increased uterine activity. Hypertension and diabetes are not factors that indicate the need for amnioinfusion. Pregnant patients with hypertension need to have their blood pressure monitored. Pregnant patients with diabetes need to have their blood glucose levels monitored. Patients receiving amnioinfusion are at a risk for overdistention of the uterine cavity because amnioinfusion increases the amniotic fluid volume.

During a prenatal interview, a patient asks the nurse about the benefits of midwifery. Which is the best response by the nurse? 1 "Use of a midwife will help reduce health care costs." 2 "Midwives can provide care and delivery only at hospitals." 3 "Midwifery care is available only to patients who are uninsured." 4 "Use of a midwife will substantially increase health care costs.

1 By opting for a midwife, the patient can participate actively in all decisions related to childbirth, with fewer interventions during labor. Midwives can provide care and delivery at home, in birth centers, and at hospitals. Availability of midwifery services is not related to insurance status. Because fewer interventions are needed, the health care costs related to pregnancy are reduced

A pregnant patient is administered terbutaline (Brethine). The nurse reports to the primary health care provider that the patient has a heart rate of 134 beats per minute and blood pressure of 80/60 mm Hg. Which intervention would be helpful in preventing complications related to terbutaline (Brethine)? 1 Administer propranolol (Inderal). 2 Monitor serum potassium levels. 3 Administer 1 g calcium gluconate. 4 Assess for the presence of oligohydramnios.

1 Terbutaline (Brethine) is a tocolytic agent that is used in the treatment of preterm labor. A heart rate of 134 beats per minute (tachycardia) combined with blood pressure that is less than 80/60 mm Hg indicates intolerable adverse effects of the drug on the cardiovascular system. Propranolol (Inderal) is administered to reverse the cardiovascular adverse effects of terbutaline (Brethine). Serum potassium levels should be monitored in the patient receiving terbutaline (Brethine). However, it is not a priority intervention. Calcium gluconate is administered to reverse the effects of magnesium sulfate. Oligohydramnios (low amniotic fluid volume) is the adverse effect of indomethacin (Indocin) and may not be associated with terbutaline (Brethine).

The nurse is caring for a pregnant patient who has been prescribed terbutaline (Brethine) to relax the uterus. Following the assessment, the nurse informs the primary health care provider that it is not safe to administer terbutaline (Brethine) to the patient. Which patient condition leads the nurse to such a conclusion? 1 Blood pressure of 80/60 mm Hg 2 Short episode of hyperglycemia 3 Irregular episodes of dysrhythmias 4 Heart rate of less than 120 beats/minute

1 Terbutaline (Brethine) relaxes the smooth muscles and inhibits uterine activity. However, the drug can adversely affect the cardiovascular system. Presence of a blood pressure lower than 90/60 mm Hg indicates an adverse effect on the cardiovascular system, and the nurse should stop the treatment to prevent further damage. Short and irregular episodes of hyperglycemia and dysrhythmias are mild and tolerable adverse effects of terbutaline (Brethine), so those conditions would not warrant the discontinuation of the medication. If the patient develops tachycardia greater than 130 beats/minute, then the treatment should be stopped.

When assessing uterine activity, nurses should be aware of what? 1 The examiner's hand should be placed on the fundus before, during, and after contractions. 2 The frequency and duration of contractions are measured in seconds for consistency. 3 Contraction intensity is given a judgment number of 1 to 7 by the nurse and patient together. 4 The resting tone between contractions is described as either placid or turbulent.

1 The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. What measures are included? 1 Encouraging the woman to try various upright positions, including squatting and standing 2 Telling the woman to start pushing as soon as her cervix is fully dilated 3 Continuing an epidural anesthetic so that pain is reduced and the woman can relax 4 Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction

1 Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

A woman is experiencing back labor and complains of constant, intense pain in her lower back. What is an effective relief measure? 1 Counterpressure against the sacrum 2 Pant-blow (breaths and puffs) breathing techniques 3 Effleurage 4 Biofeedback

1 Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

The nurse is assessing a mother in labor. Which conditions indicate possible fetal compromise? Select all that apply. 1 Maternal fever 2 Maternal hypotension 3 Meconium-stained amniotic fluid 4 Fetal heart rate of 150 beats/minute 5 Incomplete uterine relaxation between contractions

1,2,3,5 Maternal fever may indicate infection. Maternal hypotension can malperfuse the fetus. Meconium in the amniotic fluid can indicate fetal distress. Incomplete uterine relaxation compromises blood flow to the uterus. A fetal heart rate of 150 beats/minute is normal.

