CPP MI Exam 3 practice questions
During which time is the nurse correct to document the end of the third stage of labor?
At the time of placental delivery
Use of which drug is associated with the highest risk of placental abruption?
Cocaine
A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?
Dark red, "clumpy" vaginal discharge
What is the first thing the nurse should do when caring for a pregnant woman with a disability?
Establish the impact of the disability on a woman's lifestyle.
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
Fetal lie
A pregnant client with deep vein thrombosis has been diagnosed as having systemic lupus erythematosus (SLE). The nurse would monitor the client closely for the development of which complication?
Fetal malnutrition
Current research indicates that supplementation with what before pregnancy may reduce the risk of placental abruption?
Folic acid
Which of the following is a typical adolescent developmental task?
Gaining freedom and more independence from parents
Which nursing action is required before a client in labor receives an epidural?
Giving a fluid bolus of 500 ml
The nurse is caring for a newborn who was born from a mother who used methamphetamine during pregnancy. Which newborn clinical symptom does the nurse associate with the mother's drug use?
Growth restriction
A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia?
Have her blood pressure checked at every prenatal visit.
The nurse is caring for a client with an ectopic pregnancy. Which symptom is a sign that the tube has ruptured?
Hypovolemic shock
The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?
Maintain a daily blood glucose log
A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?
Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Meconium in the fluid
The maternal nurse is caring for a pregnant client who has consumed alcohol during pregnancy. Which long-term impact does the nurse recognize may impact the client's infant?
Memory deficits
A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)?
Onset of vaginal bleeding was sudden and painful
The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?
Pain originates from the cervix and lower uterine segment.
A pregnant client in her 34th week of gestation is diagnosed with amnionitis due to group B streptococcus. The nurse monitors the client closely based on the understanding that the client is at risk for which of the following?
Preterm birth
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?
ROA
The nurse is caring for a client who is intellectually disabled and in her 16th week of pregnancy. What is the priority concern when caring for this client? Transportation Support person Finances Safety
Safety
The nurse is caring for a woman at 32 weeks' gestation with severe preeclampsia. Which assessment finding should the nurse prioritize after the administration of hydralazine to this client?
Tachycardia
What is the drug methylergonovine maleate used for?
Uterine contraction
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia
A nursing instructor is teaching students about anemia during pregnancy. Which type of anemia does the instructor teach students is most prevalent during pregnancy?
iron-deficiency anemia
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?
maternal hypotension and fetal bradycardia
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?
upright
hich is the most important nursing assessment of the mother during the fourth stage of labor?
Hemorrhage
In providing culturally competent care to a laboring woman, which is a priority?
Identify how the client expresses labor pain.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority?
avoidance of infection
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point?
Counterpressure against the sacrum
Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus?
Placing a wedge under the hips
Which changes in pregnancy would the nurse identify as a contributing factor for arterial thrombosis, especially for the woman with atrial fibrillation?
hypercoagulable state
A pregnant adolescent tells the school nurse, "I want to go to the doctor and have her check my baby but I don't want to tell my parents and the doctor probably won't see me without them." What is the best response by the nurse?
"You are considered emancipated and may receive health care for you and your fetus without parental consent."
A nurse is serving as a doula to a client who is now in labor at an alternative birthing center. The client has opted for a water birth, and the nurse is now drawing the water into a large tub. What temperature should the nurse keep the water at?
37°C
A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?
6%
The nurse is eating lunch in the hospital cafeteria when she notices a pregnant woman, apparently in her third trimester, choking on her food. After assessing that the patient cannot speak, what should be the nurse's next intervention?
Deliver chest thrusts.
What does the nurse recognize as the developmental challenge of the pregnant woman who is 42 years old?
Developing generativity
A nursing instructor is teaching students about caring for a pregnant patient with a pre-existing disease. Which of the following does the instructor suggest has added to an increased incidence of pregnant women with a pre-existing disease?
More women waiting until after age 30 years to get pregnant
The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy?
