Exam 2: Lippincott Questions

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? a. First b. Second c. Third d. Fourth

c. Third Stage three begins with the birth of the baby and ends with delivery of the placenta.

Dilation (dilatation) follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement? a. 3 to 4 cm b. 7 to 8 cm c. 8 to 10 cm d. 12 to 14 cm

c. 8 to 10 cm

A nurse is asked to auscultate the fetal heart sounds in a pregnant client. Which equipment is most appropriate when auscultating fetal heart sounds at the 12th week? a. Stethoscope b. Doppler c. Tocodynometer d. Fetoscope

b. Doppler Fetal heart sounds are best heard with the Doppler from the 10th week onward. They can be heard with the fetoscope by about the 18th to 20th week only. A tocodynamometer is used to record uterine contractions and not to auscultate fetal heart tones. Fetal heart tones may not be audible with an ordinary stethoscope at the 12th week.

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? a. Maternal heart rate and blood pressure b. Fetal heart rate in relation to contractions c. The station in which the fetus is located d. Maternal request for pain medication

b. Fetal heart rate in relation to contractions The priority consideration is on the status of the fetus. Because each contraction temporarily interrupts blood flow to the placenta, there is a decrease in oxygen available. Therefore, a fetus cannot tolerate contractions lasting too long or too strong. All other options are important but not the priority.

A young couple, 8 weeks' pregnant with their first child, are being assessed at their first prenatal visit. They ask about scheduling an ultrasound to find out the gender of the fetus. For when should the nurse recommend this ultrasound be scheduled? a. For today (8 weeks' gestation) b. For 12 weeks' gestation c. For 20 weeks' gestation d. For 16 weeks' gestation

d. For 16 weeks' gestation

Patterned breathing techniques used in labor provide which benefits? Select all that apply. a. Distraction b. Conscious relaxation c. Spirituality d. Pain relief without special tools

a. Distraction b. Conscious relaxation d. Pain relief without special tools Patterned breathing can be very effective when the woman has practiced before labor and has an attentive coach. It can provide distraction, conscious relaxation, and pain relief without any special tools.

The nurse is reviewing the results of a woman's maternal serum alpha fetoprotein (AFP) blood test. The results are positive, in the high range. Which action will the nurse complete next? a. Obtain instructions on how to lower the blood levels. b. Notify the woman of the results of the test. c. Place the results in the client's medical records. d. Notify the primary health care provider of the results.

d. Notify the primary health care provider of the results.

The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare? a. Occiput presentation using a PowerPoint presentation b. Cephalic presentation using preprinted materials in the client's language c. Breech presentation using a picture d. Footling presentation drawing a hand-prepared diagram

b. Cephalic presentation using preprinted materials in the client's language

A pregnant client is undergoing an amniocentesis in her third trimester and is worried why she is undergoing this procedure. Which statement by the nurse would best alleviate this client's anxieties? a. "We want to be sure your baby's lungs are mature and this measures the development of the baby's lungs. b. "This procedure is not very dangerous and you should not worry about it." c. "The doctor can explain everything to you when we are done with the procedure." d. "We are concerned that your baby may have some genetic disorder."

a. "We want to be sure your baby's lungs are mature and this measures the development of the baby's lungs. The purpose of an amniocentesis is to determine if the lungs of the fetus are mature enough to support respirations outside the womb. Additionally, an amniocentesis is done for genetic testing for a variety of disorders.

The pregnant client at 6 weeks' gestation asks the nurse if an ultrasound will reveal the sex of the fetus yet. What is the best response by the nurse? a. "We will have to wait until the baby is 16 weeks' gestation to determine what the sex is." b. "We will be able to determine the sex of the baby today with transvaginal ultrasound." c. "We will have to wait until the baby is 20 weeks' gestation to determine the sex of the baby." d. "We will have to wait until the baby is 8 weeks' gestation to be able to determine what the sex is."

a. "We will have to wait until the baby is 16 weeks' gestation to determine what the sex is." About 4 months

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? a. 10:30 a.m. b. 10:05 a.m. c. 11:30 a.m. d. 11:15 a.m.

a. 10:30 a.m. Assess and document fetal status at least every 30 minutes. Record the baseline FHR every 30 minutes and evaluate the fetal monitor tracing for abnormal patterns. Variability should be present, except for brief periods of fetal sleep or when the mother receives opioids or other selected medications, and no late decelerations should be present. Accelerations of the FHR are normal.

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? a. Assess return of sensory and motor functions to the lower extremities. b. Let the client rest and recover while keeping her legs slightly elevated. c. Help the client get up and walk around immediately. d. Make sure the client receives plenty of fluids.

a. Assess return of sensory and motor functions to the lower extremities. After removal of the epidural catheter and medication is terminated, the nurse needs to assess for return of motor function to ambulate the mother. The mother will not be able to walk for some time (at least until the medication wears off).

During which time is the nurse correct to document the end of the third stage of labor? a. At the time of placental delivery b. When pushing begins c. Following fetal birth d. When the mother is moved to the postpartum unit

a. At the time of placental delivery

During which time is the nurse correct to document the end of the third stage of labor? a. At the time of placental delivery b. When the mother is moved to the postpartum unit c. When pushing begins d. Following fetal birth

a. At the time of placental delivery The third stage of labor concludes with the delivery of the placenta. The nurse is correct to document that time in the medical record. The beginning of the third stage of labor is the documented time of birth.

The nurse is assigned four clients in the labor and birthing unit. Which client does the nurse assess last during assessment rounds? a. Client at 37 weeks' gestation who is having an irregular pattern of contractions b. Client who is newly admitted experiencing contractions every 4 minutes c. Client at 34 weeks' gestation with a cervical dilation (dilatation) of 6 cm d. Client who is experiencing variable decelerations on the fetal monitor

a. Client at 37 weeks' gestation who is having an irregular pattern of contractions Braxton Hicks contractions, or false labor, are usually mild but can be so strong that a pregnant client mistakes them for true labor. The mark of Braxton Hicks contractions is that they are usually irregular and are painful but do not cause cervical dilation (dilatation).This client can be assessed last when doing assessment rounds and may be sent home following assessment and health care provider notification of findings. The clients in active labor with cervical dilation (dilatation) and frequent contraction intervals are a higher priority. The nurse assesses the fetal monitor strip of the client having variable decelerations to identify a frequency and pattern of decelerations.

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? a. Degree of thinning b. Extent of opening to its widest diameter c. Fetal presenting part d. Passage of the mucous plug

a. Degree of thinning Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? a. Difficulty breathing b. Intense pain c. Staggering gait d. Decreased level of consciousness

a. Difficulty breathing Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? a. Duration b. Intensity c. Peak d. Frequency

a. Duration Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? a. Effacement b. Crowning c. Dilation (dilatation) d. Molding

a. Effacement The nurse is explaining about effacement, which involves softening, thinning, and shortening of the cervical canal. Dilatation refers to widening of the cervical os from a few millimeters in size to approximately 10 cm wide. Crowning refers to a point in the maternal vagina from where the fetal head cannot recede back after the contractions have passed. Molding is a process in which there is overriding and movement of the bones of the cranial vault, so as to adapt to the maternal pelvis.