What are the factors that speed up the dilation of the cervix? Select all that apply. 1 Strong uterine contractions 2 Scarring of the cervix 3 Pressure by amniotic fluid 4 Prior infection of the cervix 5 Force by fetal presenting part

1,3,5 Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are in turn caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.

A primary health care provider orders an ultrasound for a pregnant patient before attempting external cephalic version (ECV). Upon assessing the patient's ultrasound report, the nurse suspects that the primary health care provider will not attempt ECV. Which findings support the nurse's expectation? Select all that apply. 1 The patient has a nuchal cord. 2 The patient is Rh negative. 3 The patient has oligohydramnios. 4 The fetal heart rate is 120 beats per minute. 5 The patient has uterine anomalies

1,3,5 ECV is performed to change the fetus from a breech to a vertex presentation by applying pressure on the abdomen. ECV is contraindicated in certain conditions, including the presence of a nuchal cord, oligohydramnios, and uterine anomalies. ECV should be avoided if the ultrasound shows any of the complications mentioned. ECV is not contraindicated in Rh-negative patient. Patients with an Rh-negative blood group are administered Rh immunoglobulin before performing ECV. A fetal heart rate of 120 beats per minute is considered normal, and ECV is not contraindicated in this condition.

What interventions should the nurse perform to provide emotional support to a patient in labor? Select all that apply. 1 Compliment patient efforts during labor. 2 Avoid offering food during labor. 3 Use a calm, confident approach. 4 Discourage activities that distract. 5 Involve the patient in care decisions.

1,3,5 The nurse must offer emotional support by complimenting the patient and offering positive reinforcement for efforts during labor. The patient must be involved in decision making regarding her own care. The nurse must use a calm and confident approach when assisting the patient during labor. The nurse may offer food and nourishment, if allowed by the primary health care provider. The nurse must encourage participation in distracting activities and nonpharmacologic measures for comfort.

The nurse on an obstetric unit is caring for a patient from Thailand who follows traditional religious practices. The nurse should be aware that this patient's behaviors and beliefs are associated with which essences? Select all that apply. 1 Self 2 Body 3 Spirit 4 Energy 5 Mind-heart

1,4,5 Traditional Thai practices and rituals are associated with beliefs related to three essences: body, energy, and mind-heart. Self and spirit are not essences included in traditional Thai practices and rituals.

A patient is in active labor, with her cervix dilated to approximately 5 cm. She is beginning to tire and express discouragement. What can the nurse initiate to provide comfort and help reduce the risk of prolonged labor? 1 Biofeedback 2 Hydrotherapy 3 Spinal anesthesia 4 Intradermal water block

2 An active labor with dilation of approximately 5 cm will increase contractions and pain and tire the patient, so hydrotherapy is initiated to provide pain relief and relaxation. Biofeedback may be helpful initially but the patient may need pain medication if the pain increases. The primary health care provider may order spinal anesthesia in case the patient has a cesarean birth. An intradermal water block is used to relieve lower back pain during labor.