Pulmonary hypertension
What is the best way for a woman with a spinal cord injury who cannot feel labor contractions to know that she is in labor?
She will be able to palpate her contractions with her hand.
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?
The fetus is in the true pelvis and engaged.
A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?
Threatened abortion
A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?
calcium gluconate
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?
occiput
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?
Acceleration of at least 15 bpm for 15 seconds
A pregnant client at 32 weeks' gestation is treated with magnesium sulfate for seizure management. The nurse assesses which of the following for evidence of magnesium toxicity?
Absence of knee jerk response
What nursing action has a negative effect on fetal descent?
Administering narcotic pain medication
A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management?
Administration of 500 mL of IV Ringer's lactate
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis
A client in week 38 of her pregnancy arrives at the emergency room reporting a sharp pain between her umbilicus and the iliac crest in her lower right abdomen that is increasing. She reports having experienced intense nausea and vomiting for the past 3 hours. Given these symptoms, the nurse suspects which of the following conditions?
Appendicitis
A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?
Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask.
The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper?
Blue
The nurse is caring for a laboring client whose fetus has slowed in the descent down the birth canal. The health care provider is checking on the client. Which nursing action is anticipated?
Complete a urinary catheterization
A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?
Decrease activity and rest more often.
The nurse is caring for a client with severe anxiety. The client states, "I have never had a baby before and am scared to death that I will not be able to do it." Which suggestion is mosthelpful?
Encourage the use of a doula.
A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position?
Lie in a semi-recumbent position.
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta
A woman dilated to 10 cm and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?
Pudendal block
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?
Push with contractions and rest between them.
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?
Reflexes
The nurse is preparing to teach a group of new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?
Shoulder
Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?
Significant head molding
When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?
The characteristics of labor pain follow a pattern.
A 22-year-old woman has given birth to an infant who exhibits the signs and symptoms of maternal cocaine use during pregnancy. These signs and symptoms are a result of what pathophysiological effect of opioid use during pregnancy?
Vasoconstriction leading to reduced placental blood flow
The nursing instructor is pointing out the various complications that can occur during pregnancy in women with diabetes mellitus. The instructor determines the session is successful after the students correctly choose which complication that can occur if the diabetes is not kept under control?
hydramnios
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?
increased white blood cell count
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?
lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels
A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?
naloxone
A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose?
patellar reflex
A woman at 35 weeks' gestation with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?
preterm rupture of membranes followed by preterm birth
A client is diagnosed with peripartum cardiomyopathy (PPCM). Which therapy would the nurse expect to administer to the client?
restricted sodium intake
The nurse is assessing a pregnant client who has a long history of asthma. She states, "I'm trying not to use my asthma medications because I certainly don't want my baby exposed to them." What is the nurse's best response?
"Actually, having uncontrolled asthma is much riskier for your baby than the medication."
The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful?
"Pregnancy affects insulin production, so I'll need to make adjustments in my diet."
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:
-2 station.
Why is it important for the nurse to obtain a baseline blood pressure and carefully monitor a pregnant adolescent's blood pressure carefully at each visit?
Adolescents are more prone to pregnancy-induced hypertension than the average woman
The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause?
Chromosomal abnormality
A pregnant woman with a spinal cord injury is in labor and fully dilated but cannot adequately push the baby through the birth canal. What should the nurse do next?
Prepare the patient for a cesarean section.
A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?
She is at increased risk for type 2 diabetes mellitus after her baby is born.
The school nurse observes an adolescent student most likely in her second trimester of pregnancy. When the nurse inquires if the student is receiving prenatal care, the student says that "she hasn't gotten around to it yet, but she will soon." Why might the student have delayed receiving prenatal care?
She may be having trouble accepting the pregnancy and thus is not interested in receiving prenatal care.
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:
descent, flexion, internal rotation, extension, external rotation, expulsion
A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?
diet
Which medication is administered to reverse the depressant effects of opioids?
naloxone
A pregnant woman with sickle cell anemia is very concerned her infant will also develop the disease and questions the nurse about that possibility. Which is the best response from the nurse?