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? a. Frank b. Complete c. Full d. Footling

a. Frank In a frank breech, the buttocks present first, with both legs extended up toward the face. In a full or complete breech, the fetus sits cross-legged above the cervix. In a footling breech, one or both legs are presenting.

Which is the most important factor on how much admission data is obtained when a client reports to the hospital in labor? a. Imminence of birth b. Participation in childbirth class c. Amount of prenatal care d. Support person with client

a. Imminence of birth It is best for the nurse to obtain a full admission health history, a complete maternal physical assessment, the status of labor process, and cultural preferences. However, if the client's labor has progressed, there may be little information documented before the client is sent to the delivery room. Much of the admission information is personal data and pregnancy history that the client would be able to report.

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? a. Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels b. Distraction of the brain cortex by other stimuli occuring in the body c. Blocking of nerve transmission via mechanical irritation of nerve fibers d. Release of endorphins in response to the uterine contractions

a. Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it.

Assessment of a client in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: a. Latent phase of the first stage. b. Pelvic phase of the second stage. c. Early phase of the third stage. d. Active phase of the first stage.

a. Latent phase of the first stage. The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the pregnant client.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? a. Notify the health care provider about possible meconium. b. Check the maternal heart rate. c. Prepare to administer an antibiotic. d. Check the pH to ensure the fluid is amniotic fluid.

a. Notify the health care provider about possible meconium. Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis. Therefore, the nurse would notify the health care provider.

A nurse is assessing a female client in the labor admission unit. The client has been having contractions every 5 minutes for the past 6 hours. Which finding would the nurse use to determine if the client is experiencing true labor? a. The client's cervix has changes of effacement and dilation (dilatation). b. The client has a history of giving birth to two infants. c. Walking helps the reduce the frequency of the client's contractions. d. The client reports the contractions stay in the abdomen.

a. The client's cervix has changes of effacement and dilation (dilatation). True labor is only indicated when the cervix has changes in dilation (dilatation) and effacement. True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. Contractions of true labor are reported as starting in the back and radiating around toward the front of the abdomen.

Which description is best when documenting an accurate client contraction? a. The client's contractions are 5 minutes apart and last 45 seconds. b. The client states the contraction as an 8 on the pain scale. c. The client's contractions last 30 seconds with rest between. d. The client cries with each contraction and holds the support partner's hand.

a. The client's contractions are 5 minutes apart and last 45 seconds. It is best to document a client's contraction using the following terms: frequency of contractions, duration and intensity.

A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes? a. Leakage from the perineum when the client coughs b. A positive nitrazine test c. Greenish fluid noted on the client's underwear d. A positive bacterial culture

b. A positive nitrazine test A confirmation that the client has a rupture of membranes includes a positive nitrazine test. A positive test is when the nitrazine paper turns a dark blue indicating that the fluid is alkaline. Urine also leaks when a client coughs. Greenish fluid on the underwear is not confirmation of the rupture of membranes. A positive bacterial culture is not indicative of the rupture of membranes.

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? a. White b. Blue c. Yellow d. Pink

b. Blue If the fluid in the vaginal canal is amniotic fluid, the nitrazine paper will turn a dark blue, the color of an alkaline fluid, and this is a positive nitrazine test for rupture of membranes.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? a. Having the client breathe with contractions b. Encouraging the woman to ambulate c. Providing one-to-one support d. Urging her to focus on one contraction at a time

b. Encouraging the woman to ambulate Although ambulating is beneficial during early and possibly even active labor, the strong and frequent contractions experienced and the urge to bear down may make ambulating quite difficult. During transition, women should continue to breathe with contractions and focus on one contraction at a time. Providing one-to-one support at this time helps the woman cope with the events of this phase, as well as help her maintain a sense of control over the situation.

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? a. Prepare the woman for an emergency cesarean birth. b. Help the woman change positions. c. Document the finding. d. Obtain assistance to check for a compressed umbilical cord.

b. Help the woman change positions.

A maternal serum alpha-fetoprotein (MSAFP) test reveals a human chorionic gonadotropin (hCG) level of 2.5 MoM (multiple of median). Which teaching does the nurse prepare when the client and support person attend the next prenatal visit? a. Information on caring for a child with Tay-Sachs disease b. Information on further testing due to the risk for Down syndrome c. Information on delivering and caring for a multifetal pregnancy d. Information on bleeding tendencies and hemophilia A

b. Information on further testing due to the risk for Down syndrome The nurse should inform the client that since the human chorionic gonadotropin (hCG) level is significantly elevated above 2 MoM, there is a significant risk for Down syndrome.

Assessment of a pregnant client reveals that she is experiencing Braxton Hicks contractions. Which finding would support this assessment? a. Cervical dilation (dilatation) occurring b. Irregular pattern c. Increasing duration d. Typically very strong

b. Irregular pattern The mark of Braxton Hicks contractions is that they are usually irregular and are painful but do not cause cervical dilation (dilatation). In contrast, effective uterine contractions have rhythmicity, a progressive increase in length and intensity, and accompany dilatation of the cervix.

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? a. ROP b. ROA c. LOP d. LOA

b. ROA Document the fetal position in the clinical record using abbreviations (Box 8-1). The first letter describes the side of the maternal pelvis toward which the presenting part is facing ("R" for right and "L" for left). The second letter or abbreviation indicates the reference point ("O" for occiput, "Fr" for frontum, etc.). The last part of the designation specifies whether the presenting part is facing the anterior (A) or the posterior (P) portion of the pelvis, or whether it is in a transverse (T) position.

A nurse is preparing a pregnant client for a nonstress test. To obtain the most accurate rhythm strip tracings, in which position is it best to place the client? a. Supine b. Semi-Fowler c. Client's left side d. High Fowler

b. Semi-Fowler For this diagnostic, help the client into a semi-Fowler position to prevent the uterus from compressing the vena cava and causing supine hypotension syndrome during the test. This position also elongates the abdomen, which can help in obtaining a steady fetal heart rate.

A client in the third trimester comes in for a routine prenatal visit. The nurse places the client in a comfortable position and attaches the tocodynamometer and ultrasound monitor for a nonstress test. When the health care provider documents the results of the procedure, which statement identifies the specific findings of the nonstress test? a. The client is at 2 cm cervical dilation (dilatation). b. The fetal heart rate is 132 beats/min and movement every 3 to 5 minutes. c. The fetal measurements are within normal limits for gestational age. d. The fetus is in the breech fetal position.

b. The fetal heart rate is 132 beats/min and movement every 3 to 5 minutes.

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: a. "It is elongated, the width is roomy, but the length is narrow." b. "It is flat and narrow, making it extremely difficult for the neonate to pass through." c. "It is rounded in shape and allows ample room for the neonate to fit through the passageway." d. "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally."

c. "It is rounded in shape and allows ample room for the neonate to fit through the passageway." The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid pelvis inlet allows the fetus room to pass through the dimensions of the bony passageway.

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? a. Give the medication orally every hour for the first 4 hours. b. Give the medication as an intramuscular injection using the Z-track technique. c. Administer the medication piggybacked into a primary IV line using a pump. d. Assist with insertion of a central venous access device for administration.

c. Administer the medication piggybacked into a primary IV line using a pump. Synthetic oxytocin is used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity.