The nurse is conducting a focused assessment of a pregnant patient in the birthing unit. Which vital sign measurement is abnormal and should be reported to the physician? 1 Temperature 37.3°C (99.1°F) 2 Blood pressure 142/110 mm Hg 3 Fetal heart rate 140 beats/minute 4 Maternal heart rate 96 beats/minute

2 Hypertension during pregnancy is defined as a sustained blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic or higher; therefore, a blood pressure of 142/110 mm Hg should be reported to the physician. A temperature of 37.3°C (99.1°F) is a normal finding. A fetal heart rate of 140 beats/minute is a normal finding. A maternal heart rate of 96 beats/minute is a normal findi

The nurse is performing the first Leopold maneuver on a full-term patient in the birthing unit to determine presentation and position of the fetus and aid in location of fetal heart sounds. Which assessment finding indicates the fetus is in breech presentation? 1 Palpation of a soft, irregular shape at the fundus 2 Palpation of a hard, round, uniform shape at the fundus 3 Palpation of a smooth, convex surface on the left side of the uterus 4 Palpation of nodular, irregular, protruding parts on the right side of the uterus

2 In breech presentation, the head is felt in the fundus, which is a hard, round, uniform shape. Palpation of a soft, irregular shape at the fundus indicates cephalic presentation. Palpation of a smooth, convex surface on the left side of the uterus indicates the fetal back during the second maneuver. Palpation of nodular, irregular, protruding parts on the right side of the uterus indicates the fetal arms and legs during the second maneuver.

Which test is performed to determine if membranes are ruptured? 1 Urine analysis 2 Fern test 3 Leopold maneuvers 4 AROM

2 In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.

The nurse is assigned to a patient in labor in the birth center. Nursing interventions aimed at helping the patient cope with labor should be implemented after observing which sign of ineffective coping? 1 The patient states, "I can do this." 2 The patient requests epidural anesthesia. 3 The patient has rhythmic breathing patterns. 4 The patient closes her eyes and rests between contractions.

2 Specific requests for medication and other pain control measures such as epidural anesthesia suggest the patient may not be coping with labor. The patient stating, "I can do this," rhythmic breathing patterns, and resting and relaxing between contractions are signs of coping.

A patient is expressing concern to the nurse about experiencing pain and discomfort during labor. To assist the patient in planning her labor, the nurse educates the patient about different positions of comfort. Which patient statement demonstrates that teaching was effective? 1 "Lying flat on my back is the best position to avoid pain during labor." 2 "Standing will allow the baby to descend down into my pelvis during labor." 3 "The semi-sitting position will eliminate all pain and discomfort during labor." 4 "Walking around the unit will prolong labor and possibly decrease blood flow to the baby.

2 Standing adds gravity to the force of contractions to promote fetal descent, and contractions will be less uncomfortable and more efficient. Lying flat or supine should be avoided to prevent a decrease in blood flow. Pain is expected and has a purpose in labor and cannot be completely eliminated. Ambulating and frequent position changes decrease pain, improve maternal-fetal circulation, and decrease the length of labor.

Concerning the third stage of labor, nurses should be aware of what? 1 The placenta eventually detaches itself from a flaccid uterus. 2 The duration of the third stage may be short and lasts from the birth of the fetus until the placenta is delivered. 3 It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. 4 The major risk for women during the third stage is a rapid heart rate.

2 The duration of the third stage of labor may be short. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

The nurse is monitoring the fetal heart rate (FHR) of a patient and notices late decelerations, including a gradual decrease in and return to baseline, associated with uterine contractions. To which condition does the nurse attribute this? 1 Fundal pressure 2 Uteroplacental insufficiency 3 Vaginal examination 4 Fetal scalp stimulation

2 Uteroplacental insufficiency leads to disruption of the oxygen transfer from the maternal blood to the fetus. This can lead to late decelerations of the fetal heart rate. Early FHR decelerations may be caused by fetal head compression caused by fundal pressure or vaginal examination. Fetal scalp stimulation typically causes FHR accelerations, not late FHR decelerations.

The nurse is briefing a patient who is pregnant for the first time about "lightening." Which statement should the nurse mention to describe lightening to the patient? 1 Occurs when true labor is in progress 2 Allows the patient to breathe more easily 3 Decreases the pressure on the bladder 4 Leads to decreased urinary frequency

2 When the fetal head descends into the true pelvis during "lightening," the patient will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency.