Both parents have to carry the trait.
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?
Cervix
If a woman has a hip contracture, which position would be best for a vaginal delivery?
Sims'
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?
Take no extra measures; prepare for a standard labor.
The nurse is attempting to obtain a detailed history to determine risk for a pregnant adolescent who is accompanied by her parents during her first prenatal visit. How is this information best obtained?
With the adolescent in the room without the parents present
What special interventions would the nurse implement in a client who is carrying twin fetuses? -Schedule non-stress tests (NST) starting at 16 weeks. -Demonstrate to the client how to perform fetal movement counts after 32 weeks. -Assist the physician on doing uterine ultrasounds every 2 weeks to monitor fetal size and placental information. -Remind the client to monitor her intake since she does not need any more food for a multiple pregnancy than she would ingest for a singleton pregnancy.
Demonstrate to the client how to perform fetal movement counts after 32 weeks.
A nurse in the prenatal clinic is preparing a 41-year-old female client at 17 weeks' gestation for a triple marker test (HCG, estriol, AFP). The client is slightly overweight, and her lab findings show she is Rh negative. The nurse suspects the health care provider is ruling out which disorder?
Down syndrome
A 16-year-old sexually active female is being treated with isotrerinoin (Accutane) for severe cystic acne. What instructions should the nurse give this patient?
Be sure to use two forms of birth control because this medication is teratogenic.
A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?
Twin-to-twin transfusion syndrome (TTTS)
What early nursing measure is most helpful in insuring that a client with special needs has an individual labor plan?
Use a database to begin planning for labor at the first prenatal visit.
A client has just received combined spinal epidural. Which nursing assessment should be performed first?
Vital signs
A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor?
Second
A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate?
"Come to the clinic or emergency department for an evaluation."
A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?
"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."
The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching?
Increased risk of spontaneous abortion Polyhydramnios Hypertension
The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth?
cesarean
A nurse is explaining the fetus's position to a female client whose baby is in the frank breech position. Which statement by the client would indicate that the teaching was understood?
"My baby's hips are flexed, and the knees are extended."
A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?
"Our baby will come out face first."
A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?
"Purse-string sutures are placed in the cervix to prevent it from dilating."
A pregnant woman who has been taking penicillin prophylactically because she had rheumatic fever as a child tells the nurse that she wants to stop taking it now that she is pregnant. Which of the following is the best response by the nurse?
"You should continue taking this drug, because penicillin is not known to be a fetal teratogen."
It is most likely that the physician would consider performing an amnioinfusion if the EFM tracing shows which of the following? -Consistent early accelerations, variability present, and occasional decelerations -Flat line without variability and no decelerations -Occasional mild variable decelerations and moderate variability present -Deep variable decelerations more than 60 bpm below the baseline with every contraction
-Deep variable decelerations more than 60 bpm below the baseline with every contraction
Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?
0
The maternal health nurse is caring for a pregnant client with iron-deficiency anemia who reports "extreme fatigue and shortness of breath" during a prenatal checkup at the outpatient clinic. The nurse prepares to educate the client regarding proper nutrition for this condition. Which dietary choice(s) will the nurse suggest?
Beef stew with potatoes and milk Fortified dried cereal with milk and orange juice Dark leafy green salad with sunflower seeds and water Red beans and rice with cranberry juice
A 40-year-old primipara has been in labor for 12 hours and is still only 6 centimeters dilated. What does the nurse understand may be the cause for this prolonged labor?
Cervical dilation may not occur as spontaneously as in a younger woman.
The nurse is caring for a pregnant client who has a preexisting spinal cord injury. During labor, the client suddenly experiences a headache and blood pressure of 298/100 mm Hg. What is the nurse's priority intervention?
Elevate the client's head of bed maintaining spinal precautions
A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control?