Which nursing action has a negative effect on fetal descent? a. Using a tap water enema b. Laying the client on the left side c. Administering opioid pain medication d. Walking the client in the hall

c. Administering opioid pain medication Opioid pain medication is known to help with the pain associated with contractions and childbirth but it is also known to slow or even stop the progression of the labor process.

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? a. False pelvis b. Perineum c. Cervix d. Uterus

c. Cervix The cervix and vagina are soft tissues that form the part of the passageway known as the birth canal.

In providing culturally competent care to a laboring woman, which is a priority? a. Identify who is the support person during the labor. b. Identify the decision maker within the family. c. Identify how the client expresses labor pain. d. Identify any cultural foods used prior to labor.

c. Identify how the client expresses labor pain. Pain is a part of the labor process and management of the pain impacts the labor process itself. The nurse must effectively be able to assess the client's pain level to be able to provide care. Individuals from different cultures express pain in different ways. All of the other options are important to understand but they do not directly relate to the client and birth process.

Which nursing instruction is best when helping the woman deliver the fetus in a controlled manner? a. Instruct the client to change positions frequently. b. Instruct the client to limit fluid intake until after the second stage of labor. c. Instruct the client to blow through the lips like blowing out candles. d. Instruct the client to bare down and push with each contraction.

c. Instruct the client to blow through the lips like blowing out candles. To deliver the fetus in a controlled manner, the client expels the fetus without force, allowing the body to naturally birth the baby. To accomplish this, the nurse instructs the client to blow through the lips instead of holding the breath and bearing down. This adds force and pressure to the birth. Changing positions and limiting fluid does not impact the birth process. The client is typically supine or in the lithotomy position for the birth.

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? a. Transition phase b. Stage three c. Latent phase d. Stage two

c. Latent phase The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage 2 she may remain positive, but the work of labor is very intense.

The student nurse is preparing to assess the fetal heart rate (FHR) and 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: a. Left upper quadrant. b. Right lower quadrant. c. Left lower quadrant. d. Right upper quadrant.

c. Left lower quadrant. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

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? a. The client is more sensitive to preanesthetic medications. b. The client is less sensitive to inhalation anesthetics. c. Neonatal depression is possible. d. Fetal hypersensitivity to anesthetic is possible.

c. Neonatal depression is possible. General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration.

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? a. Variable decelerations b. Accelerations c. Prolonged decelerations d. Early decelerations

c. Prolonged decelerations

A woman telephones the prenatal clinic and reports that her water just broke. Which suggestion by the nurse would be most appropriate? a. "Drink 3 to 4 glasses of water and lie down." b. "Come in as soon as you feel the urge to push." c. "Call us back when you start having contractions." d. "Come to the clinic or emergency department for an evaluation."

d. "Come to the clinic or emergency department for an evaluation." When the amniotic sac ruptures, the barrier to infection is gone, and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? a. "My contractions are about 6 minutes apart and regular." b. "I'm feeling contractions mostly in my back." c. "If I try to talk to my partner during a contraction, I can't." d. "The contractions slow down when I walk around."

d. "The contractions slow down when I walk around." False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

A client in her third trimester comes to the clinic for an evaluation. Assessment reveals that the cervix is thinning. The client says, "I know my cervix needs to dilate, but why does it get thinner?" Which response by the nurse would be appropriate? a. "It thins to let your baby change positions during labor." b. "Cervical thinning is a sign that you are in true labor." c. "Your cervix thins so that your contractions can increase." d. "You need the cervix to thin so it can stretch more easily."

d. "You need the cervix to thin so it can stretch more easily." As labor approaches, the cervix changes from an elongated structure to a shortened, thinned segment. Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix.

A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions? a. Bloody mucus in the toilet once earlier in the day b. Scant amount of thick, white vaginal discharge, no odor c. Contractions, irregular, lasting 15 to 20 seconds d. Contraction, regular and lasting longer and stronger

d. Contraction, regular and lasting longer and stronger True labor contraction will progressively get worse and last longer. The pain will come to a point where the woman will not be able to walk or talk through the contractions. Irregular contractions, bloody show, and white vaginal discharge are normal for pregnancy but do not indicate true labor.

The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time? a. Administer fluids. b. Continue to monitor the pattern every 15 minutes. c. Notify the health care provider. d. Have the client change position.

d. Have the client change position. Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the client to change position to see if that will take the pressure off the cord. The health care provider should be notified, especially if a change of position is ineffective.

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? a. Excessive contractions of the uterus b. Passage of the drug to the fetus c. Increased frequency of micturition d. Headache following anesthesia

d. Headache following anesthesia The nurse should inform the client and her family about the possibility of headache after spinal anesthesia.

The nurse is monitoring the electronic fetal heart rate monitor and notes the following: variable V-shaped decelerations in the fetal heart rate (FH)R lasting about 30 seconds, accelerations of about 5 beats/min before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? a. Discontinue supplemental oxygen. b. Start an oxytocic infusion and decrease the rate of IV fluids. c. Encourage pushing with contractions during second stage of labor. d. Help the woman change positions.

d. Help the woman change positions. The electronic fetal heart rate monitor reading is associated with cord compression. Changing to a different position is a first intervention to determine if this will improve the oxygen to the fetus.

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: a. Press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. b. Lead the client through a series of visualizations to aid in relaxation. c. Instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. d. Instruct the client or her partner to perform light fingertip repetitive abdominal massage.

d. Instruct the client or her partner to perform light fingertip repetitive abdominal massage. Effleurage is light fingertip repetitive abdominal massage. The relaxation technique of visualization is used in hypnobirthing or focused meditation

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? a. Intrathecal anesthesia will not cause hypotension like epidural anesthesia can. b. Ambulation is still possible after an intrathecal anesthetic but not after receiving an epidural anesthetic. c. Epidural anesthesia has a tendency to wear off faster than intrathecal anesthesia. d. Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia.

d. Intrathecal anesthesia is a simpler technique providing quicker pain relief than epidural anesthesia. Onset of intrathecal (spinal) anesthesia is immediate. Epidural anesthesia can take 15 to 30 minutes to provide pain relief. Epidural anesthesia can be given in a continuous dosage; spinal anesthesia is given as a one-time injection that can wear off before delivery, thus requiring some form of additional pain medication. Both epidural anesthesia and spinal anesthesia can cause hypotension. Both can be modified to effect mobility, allowing the woman to be able to ambulate.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? a. Transverse b. Oblique c. Obtuse d. Longitudinal

d. Longitudinal The picture shows the fetus parallel to the maternal spine, which denotes the longitudinal lie. In the transverse lie, the fetus lies crosswise to the maternal spine. An oblique lie is between the two. There is not an obtuse lie.

An 18-year-old pregnant woman asks the nurse why she has to have a routine alpha-fetoprotein serum level drawn. The nurse explains that this: a. Measures the fetal liver function. b. Is a screening test for placental function. c. Tests the ability of her heart to accommodate the pregnancy. d. May reveal chromosomal abnormalities.

d. May reveal chromosomal abnormalities. An alpha-fetoprotein analysis is a cost-effective screening test to detect chromosomal and open-body-cavity disorders.