A nurse is caring for a patient whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of what? 1 Uterine contractions occurring every 8 to 10 minutes 2 A fetal heart rate (FHR) of 180 with absence of variability 3 The patient needing to void 4 Rupture of the patient's amniotic membranes

2 An FHR of 180 with absence of variability is nonreassuring. The oxytocin should be immediately discontinued and the physician should be notified. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. The oxytocin should be discontinued if uterine hyperstimulation occurs. The patient needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is nonreassuring or the patient experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the patient's membranes have ruptured.

A nurse caring for a woman in labor understands that increased variability of the fetal heart rate might be caused by what? 1 Narcotics 2 Barbiturates 3 Methamphetamines 4 Tranquilizers

2 The use of illicit drugs such as cocaine or methamphetamines might cause increased variability. Maternal ingestion of narcotics may be the cause of decreased variability. The use of barbiturates may also result in a significant decrease in variability because these are known to cross the placental barrier. Tranquilizer use is a possible cause of decreased variability in the fetal heart rate.

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine 2 1 cm above the ischial spine 3 at the level of the ischial spine 4 1 cm below the ischial spine

2 When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

Nurses can help their patients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? Select all that apply. 1 Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours 2 Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours 3 Lull: no contractions; dilation stable; duration of 20 to 60 minutes 4 Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours 5 Full cervical dilation marks the end of the first stage of labor

2, 5 The active stage is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes. Full cervical dilation marks the end of the first stage of labor. No official "lull" phase exists in the first stage.

Which techniques are variations of cutaneous stimulation? Select all that apply. 1 Imagery 2 Acupressure 3 Self-massage 4 Hydrotherapy 5 Counter pressure 6 Thermal stimulation

2,3,5,6 Acupressure, self-massage, counter pressure, and thermal stimulation are variations of cutaneous stimulation. Imagery is a variation of mental stimulation, not cutaneous stimulation. Hydrotherapy is its own type of nonpharmacologic intervention and is not a variation on cutaneous stimulation.

The nurse is performing Leopold maneuvers in a patient who is in the first stage of labor. What information does the nurse obtain while performing these maneuvers? Select all that apply. 1 The fetal heart rate 2 The fetal part in the fundus 3 The tone of the uterus 4 The presenting part of the fetus 5 The descent of the fetus into the pelvis

2.4.5 Leopold maneuvers, or abdominal palpation, during the first stage of labor help determine the fetal part present in the fundus, which indicates the fetal lie. The presenting part of the fetus would help determine if the patient should undergo vaginal birth or requires a cesarean delivery. The position and location of the fetal back helps to determine the descent of the fetus into the pelvis, which indicates the approximate time required for vaginal delivery. The fetal heart rate can only be auscultated using a Doppler ultrasound. However, using abdominal palpation, the point of maximum intensity of the fetal heart rate can be determined. The nurse may not assess the tone of the fundus during the first stage of labor. The tone of the fundus is assessed after the delivery of the child to determine the risk of postpartum hemorrhage.

Of what should a nurse providing care to a woman in labor be aware regarding cesarean birth? 1 It is declining in frequency in the United States. 2 It is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier patients do. 3 It is performed primarily for the benefit of the fetus. 4 It can be either elected or refused by women as their absolute legal right.

3 The most common indications for cesarean birth are dangers to the fetus related to labor and birth complications. Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? 1 Encourage her to empty her bladder. 2 Decrease her intravenous (IV) rate to a keep-vein-open rate. 3 Turn the woman to the left lateral position or place a pillow under her hip. 4 No action is necessary because a decrease in the woman's blood pressure is expected.

3 Turning the woman to her left side is the best action to take in this situation because this will increase placental perfusion to the infant while waiting for the doctor's or nurse-midwife's instruction. Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.