Exercise
A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:
check her blood sugars frequently and adjust insulin accordingly.
When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which source?
complex carbohydrates
A woman at 10 weeks' gestation comes to the clinic for an evaluation. Which assessment finding should the nurse prioritize? -report of frequent mild nausea -blood pressure of 120/84 mm Hg -history of bright red spotting 6 weeks ago -fundal height measurement of 18 cm
fundal height measurement of 18 cm
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?
difficulty breathing
A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?
gestational trophoblastic disease
A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination, there is an elevated human chorionic gonadotropin (hCG) level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition?
gestational trophoblastic disease
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?
inability to push
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:
left lower quadrant.
In women with cardiac failure, the maternal blood pressure becomes insufficient to provide an adequate supply of blood to the placenta. The infant will likely experience some undesired effects, including which of the following?
low birth weight
The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?
meperidine
During a routine prenatal visit, a client is found to have proteinuria and a blood pressure rise to 140/90 mm Hg. The nurse recognizes that the client has which condition?
mild preeclampsia
The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents?
"Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain."
The maternal health nurse cares for a homeless pregnant woman who presented to the emergency room in precipitous labor. The woman has not had prenatal care. Upon delivery, her infant weighs 4.6 kg and notes the infant appears to be jittery. Which nursing action will the nurse perform first?
Check the infant's blood glucose level
A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor?
Chromosomal defects in the fetus
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?
Complete cervical dilation (dilatation) and time of fetal birth
An experienced nurse is instructing a novice nurse on the rare procedure of a postmortem cesarean birth. Which information is correct? Select all that apply. Consent is not necessary. A classical incision is performed. Infant survival is best if the surgery is performed within 20 minutes. Postmortem cesarean is attempted only if the fetus is past 20 weeks. A neonatal resuscitation team is necessary.
Consent is not necessary. A classical incision is performed. A neonatal resuscitation team is necessary.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
fetal status
The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?
Molding
A client suffering a miscarriage at 12 weeks' gestations is very upset that the health care provider has ordered a D&C. How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation?
"This procedure is needed to adequately remove all the fetal tissue."
A pregnant 16-year-old has decided to have an amniocentesis for a positive Down syndrome screen. How should the nurse counsel this patient?
"You do not need your parent's permission for this procedure."
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?
A dipstick value of 2+ for protein
The nurse is caring for a primipar who is 41 years old. Which complication due to age places her at an increased risk for postpartum hemorrhage?
A lack of elasticity in the uterus and poor uterine tone.
A nurse is explaining the various methods of pain control used during labor and birth. When explaining why general anesthesia is rarely used, which information would the nurse include?
A pregnant woman has a risk for vomiting and aspiration. General anesthesia readily crosses the placenta.
A client at 34 weeks gestation has reported to the hospital in labor. The following is documented on history and physical assessment: No rupture of membranes, mild cramping, no bleeding Reassurring pattern on fetal heart monitor Cervix is dilated 3 cm, effacement 30%. The nurse anticipates which treatment plan?
Admission to the hospital, bed rest, and a tocolytic agent
The labor nurse reports to the nurse on the oncoming shift, "The woman in labor room 2 is handling her pain very well. She smiles whenever I go in to talk to her, and she doesn't complain at all!" What assessment by the oncoming labor nurse would best reveal if the off-going labor nurse's observations were correct?
Asking the woman to describe her pain and rate it on a scale of 0 to 10
At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdominal pain that started suddenly about 1 hour ago and has not subsided. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. What should the nurse do next?
Assess fetal heart rate
When caring for a woman in labor with a spinal cord injury, you notice a drop in her heart rate accompanied by sudden onset of severe hypertension. What would you most likely suspect?
Autonomic dysreflexia
A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority?
Confine the client to bed rest in a darkened room.
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?
Ectopic pregnancy
Which lab value in a pregnant woman at term might indicate trauma?