A woman is confused after finding out the ultrasound results predict a different due date for the birth of her baby. Which factor should the nurse point out is most likely the reason for the miscalculation of the fetal age? a. Not seeking prenatal care in the beginning b. An error in math when calculating c. Amount of weight gain of mother in early weeks of pregnancy d. Mistaking implantation bleeding for last menstrual period (LMP)

d. Mistaking implantation bleeding for last menstrual period (LMP)

Prenatal testing is used to assess for genetic risks and to identify genetic disorders. In explaining to a couple about an elevated maternal serum alpha-fetoprotein screening test result, the nurse would discuss the need for: a. Special care needed for a Down syndrome infant. b. Immediate termination of the pregnancy based on results. c. A more specific determination of the acid-base status. d. More definitive evaluations to conclude anything.

d. More definitive evaluations to conclude anything. Increased maternal serum alpha-fetoprotein levels may indicate a neural tube defect, Turner syndrome, tetralogy of Fallot, multiple gestation, omphalocele, gastroschisis, or hydrocephaly. Therefore, additional information and more specific determinations need to be done before any conclusion can be made. Down syndrome is associated with decreased maternal serum alpha-fetoprotein levels.

Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of: a. Fetal gastrointestinal malformations. b. Maternal diabetes. c. Neural tube defects. d. Placental insufficiency.

d. Placental insufficiency. A deficiency of amniotic fluid, oligohydramnios, is associated with uteroplacental insufficiency and fetal renal abnormalities. Excess amniotic fluid is associated with maternal diabetes, neural tube defects, and malformations of the gastrointestinal tract and central nervous system.

The nurse is teaching a group of nursing students about pharmacologic interventions for pain in labor. The teaching has been effective when the students state that complications associated with epidural and spinal anesthesia include which conditions? Select all that apply. a. Maternal fever b. Aspiration c. Hypotension d. Pruritis e. Respiratory depression

d. Pruritis c. Hypotension e. Respiratory depression Hypotension is the most frequent side effect associated with epidural or intrathecal anesthesia. When opioids are used in addition to anesthetics, pruritus is a common side effect. Respiratory depression is another possible side effect when opioids are used for spinal and/or epidural anesthesia.

The nurse is caring for a multigravid client at 38 weeks' gestation and is reviewing diagnostic studies that estimate 1 liter of amniotic fluid surrounding the fetus. The nonstress test is reactive with a heart rate of 142 beats/min and moderate variability. The client verbalizes lower back discomfort. Which interpretation of the fetal status will the nurse make? a. There is limited amniotic fluid, but the fetal heart is not compromised. b. The mother is experiencing back labor pains, causing a rupture of membranes. c. The fetal heart is stressed, with an elevated heart rate and nonstress test reactivity. d. There is no concerning data. Fetal heart rate is normal and kidney function exists.

d. There is no concerning data. Fetal heart rate is normal and kidney function exists.

A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply. a. "They usually happen in a regular pattern." b. "They typically last for about 3 minutes each time you have them." c. "They often spread downward before they go away." d. "They go away when you walk around or change position." e. "They usually feel like a tightening across the top of your uterus."

e. "They usually feel like a tightening across the top of your uterus." c. "They often spread downward before they go away." d. "They go away when you walk around or change position." Braxton Hicks contractions are typically felt as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually spread downward before relaxing. In contrast, true labor contractions are more commonly felt in the lower back. These contractions aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix. However, the contractions are irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. Braxton Hicks contractions usually last about 30 seconds but can persist for as long as 2 minutes.

A multigravida client is concerned that she may deliver early. When asking the nurse what is the earliest her baby can be delivered and survive, which time frame would the nurse point out? a. The end of the fourth trimester b. The end of the third trimester c. The end of the first trimester d. The end of the second trimester

d. The end of the second trimester (14-26 weeks)

A pregnant woman undergoing amniocentesis asks her nurse why the baby needs this fluid. What would be an accurate response from the nurse? a. "Amniotic fluid cushions your baby to prevent injury." b. "Amniotic fluid supplies the food your baby needs to grow." c. "Amniotic fluid keeps the fetus from moving freely inside it to prevent injury." d. "Amniotic fluid provides fetal blood circulation."

a. "Amniotic fluid cushions your baby to prevent injury."

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies? a. "Tell me how you handled labor pain in your past deliveries." b. "Who do you want to be with you when you are in labor?" c. "Picking from these options, what options do you feel is best?" d. "How do you want the health care team to plan your care?"

a. "Tell me how you handled labor pain in your past deliveries." When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies.

The nurse is evaluating the fetal heart rate rhythm strip and determines that the amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding indicate to the nurse about variability? a. Variability is absent. b. Variability is normal. c. Variability is minimal. d. Variability is marked.

b. Variability is normal.

The nurse is caring for a client who is a primigravida. Which statement is best to improve the client's psyche? a. "Your second pregnancy will be easier." b. "You will be pushing very soon." c. "You will be finished soon." d. "You are doing a great job"

d. "You are doing a great job"

The fetal-assessment technique of a rhythm strip refers to: a. A fetal EKG, because it is effected by glucose stimulation. b. The response of fetal heart rate to oxytocin-stimulated contractions. c. A tracing of fetal heart rate and pattern. d. The rhythm of fetal heart rate compared to maternal pulse.

c. A tracing of fetal heart rate and pattern.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? a. Assess fetal heart rate. b. Assess for constipation. c. Assess maternal blood pressure. d. Assess for dry mouth.

a. Assess fetal heart rate. After administering an opioid to a laboring mother, the priority is to assess the impact on the fetus. Opioid administration can cross the placental barrier and affect fetal heart rate and variability. After birth, there may be a decrease in alertness of the neonate.

The client's pregnancy screening test shows that the maternal serum alpha-fetoprotein (MS-AFP) level is high. Which information should the nurse provide the client upon this finding? a. "A high level of MS-AFP is associated with neural tube defects. We will schedule you for another type of test to determine if your baby has a neural tube defect." b. "A high level of MS-AFP is associated with an increased risk of preterm labor. We will monitor you closely and start medication if needed." c. "A high level of MS-AFP is associated with a healthy fetus. We will not need to do any additional testing at this time." d. "A high level of MS-AFP is associated with Down syndrome. We will schedule you for another type of test to determine if your baby has Down syndrome."

a. "A high level of MS-AFP is associated with neural tube defects. We will schedule you for another type of test to determine if your baby has a neural tube defect." High levels of MS-AFP indicate an increased risk of a neural tube defect and need to be followed up with a diagnostic test. Low levels of MS-AFP are an indicator of increased risk for down syndrome.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? a. "It distracts your brain from the sensations of pain." b. "It causes the release of endorphins." c. "It blocks the transmission of nerve messages of pain at the receptors." d. "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

a. "It distracts your brain from the sensations of pain."

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? a. "The presenting part is at the true pelvis and is engaged." b. "This is just a way of determining your progress in labor." c. "This means +1 and the baby is entering the true pelvis." d. "This indicates that you start labor within the next 24 hours."

a. "The presenting part is at the true pelvis and is engaged." 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. What will the nurse document? a. Completion of the third stage of labor b. Completion of the fourth stage of labor c. Transition phase d. Attachment phase

a. Completion of the third stage of labor The third stage of labor ends with the expulsion of the placenta. Transition precedes the second stage and recovery follows later. The fourth stage begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1 to 4 hours after birth).