The nurse is performing a fetal heart rate (FHR) assessment. Which FHR would alert the nurse to a potential complication? 1 120 beats/minute 2 140 beats/minute 3 160 beats/minute 4 180 beats/minute

4 A normal FHR range is 110 to 160 beats/minute. An FHR of 180 beats/minute is too fast and should alert the nurse to potential complications. FHRs of 120 beats/minute, 140 beats/minute, and 160 beats/minute are within the normal range.

he nurse is monitoring a pregnant patient after amniotomy. Which observation would indicate a likelihood of umbilical cord compression? 1 The fetal heart rate (FHR) confirms tachycardia. 2 The patient's vaginal drainage has a foul-smell. 3 The patient has maternal chills frequently. 4 The FHR has variable decelerations.

4 Amniotomy is performed in a pregnant patient in order to rupture the membranes artificially. After the procedure, the nurse should closely monitor the FHR. Reduced FHR and variable decelerations in FHR indicate that the patient's umbilical cord is compressed. The nurse should immediately inform the primary health care provider of the patient's condition. Tachycardia or increased FHR are common manifestations observed after amniotomy. Tachycardia does not require immediate clinical action. Maternal chills and foul-smelling vaginal discharge after amniotomy indicate infection of the ruptured membranes. However, this would not be a reason to expect umbilical cord compression.

The sonographic reports of a pregnant patient reveal extreme asynclitism of the fetal head. What does the nurse conclude from this report? 1 The fetal head is parallel to the anteroposterior plane of the pelvis. 2 The patient will have a normal vaginal delivery. 3 The position of the fetal head will facilitate descent. 4 Cephalopelvic disproportion will be seen during labor.

4 Extreme asynclitism of the fetal head makes the fetus unable to descend during the birth process and causes cephalopelvic disproportion. The fetal head is parallel to the anteroposterior plane of the pelvis in a synclitic position. The patient will most probably have a cesarean delivery because extreme asynclitism indicates that the fetal head is deflected in a way that may interfere with vaginal delivery. Asynclitism, not extreme asynclitism, facilitates fetal descent, because the head is being positioned to accommodate the pelvic cavity.

A patient has come to the birth center because she is having contractions. After performing a physical examination, the nurse determines that the patient's membranes are intact, and she is to be discharged home. This is the patient's first pregnancy, and she expresses frustration about knowing when she is in labor. The nurse wants the patient to be able to describe reasons to return to the birth center for evaluation before she is discharged. What does the nurse do next? 1 Performs the Leopold maneuver 2 Attaches an electronic fetal heart monitor 3 Hands the patient her discharge paperwork 4 Reviews guidelines for returning to the birth center

4 The next step in the nursing process for the patient being discharged after determining false labor is implementation by reviewing the guidelines for returning to the birth center. Performing the Leopold maneuver is an assessment technique and is not the next step in the nursing process. Attaching an electronic fetal heart monitor is not the next step in the nursing process for the patient to be discharged home. Handing the patient discharge paperwork is not the next step in the nursing process because the nurse has not implemented and evaluated teaching prior to discharge.

The nursing instructor asks a student about the different stages of labor. Which statement by the student indicates effective learning? 1 "There is no abnormal bleeding in the first stage of labor." 2 "The placenta is delivered in the fourth stage of labor after the birth." 3 "The full effacement and dilation of the cervix indicates the beginning of the second stage." 4 "The second stage lasts from full dilation of the cervix to the birth of the fetus."

4 The second stage of labor is composed of two phases: the latent (passive fetal descent) phase and the active pushing phase. In the latent phase, the fetus continues to descend passively through the birth canal, rotating in an anterior position due to the uterine contractions. In the active pushing phase, the fetus presses on the stretch receptors of the pelvic floor. Abnormal bleeding may sometimes occur in the first stage of labor, which needs prompt attention by the primary health care provider. The placenta separates in the third stage of the labor after the birth of the fetus. The full effacement and dilation of the cervix ends at the first stage of the labor.

When monitoring a woman in labor who has just received spinal analgesia, which assessment findings should the nurse report to the health care provider? Select all that apply. 1 Maternal blood pressure of 108/79 mm Hg 2 Maternal heart rate of 98 beats/min 3 Respiratory rate of 14 breaths/min 4 Fetal heart rate of 100 beats/min 5 Minimal variability on a fetal heart monitor

4,5