Elevated liver enzymes
A woman in week 36 of her pregnancy has been involved in a car accident and suffered significant trauma. Which of the following is the most reliable indicator of the presence or absence of a specific complication caused by the accident? Elevation of serum liver enzyme levels, indicating liver trauma Pulse rate of 95 beat/min, indicating hemorrhage Warmth and perfusion in extremities, indicating absence of shock Elevated leukocyte count, indicating infection
Elevation of serum liver enzyme levels, indicating liver trauma
The maternal health nurse is caring for a pregnant client who confides to the nurse that she is still using illicit drugs. What is the nurse's priority when caring for the client? Contact child protective services Encourage the client to continue prenatal visits Notify the health care provider Encourage the client to stop using the drugs
Encourage the client to continue prenatal visits
A nurse is meeting with a client to develop the nursing care plan for her delivery to include the use of an injectable pain medication. When comparing the various options for the client, which advantage of using an intrathecal anesthesia over an epidural anesthesia should the nurse point out?
Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia.
The maternal health nurse is caring for an adolescent who is pregnant. Which complication(s) will the nurse be most concerned about with this client?
Iron-deficiency anemia Premature labor
The nurse is caring for a pregnant client with pregestational diabetes. Which goal does the nurse identify as priority during the client's pregnancy?
Maintain glycemic control
A nurse is assessing a client in her seventh month of pregnancy who has an artificial valve prosthesis. The client is taking an oral anticoagulant to prevent the formation of clots at the valve site. Which of the following nursing interventions is most appropriate in this situation?
Observe the client for signs of petechiae and premature separation of the placenta
A young woman with scoliosis has just learned that she is pregnant. Several years ago, she had stainless-steel rods surgically implanted on both sides of her vertebrae to strengthen and straighten her spine. However, her pelvis is unaffected by the condition. Which of the following does the nurse anticipate in this woman's pregnancy?
Potential for greater than usual back pain
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritizeat this stage?
Practicing effleurage on the abdomen
The client may spend the latent phase of the first stage of labor at home unless which occurs?
The client experiences a rupture of membranes
Why is a young adolescent at higher risk for postpartum hemorrhage?
The uterus may not be fully developed and may become overdistended.
The obstetric nurse is caring for a pregnant client who has been diagnosed with hydatidiform mole. What assessment should the nurse prioritize?
Vaginal bleeding
The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. The nurse will stress the importance of frequent office visits to the client with:
a molar pregnancy.
A woman who is 8 months' pregnant comes to the clinic with urinary frequency and pain on urination. The client is diagnosed with a urinary tract infection (UTI). Which medication would the nurse anticipate the physician will prescribe?
amoxicillin
The clinic nurse teaches a pregestational type 1 diabetic client that constant insulin levels are very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:
an insulin pump
A pregnant woman with a history of mitral valve stenosis is to be prescribed medication as treatment. Which medication class would the nurse expect the client to be prescribed?
anticoagulant
A woman's obstetrician prescribes vitamin K supplements for a client who is on antiepileptic medications beginning at 36 weeks' gestation. The mother asks the nurse why she is taking this medication. The nurse's best response would be:
antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn.
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions?
begin irregularly but become regular and predictable felt first in lower back and sweep around to the abdomen in a wave increase in duration, frequency, and intensity
Which assessment findings, experienced by the client at 36 weeks' gestation, would the nurse document as diagnostic signs of severe preeclampsia?Select all that apply. -blood pressure of 164/110 mm Hg -elevated liver enzymes -edema -+1 proteinuria -Elevated serum creatinine
blood pressure of 164/110 mm Hg elevated liver enzymes +1 proteinuria Elevated serum creatinine
A pregnant client with a history of heart disease has been admitted to a health care center reporting breathlessness. The client also reports shortness of breath and easy fatigue when doing ordinary activity. The client's condition is markedly compromised. The nurse would document the client's condition using the New York Heart Association (NYHA) classification system as which class?
class III
The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?
dyspnea, crackles, and irregular weak pulse
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?