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: a. -2 station. b. 0 station. c. +2 station. d. Crowning.

a. -2 station. The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action? a. Complete bed rest b. Ambulation ad lib c. Up in chair TID d. Bathroom privileges

b. Ambulation ad lib To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.

A client has opted to receive epidural anesthesia during labor. Which intervention should the nurse implement to reduce the risk of a significant complication associated with this type of pain management? a. Administration of 500 mL of IV Ringer's lactate b. Administration of 1000 mL of IV glucose solution c. Move the woman into a supine position d. Administration of aspirin

a. Administration of 500 mL of IV Ringer's lactate The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This risk can be reduced by being certain a woman is well hydrated with 500 to 1000 mL of IV fluid, such as Ringer's lactate, before the anesthetic is administered. Ringer's lactate is preferable to a glucose solution because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn.

A nurse is caring for a client who is in the first stage of labor. Which action is helpful to make the client's labor and birth as natural as possible? a. Allow the client to be able to move about freely during labor. b. Implement routine intravenous fluid. c. Encourage independent labor progression and focus. d. Utilize the supine position for fetal monitoring.

a. Allow the client to be able to move about freely during labor. There are six major concepts that make labor and birth as natural as possible. One of these is that pregnant clients should be able to move about freely throughout labor, not be confined to bed. This request can be incorporated into the client's birth plan. Other concepts that make the birth as natural as possible include having support from a caring person selected by the client

A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function? a. Amniotic fluid volume b. Fetal breathing record c. Fetal heart rate d. Fetal reactivity

a. Amniotic fluid volume The fetal heart and breathing record measures short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.

The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage? a. Cervix b. Perineum c. Birth canal d. Back

a. Cervix The first stage of labor is when the cervix is dilating. The woman in labor will have pain from the stretching and dilation (dilatation) of the cervix. Stretching of the perineum and birth canal is associated with the second stage of labor. Not all women have back pain, and typically when they do it is referred pain from the lower abdomen and can happen in both the first and second stage of labor.

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? a. Clear to straw-colored fluid b. Greenish fluid c. Cloudy white fluid d. Bloody fluid

a. Clear to straw-colored fluid The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best? a. Continue to monitor the progress of labor. b. Prepare the client for cesarean birth of the fetus. c. Educate the client this fetal position may result in a longer labor. d. Auscultate fetal heart rate (FHR) in the left upper quadrant.

a. Continue to monitor the progress of labor. ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part. This is a common and favorable position for vaginal birth. Based on the ROA location, the nurse will auscultate FHR at the right lower quadrant of the client's abdomen (FHR will be loudest where the fetus' back is located). Occiput posterior (not anterior) positions are associated with longer, more difficult births.

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client? a. Continuous labor support b. Prenatal classes c. Pharmacologic pain management d. Massage therapy

a. Continuous labor support Continuous labor support by a caring nurse or doula can help decrease a woman's anxiety during labor. Anxiety causes the release of catecholamines, which slow down the labor process. The continuous support helps keep the woman focused on what is important as well as provide necessary guidance and education as needed.

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred? a. Engagement b. Expulsion c. Extension d. Flexion

a. Engagement The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? a. Fetal position b. Fetal attitude c. Fetal size d. Fetal Station

a. Fetal position When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.

Which complication occurs as a result of ineffective breathing patterns? a. Hyperventilation b. Flatus c. Hiccups d. Nausea

a. Hyperventilation Vigorous application of breathing techniques can lead to hyperventilation. If hyperventilation occurs, have the client breathe into cupped hands or a paper bag. Hyperventilation is directly related to the breathing pattern. The other options may occur for a variety of reasons during the labor process.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? a. Lie b. Position c. Attitude d. Presentation

a. Lie

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered? a. Naloxone b. Promethazine c. Fentanyl d. Butorphanol

a. Naloxone Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.

The client is having her blood drawn for a Triple or Quad screen. For what does this test screen? Select all that apply. a. Neural tube defects b. Pre-eclampsia c. Gestational diabetes d. Rubella e. Down syndrome

a. Neural tube defects e. Down syndrome Maternal blood is drawn between 15 and 20 weeks and is used in screening for Down syndrome and other trisomies, neural tube defects, gastroschisis, and other fetal abnormalities.

A group of nursing students are preparing a presentation that will illustrate various components of the birthing process. When discussing the pelvis, the students should point out that the pelvis is often referred to as which term? a. Passageway b. Powers c. Passenger d. Psyche

a. Passageway The passageway is one of the 4 Ps and involves the pelvis, both bony pelvis and the soft tissues, cervix, and vagina. The passenger refers to the fetus. The primary powers are the involuntary contractions of the uterus, whereas the secondary powers come from the maternal abdominal muscles. The psyche refers to the mother's mental state.

A client at 38 weeks' gestation is diagnosed with placental insufficiency. Which prescription from the health care provider will the nurse anticipate? a. Prepare the client for an induction of labor. b. Discharge the client home with daily nonstress testing. c. Assess the client's blood pressure every 2 hours. d. Administer one dose of betamethasone.

a. Prepare the client for an induction of labor. Placental insufficiency is a serious complication where the placenta no longer works properly to provide nutrition and oxygen to the fetus, nor remove waste products from the fetus. Because this client's fetus is at full term, the nurse would anticipate an induction of labor or a cesarean birth.

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? a. Respiratory depression b. Accidental intrathecal block c. A failed block d. Postdural puncture (spinal) headache

a. Respiratory depression Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

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? a. Take no extra measures; prepare for a standard labor. b. Notify the client's support person that the labor is typically long. c. Anticipate this client is a one-to-one registered nursing assignment. d. Prepare for vital signs and fetal monitoring hourly.

a. Take no extra measures; prepare for a standard labor. The gynecoid pelvis is most favorable for a vaginal birth. The rounded shape of the gynecoid inlet allows the fetus room to pass through the dimensions of the bony passageway.

The client may spend the latent phase of the first stage of labor at home unless which occurs? a. The client experiences a rupture of membranes b. The contractions vary in length and intensity c. The client begins back labor d. The client passes the bloody show

a. The client experiences a rupture of membranes Once the client experiences a rupture of membranes, the client is instructed to report to the health care facility. When the rupture of membranes occurs, there is a potential for infection. Also, assessment of the client is required as this is the time of greatest threat of a prolapsed cord.

When developing a labor plan with the client, which outcome is the priority? a. The client will direct her pain management techniques. b. The client will attend all prenatal classes prior to delivery. c. The client will be pain-free during the labor process. d. The client will deliver the fetus vaginally.

a. The client will direct her pain management techniques. Clients who have their pain managed report higher satisfaction with the birth experience. By working with the nurse in determining the labor plan, the health care provider, nurse, and client can work together to obtain a plan to manage labor pain. This puts the client in control of her care.

A 33-year-old pregnant client asks the nurse about testing for birth defects that are safe for both her and her fetus. Which test would the nurse state as being safe and noninvasive? a. Ultrasound b. Chorionic villus sampling c. Amniocentesis d. Percutaneous umbilical cord sampling

a. Ultrasound

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? a. "My cervix should be dilated more than 5 cm before I try using this method." b. "The temperature of the water should be at least 105℉ (40.5℃)." c. "The warmth and buoyancy of the water has a nice relaxing effect." d. "I can stay in the bath for as long as I feel comfortable."

b. "The temperature of the water should be at least 105℉ (40.5℃)." Hydrotherapy is an effective pain relief method. The water temperature should not exceed body temperature. Therefore, a temperature of 105℉ (40.5℃) would be too warm. The warmth and buoyancy have a relaxing effect, and women are encouraged to stay in the bath as long as they feel comfortable. The woman should be in active labor with cervical dilation greater than 5 cm.

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range? a. 90 to 140 bpm b. 110 to 160 bpm c. 120 to 170 bpm d. 100 to 150 bpm

b. 110 to 160 bpm

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? a. 5 to 7 b. 8 to 10 c. 3 to 4 d. 0 to 2

b. 8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation (dilatation) would be 8 cm to 10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

The nurse is reporting a maternal serum alpha-fetoprotein (MSAFP) level of 2.5 MoM on shift hand-off. The oncoming nurse would be correct to initiate a teaching plan related to the fetus being at higher risk for which condition? a. Tay-Sachs disease b. Down syndrome c. Edwards syndrome d. Hemophilia A

b. Down syndrome The nurse is correct to interpret the lab results and develop a teaching plan. The nurse would teach the client that since the serum level is elevated above 2 MoM, there is a significant risk of Down syndrome.

A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? a. Agree with the client, and administer the drug immediately to keep the pain manageable. b. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. c. Explain to the client that opioids should only be administered an hour or less before birth. d. Refuse to administer opioids because they can develop dependency in the client and the fetus.

b. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. The timing of administration of opioids in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, opioids are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth? a. Vaginal b. Cesarean c. Forceps-assisted d. Vacuum extraction

b. Cesarean The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? a. Alleviating perineal discomfort with the application of ice packs b. Encouraging the client to push when they have a strong desire to do so c. Palpating the client's fundus for position and firmness d. Completing the identification process of the newborn with the pregnant parent

b. Encouraging the client to push when they have a strong desire to do so During the second stage of labor, nursing interventions focus on motivating the client, encouraging the client to put all their efforts toward pushing.

The nurse is conducting an obstetrics assessment on a client at 20 weeks' gestation who is questioning the nurse about the development of the fetus. Which new occurring developments can the nurse point out to this client? a. Lungs are fully shaped. b. Eyebrows and scalp hair are present. c. Eyelids are open. d. A developed startle reflex is evident.

b. Eyebrows and scalp hair are present. At 20 weeks, the fetus is still developing. All structures are present, but not in full size. The fetus will have limited amounts of eyebrows and scalp hair. At 20 weeks, the eyelids are not present; the lungs are present, but not developed. The startle reflex will not be evident until after birth.

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? a. Fetal presentation b. Fetal lie c. Fetal attitude d. Fetal position

b. Fetal lie

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? a. Risk factors b. Fetal status c. Maternal status d. Maternal obstetrical history

b. Fetal status The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately.

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? a. Rapid progress of labor b. Inability to push c. Dry, cracked lips d. Urinary retention

b. Inability to push If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

A woman at 15 weeks' gestation is about to undergo amniocentesis. Which nursing intervention should be made first? a. Have the client void. b. Obtain a signed consent form. c. Observe the fetal heart rate monitor. d. Place the client in supine position.

b. Obtain a signed consent form. Nursing responsibilities for assessment procedures include seeing a signed consent form has been obtained as needed (necessary if the procedure poses any risk to the mother or fetus that would not otherwise be present, as is the case with amniocentesis). All of the answers are nursing interventions that should be made before or during amniocentesis, but having the client sign a consent form should be completed before the others.

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer? a. Midline but low on the abdomen b. On the uterine fundus c. On the right side of the abdomen d. At the level of the umbilicus

b. On the uterine fundus

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 prioritize at this stage? a. Administering an opioid such as meperidine or fentanyl b. Practicing effleurage on the abdomen c. Immersing the client in warm water in a pool or hot tub d. Administering a sedative such as secobarbital or pentobarbital

b. Practicing effleurage on the abdomen In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage.

A client comes to the clinic with concerns about her pregnancy. She is in her first trimester and is now experiencing moderate abdominal pain on the right side. What would be the nurse's first action? a. Reassure the mother that this is normal as the baby is implanting into the uterus. b. Recommend an abdominal ultrasound to the doctor since this may be ectopic pregnancy. c. Obtain a detailed 24-hour intake to determine if the pain is related to what she has eaten. d. Encourage her to ambulate since gas pains are common in early pregnancy.

b. Recommend an abdominal ultrasound to the doctor since this may be ectopic pregnancy. The nurse should recognize that abdominal pain is not normal during pregnancy and warrants investigation since ectopic pregnancy is a distinct possibility. An abdominal ultrasound would be best practice for this complaint. Dismissing her reports as normal is not a wise choice.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? a. The client has contractions once every two minutes. b. The client's cervix is fully dilated. c. The infant is born. d. The client experiences her first full contraction.

b. The client's cervix is fully dilated. The first stage of labor ends with the client's cervix being fully dilated at 10 cm. The onset of contractions signals the beginning of the first stage and birth occurs at the end of the second stage.

A nurse is performing a physical assessment of a pregnant client at term who is in labor. The nurse assesses the client's fundal height, expecting to find it at which location? a. The symphysis b. The xiphoid process c. Between the symphysis and umbilicus d. The umbilicus

b. The xiphoid process Assessing a pregnant client's abdomen is important to estimate fetal size by fundal height (which should be at the level of the xiphoid process at term).

The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? a. Pain perception is decreased if anxiety is present. b. These methods are a technique to prevent the painful stimuli from entering the brain. c. The gating mechanism is located at the pain site. d. The gating mechanism opens so all the stimuli pass through to the brain.

b. These methods are a technique to prevent the painful stimuli from entering the brain. Gate-control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location. Gate control does not need to be applied directly to the site of the pain. Anxiety heightens the painful feelings. Gating blocks the flow of painful stimuli to the sensory centers in the brain.

A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure? a. To decrease the heart rate of the fetus b. To prevent supine hypotension syndrome. c. To prevent the woman from falling out of bed d. To aid the woman as she pushes during labor

b. To prevent supine hypotension syndrome.

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication? a. Inadequate pain block b. Uterine atony c. Pruritus d. Maternal hypotension

b. Uterine atony A complication of general anesthesia is the relaxation of the uterine muscles, leading to uterine atony and possible postpartum hemorrhage. Maternal hypotension, a failed block, and pruritus are side effects of epidural analgesia.

A client is to have an amniocentesis with ultrasound. What does the nurse explain to the client that amniocentesis can determine? Select all that apply. a. What the eye color of the baby will be b. Whether the fetal lungs are mature enough to support respiration outside of the womb c. What type of facial features the fetus will have d. The amniotic fluid can be used for genetic testing e. How much the fetus will weigh at birth

b. Whether the fetal lungs are mature enough to support respiration outside of the womb d. The amniotic fluid can be used for genetic testing

A nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information? a. "False labor contractions are regular." b. "False labor contractions intensify with walking." c. "False labor contractions usually occur in the abdomen." d. "False labor contractions move from the back to the front of the abdomen."

c. "False labor contractions usually occur in the abdomen." False labor contractions are usually felt in the abdomen, are irregular, and are typically relieved by walking. True labor contractions move from the back to the front of the abdomen, are regular, and aren't relieved by walking.