elevated liver enzymes
A client in her fifth month of pregnancy is having a routine clinic visit. The nurse should assess the client for which common second trimester condition?
physiological anemia
A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?
respiratory depression
Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor?
scalp edema
A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?
sudden gush of dark blood from the vagina
A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?
use of IUD for contraception
What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?
starting an IV and hanging IV fluids
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8-10 cm
Which of the following pregnant women would be considered a patient with special needs? (Select all that apply.) A 16 year old A 42 year old A woman having her third child A woman with a history of cocaine addiction An unmarried woman
A 16 year old A 42 year old A woman with a history of cocaine addiction
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?
Assess the client's vital signs.
A young client who has just learned that she is pregnant admits that she is a frequent heroin user. Which of the following interventions would be the most effective for this client?
Refer the client to a methadone maintenance program
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?
Third
Which action is a priority when caring for a woman during the fourth stage of labor?
assessing the uterine fundus
It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
at 28 weeks' gestation and again within 72 hours after birth
The maternal health nurse is caring for a pregnant client of advanced maternal age. The client asks the nurse about preventative measures to decrease the risk of the development of varicose veins. Which teaching(s) will the nurse include?
"Rest in a side-lying position to ensure adequate vein drainage." "Elevate your legs on a foot stool while sitting at your desk." "Put your prescribed support stockings on in the morning before getting out of bed."
A 35-year-old client is seen for her 2-week postoperative appointment after a suction curettage was performed to evacuate a hydatidiform mole. The nurse explains that the human chorionic gonadotropin (hCG) levels will be reviewed every 2 weeks and teaches about the need for reliable contraception for the next 6 months to a year. The client states, "I'm 35 already. Why do I have to wait that long to get pregnant again?" What is the nurse's best response?
"A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy."
A pregnant client with cystic fibrosis (CF) comes to the office for a prenatal visit. She asks the nurse for information on breast-feeding. The best response by the nurse is:
"Breast-feeding is not a good idea. Because your breast milk is high in sodium due to CF, there is a risk of the infant receiving too much sodium."
A pregnant client with a history of asthma since childhood presents for a prenatal visit. What statement by the client would the nurse prioritize?
"I sometimes get a bit wheezy."
The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or at delivery for her baby. Which statement by the mother indicates that further teaching is needed by the nurse?
"If my blood sugars are elevated, my baby's lungs will mature faster, which is good."
The nurse is caring for a pregnant woman determined to be at high risk for gestational diabetes. The nurse prepares to rescreen this client at which time frame?
24 to 28 weeks
The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?
6.5
What criteria would the ob/gyn base a decision on to begin insulin therapy for a mother with gestational diabetes?
A 2-hour postprandial glucose level cannot be kept below 120 mg/dl.
The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize?
Assess return of sensory and motor functions to the lower extremities.
The nurse is preparing for a prenatal visit with a pregnant woman who cannot ambulate because of a thoracic spine injury several years ago. What should the nurse do first to prepare for this patient's visit?
Assess the impact of the disability on the patient's lifestyle before offering assistance.
A 44-year-old client is experiencing postpartum hemorrhaging soon after the birth of her first child. She is frightened and asks the nurse what could be causing it. Which of the following should the nurse mention to the client?
Because of her age, the client is more likely to experience a uterus not contracting as readily in the postpartum period, which predisposes her to postpartum hemorrhaging
A pregnant adolescent is in the early stage of gestational hypertension with a blood pressure of 162/88. The best treatment initially would be which?
Bed rest, particularly the left lateral position
The maternal health nurse is caring for a pregnant client with a history of epilepsy. The client's antiepileptic drug (AED) levels have been in the non-therapeutic range the last two times the labs were drawn. Which factor does the nurse associate with this finding?
Drug metabolism changes during pregnancy
The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition?
Gestational diabetes
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated (dilatated)?
Have the client pant and blow through the contraction.
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?
Help the woman change positions.
Which complication occurs as a result of ineffective breathing patterns?