Which statement is true regarding analgesia versus anesthesia? a. Increased FHR variability is a common side effect when regional anesthesia is used. b. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. c. Analgesia and anesthesia perform the same function when it comes to blocking pain. d. Hypertension is the most common side effect when systemic analgesia is used.

c. Analgesia and anesthesia perform the same function when it comes to blocking pain. Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

The nurse's note (above) was documented by the client's labor nurse minutes after epidural initiation. What action should the nurse take first? a. Administer oxygen at 8 to 10 liters per minute. b. Offer IV ondansetron. c. Assess blood pressure. d. Initiate 500 ml IV fluid bolus.

c. Assess blood pressure. Hypotension is a common side effect after epidural block and can cause nausea, dizziness, and lightheadedness. The nurse should first reassess the blood pressure to determine if hypotension is the cause of these symptoms. The hypotension may be treated with an IV fluid bolus or with an antihypotensive agent such as ephedrine.

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? a. Braxton Hicks contractions get closer together with activity. b. Braxton Hicks contractions do not last long enough to be true labor. c. Braxton Hicks contractions usually decrease in intensity with walking. d. Braxton Hicks contractions cause "ripening" of the cervix.

c. Braxton Hicks contractions usually decrease in intensity with walking. Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular, practice contractions usually decrease in intensity with walking and position changes.

A nurse notes the digital readings of the electronic fetal monitor show decreased beat-to-beat variability in a client who was just admitted to the unit. The nurse interprets this as indicating which system is mainly being affected in the fetus? a. Genitourinary system b. Musculoskeletal system c. Central nervous system (CNS) d. Gastrointestinal system

c. Central nervous system (CNS) Baseline variability is the beat-to-beat variations in the fetal heart rate (FHR), which is a normal FHR finding. Decreased beat-to-beat variability indicates CNS involvement.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? a. Admission time and time of fetal birth b. Time of mucus plug expulsion and full cervical dilation c. Complete cervical dilation (dilatation) and time of fetal birth d. Effacement time and time when contractions are regular

c. Complete cervical dilation (dilatation) and time of fetal birth The second stage of labor begins with complete cervical dilation (dilatation) of 10 cm and ends with delivery of the neonate.

A nonstress test is an assessment test based on which phenomenon? a. Fetal heart rate slows in response to a uterine contraction. b. Fetal movement causes an increase in maternal heart rate. c. Fetal heart sounds increase in connection with fetal movement. d. Braxton-Hicks contractions cause fetal heart-rate alterations.

c. Fetal heart sounds increase in connection with fetal movement.

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? a. Fetal presentation b. Fetal attitude c. Fetal lie d. Fetal position

c. Fetal lie

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? a. Fetal heart rate b. Irregular contractions c. Green-colored fluid in the vagina d. Possible maternal infection

c. Green-colored fluid in the vagina

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? a. Have the client divert the energy to squeezing a hand. b. Assist the client to a Fowler position. c. Have the client pant and blow through the contraction. d. Have the client lightly push to meet the need.

c. Have the client pant and blow through the contraction. The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time.

Assessment for surfactant level via lecithin/sphingomyelin (L/S) ratio in the amniotic fluid is a primary estimation of fetal maturity. The purpose of surfactant is to: a. Promote maturation of lung alveoli. b. Encourage immunologic competence of lung tissue. c. Prevent alveoli from collapsing on expiration. d. Increase lung resistance on inspiration.

c. Prevent alveoli from collapsing on expiration. Surfactant is a phospholipid that reduces surface tension; it prevents alveoli from collapsing on expiration. Resistance to airflow is an effect of tissue elasticity and airway size. Immunologic competence is provided by antibodies in the mucus layer. Fully matured alveoli contain squamous cells as well as type II surfactant cells.

While in utero, a fetus swallows many substances that are deposited in the fetal intestinal system as meconium. What problem can arise from this occurrence? a. Meconium-stained fluids cause an increased risk of jaundice. b. The fetus can become constipated following birth. c. If the fetus becomes stressed, the meconium is released into the amniotic fluid, placing the fetus at risk for pneumonia. d. Abdominal distension occurs and infection can set in.

c. If the fetus becomes stressed, the meconium is released into the amniotic fluid, placing the fetus at risk for pneumonia. Infants develop meconium in their intestines; if they are stressed or hypoxic, the anal sphincter relaxes and meconium is passed into the amniotic fluid. This poses a danger to the fetus since they breathe in this fluid and swallow it. The meconium lines the lungs and respiratory passages, making it difficult for the infant to breathe once it is born.

A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? a. Contact the primary care provider. b. Auscultate the fetal heart tones. c. Inspect the perineum. d. Time the contractions.

c. Inspect the perineum. The nurse needs to determine if birth is imminent by assessing the perineum and be prepared for birth. Once the nurse assesses the coming labor, she can then assess the heart sounds, contraction rate, and contact the primary care provider—if there is time.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? a. Brow b. Shoulders c. Occiput d. Buttocks

c. Occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team? a. Assist the providers in the delivery room. b. Observatory to assist the RN. c. Provide care under the supervision of an RN. d. Provide direct independent care to the client.

c. Provide care under the supervision of an RN. The LPN may provide care within the appropriate scope of practice under the direct supervision of an RN. The RN is responsible for providing direct independent care of the client. Both LPN/LVNs and RNs assist health care providers in the delivery room. The LPN/LVNs provide more than just observatory functions for the RN.

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? a. Decrease in duration of contractions b. Decrease in vaginal secretions c. Rupture of amniotic membranes d. Development of a membrane further closing the cervix

c. Rupture of amniotic membranes The nurse should identify the rupture of amniotic membranes as the best indicator of approaching labor. In labor, the client experiences increased vaginal secretions, increased duration of contractions, and also loss of mucus plug.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings? a. The client can be sent home. b. The client is in active labor. c. The frequency of the contractions is every 5 minutes. d. The duration of the contractions is every 5 minutes.

c. The frequency of the contractions is every 5 minutes. Based on the information, the nurse knows the contractions are regular and every 5 minutes apart.

The nurse is preparing a 38-year-old primigravid client for an amniocentesis. Which nursing consideration is appropriate regarding the testing process? a. Instruct the client that minor bleeding and cramping are common. b. Monitor the client's vital signs during the test and hourly afterward for 8 hours. c. Use an external fetal heart monitor during the test to ensure the fetus is not in distress. d. Instruct the client not to empty their bladder before the test.

c. Use an external fetal heart monitor during the test to ensure the fetus is not in distress. The nurse should monitor fetal heart tones (FHTs) to ensure that the fetus is not in distress; the external fetal monitor is most often used. The nurse should also instruct the client to empty their bladder before the test (to prevent bladder rupture) and monitor the client's vital signs during the test and for at least 1 hour afterward. This is an outpatient procedure so the client would not be present for 8 hours. The client should be instructed to notify the health care provider if they have any difficulties after returning home, including any bleeding or cramping.

A pregnant client scheduled for an amniocentesis asks the nurse how the placenta is not punctured during the procedure. How should the nurse respond to the client? a. "A uterus feels soft over the placenta site." b. "Placentas always form on the posterior uterine wall." c. "It would not be harmful even if it were punctured." d. "A sonogram to locate it will be done first."

d. "A sonogram to locate it will be done first." After the client is placed in the supine position, a sonogram is done to determine the position of the fetus, the location of a pocket of amniotic fluid, and the placenta. The uterus does not feel soft over the placenta site. It would be harmful if the placenta were punctured during the procedure. Placentas do not always form on the posterior uterine wall.

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? a. "I feel the tightening primarily in the front of my belly." b. "The contractions lessen after I drink a large glass of water." c. "I will have a strong one and then the next one will be weaker." d. "I feel pressure in my vagina when I have the contraction."

d. "I feel pressure in my vagina when I have the contraction." True labor is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement. True labor contractions are regular, becoming closer together, getting stronger with time with pressure in the vagina being felt. In contrast, false labor contractions are usually felt in the front of the abdomen, alternate in intensity (strong one followed by a weaker one), and diminish with activity, position changes, and drinking fluids.

A multigravida client at 39 weeks' gestation has been in labor for 8 hours without much change. The last vaginal exam revealed cervix 8 cm dilated and 0 station. Which is the best response if the client asks the nurse how far the fetus has advanced in the past half hour? a. "Checking your cervix will not speed up labor; let's wait." b. "The health care provider will have to check you. I'll call him." c. "I can arrange for a cervix check, if you want." d. "Once your labor signs change, we can find out."

d. "Once your labor signs change, we can find out." The cervix must be assessed with a vaginal exam. The frequency of vaginal exams is based on the signs of changes in labor. The client has not demonstrated any changes in her labor pattern; the nurse should provide education on the reason for not checking her. Frequent exams can interfere with the labor process as well as increase the risk of infection.

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best? a. "The analgesia will limit your ability to be out of bed without assistance." b. "The analgesia will block pain sensation and limit your ability to push." c. "The analgesia will allow for a pain-free birth experience." d. "The analgesia will reduce the sensation of pain for a limited period of time."

d. "The analgesia will reduce the sensation of pain for a limited period of time." It is best to prepare the client for the role of analgesia in her labor experience. It is best to explain that analgesia will reduce, not block or eliminate, the pain sensation for a limited period of time depending upon the medication selected

Fetal heart rate monitoring reveals baseline tachycardia in the fetus. Which rate would be most likely? a. 154 beats per minute b. 134 beats per minute c. 144 beats per minute d. 164 beats per minute

d. 164 beats per minute

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? a. Regular contractions b. Placental separation c. Fetal movement through the birth canal d. Cervical dilation (dilatation)

d. Cervical dilation (dilatation) The primary change occurring during the first stage of labor is progressive cervical dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal movement through the birth canal is the major change during the second stage of labor. Placental separation occurs during the third stage of labor.

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first? a. Notify the registered nurse. b. Wait 2 minutes to review another tracing. c. Notify the health care provider. d. Assess and reposition the woman.

d. Assess and reposition the woman. Due to maternal movement, the fetal heart monitor may become dislodged and not provide accurate tracings. Reposition and assess the woman to note any change with the next contraction. If concern remains, notify the registered nurse. The registered nurse will interpret the tracing and notify the health care provider.

A woman has just learned that she is pregnant and would like to know how soon she can find out via ultrasound the sex of her fetus. The nurse should respond with which of the following? a. At about 6 months b. Fetal gender can only be determined by analysis of maternal serum. c. At about 2 months d. At about 4 months

d. At about 4 months

A pregnant woman is asked to observe fetal movements as a fetal-assessment technique. You would instruct her to: a. Count only movements that are strong enough to hurt. b. Choose a different time frame each day to count movements. c. Report if she feels no movement for any half-hour period. d. Count fetal movements for 1 hour at the same time each day.

d. Count fetal movements for 1 hour at the same time each day. A healthy fetus moves at least 10 times daily. Counting fetal movements at the same time each day can help document fetal health.

Which cardinal movement of delivery is the nurse correct to document by station? a. Internal rotation b. Flexion c. Extension d. Descent

d. Descent Descent is documented by station, which is the relationship of the fetal presenting part to the maternal ischial spines.

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? a. Fetal baseline rate increasing at least 5 mm Hg with contractions b. Variable decelerations, too unpredictable to count c. A shallow deceleration occurring with the beginning of contractions d. Fetal heart rate declining late with contractions and remaining depressed

d. Fetal heart rate declining late with contractions and remaining depressed

Which is the most important nursing assessment of the mother during the fourth stage of labor? a. Heart rate b. Blood pressure c. The mother's psyche d. Hemorrhage

d. Hemorrhage During the fourth stage of labor, there is a period of recovery for the mother after delivery of the placenta. During this time, the nurse's assessment focuses heavily on watching for signs of hemorrhage. Hemorrhage may occur from such things as lacerations or retained placenta fragments.

A client calls the health care facility stating that they are in labor. The nurse would urge the client to come to the facility if the client reports which symptom? a. Increased energy level with alternating strong and weak contractions b. Pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds c. Contractions noted in the front of the abdomen that stop when the client walks d. Moderately strong contractions every 4 minutes, lasting about 1 minute

d. Moderately strong contractions every 4 minutes, lasting about 1 minute Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

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? a. Pain is focal in nature. b. It is reported as the worst pain a woman will ever feel. c. Diffuse abdominal pain signals a complication with progression of labor. d. Pain originates from the cervix and lower uterine segment.

d. Pain originates from the cervix and lower uterine segment. Pain sensations associated with labor originate from different places depending on the stage of labor. During the first stage of labor, the stretching required to efface and dilate the cervix stimulates pain receptors in the cervix and lower uterine segment.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? a. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her. b. Gently remind the client of her goal of a natural birth and encourage and help her. c. Suggest a less extreme alternative such as a sedative. d. Support the client's decision and call the provider.

d. Support the client's decision and call the provider. Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

When describing the characteristics of the amniotic fluid to a pregnant woman, the nurse would include which information? a. It limits fetal movement in utero. b. It is composed primarily of organic substances. c. It is usually an acidic fluid. d. The amount gradually fluctuates during pregnancy.

d. The amount gradually fluctuates during pregnancy. Amniotic fluid is alkaline. Amniotic fluid is composed of 98% water and 2% organic matter. Amniotic fluid volume gradually fluctuates throughout pregnancy. Sufficient amounts promote fetal movement to enhance musculoskeletal development.

A client has just received combined spinal epidural. Which nursing assessment should be performed first? a. Assess for fetal tachycardia. b. Assess for spontaneous rupture of membranes. c. Assess for progress in labor. d. Assess pain level using a pain scale. e. Assess vital signs.

e. Assess vital signs. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

The nurse is assessing a young female who just found out she is pregnant. She is now reporting vague abdominal discomfort. After noting the client has a history of PID, the nurse predicts the health care provider will give priority to ruling out which situation? a. UTI b. Endometriosis c. Ectopic pregnancy d. Repeat PID

c. Ectopic pregnancy An ectopic pregnancy or tubal pregnancy can result when there is blockage or scarring of the fallopian tubes due to infection (PID) or trauma (tubal ligation reversal). Ectopic pregnancy may present with vague signs and symptoms but is the leading cause of maternal death in the first trimester and should be given priority when determining the cause of abdominal complaints. The other choices would be ruled out after the ectopic pregnancy is ruled out.