Hyperventilation
The maternal health nurse is developing the plan of care for an adolescent client who is pregnant. Which risk will the nurse prioritize in the care plan?
Imbalanced nutrition
A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?
Immediate surgery
Which postpartum complication is the nurse most likely to see in a mother who abuses marijuana?
Inadequate milk production
An infant is born to a mother with gestational diabetes. Which long-term maternal complication is associated with this diagnosis?
Increased risk of development of type 2 diabetes
The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?
Intermittent fetal heart rate auscultation
When documenting the fetus is at "zero station", the nurse knows this is where in relation to the pelvic structure?
Ischial spines
A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client?
Lab work will be drawn to rule out acid-base imbalances.
A pregnant adolescent is at increased risk for all of the following EXCEPT Preterm labor Pregnancy-induced hypertension Large for gestational age infant Iron deficiency anemia
Large for gestational age infant
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?
Latent
A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which of the following tests would the nurse expect to be used to predict fetal lung maturity when the client goes into labor?
Lecithin/sphingomyelin ratio
All of the following are commonly seen in infants born to cocaine-addicted mothers EXCEPT Lethargy Intracranial hemorrhage Irritability Muscle rigidity
Lethargy
General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?
Neonatal depression is possible.
The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement?
Orange juice
A nurse is educating a group of nursing students about the etiology of labor. Which of the following should the nurse explain as the hormone produced by the posterior pituitary?
Oxytocin
A client with a multiple gestation has come to a health care facility for a regular antenatal check-up. When educating the client on pregnancy, about which complication should the nurse inform the client?
Placental dysfunction
The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy?
Polyhydramnios
When assessing a pregnant client for possible gestational hypertension, which factors would lead the nurse to suspect that the client is at increased risk?
Preexisting hypertension Primiparas, particularly obese clients History of antiphospholipid syndrome
A 17-year-old primigravida with type 1 diabetes is at 37 weeks' gestation comes to the clinic for an evaluation. The nurse notes her blood sugar has been poorly controlled and the health care provider is suspecting the fetus has macrosomia. The nurse predicts which step will be completed next?
Preparing for amniocentesis and fetal lung maturity assessment
A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?
Prevent maternal seizures
A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?
Reassuring; it is associated with normal acid-base balance.
A pregnant woman is in an automobile accident and does not survive the trauma. The spouse requested that the physician do an emergency postmortem cesarean birth. Which conditions would most promote infant survival? The fetus is past 24 weeks and no more than 5 minutes have passed since the mother died. The fetus is past 32 weeks and no more than 45 minutes have passed since the mother died. The fetus is past 20 weeks and no more than 30 minutes have passed since the mother died. The fetus is past 24 weeks and no more than 30 minutes have passed since the mother died.
The fetus is past 24 weeks and no more than 5 minutes have passed since the mother died.
How can the nurse determine that a patient who reports using cocaine has an actual substance dependence?
The patient has withdrawal symptoms when she stops taking the drug.
A pregnant adolescent comes to the clinic and reports that she "feels tired all the time." The nurses assesses pale mucous membranes. Laboratory tests show show a hemoglobin of 10.2 g/dL. What does the nurse suspect is occurring with this patient?
The patient most likely has iron-deficiency anemia.
Which of the following statements is true regarding trauma in pregnancy? -Trauma is most likely to occur in the 1st trimester. -Pregnant women should wear only lap seat belts and should avoid shoulder restraints. -In the event of trauma, a woman's body will maintain hemostasis of the fetus over that of her own body. -The uterus is a peripheral organ and will see severely decreased blood flow in the event of trauma.
The uterus is a peripheral organ and will see severely decreased blood flow in the event of trauma.
A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome?
hemolysis elevated liver enzymes low platelet count
A pregnant client with severe preeclampsia has developed HELLP syndrome. In addition to the observations necessary for preeclampsia, what other nursing intervention is critical for this client?
observation for bleeding
