Exam 2 Maternal

A nurse is developing a plan of care for a PP woman with hemorrhoids. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? 1.Assess vital signs every 4 hours 2.Inform health care provider of assessment findings 3.Measure fundal height every 4 hours 4.Prepare an ice pack for application to the area.

4.Prepare an ice pack for application to the area. Application of ice will reduce swelling caused by hemorrhoids.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: 1.Uses soap and warm water to wash the vulva and perineum 2.Washes from symphysis pubis back to episiotomy 3.Changes her perineal pad every 2 - 3 hours 4.Uses the peribottle to rinse upward into her vagina

4.Uses the peribottle to rinse upward into her vagina Responses 1, 2, and 3 are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? 1. To provide analgesia 2. To relax the uterus 3. To induce labor 4. To prevent hemorrhage

2. To relax the uterus

46. The health care provider's prescription reads diphenhydramine (Benadryl), 25 mg IV stat. The medication vial reads diphenhydramine (Benadryl), 50 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Record your answer to one decimal point. _____ mL

0.5 mL Desired/available ´ volume = milliliters per dose 25 mg/50 mg ´ 1 mL = 0.5 mL/per dose

Select all of the physiological maternal changes that occur during the PP period. 1.Cervical involution ceases immediately 2.Vaginal distention decreases slowly 3.Fundus begins to descend into the pelvis after 24 hours 4.Cardiac output decreases with resultant tachycardia in the first 24 hours 5.Digestive processes slow immediately.

1 and 3. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.

A client at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound. What should be included in the nursing plan? Select all that apply. 1. No vaginal exams 2. Encouraging activity 3. No intravenous access until labor begins 4. Evaluating fetal heart rate with an external monitor 5. Monitoring blood loss, pain, and uterine contractility

1, 4, 5 Explanation: 1. Expectant management of placenta previa is made by localizing the placenta via tests that require no vaginal examination. 4. Expectant management of placenta previa, when the client is at less than 37 weeks' gestation, includes evaluating FHR with an external monitor. 5. Expectant management of placenta previa, when the client is at less than 37 weeks' gestation, includes monitoring blood loss, pain, and uterine contractility.

The nurse is admitting a client for a cerclage procedure. The client asks for information about the procedure. What is the nurse's most accurate response? 1. "A stitch is placed in the cervix to prevent a spontaneous abortion or premature birth." 2. "The procedure is done during the third trimester." 3. "Cerclage is always placed after the cervix has dilated and effaced." 4. "An uncomplicated elective cerclage may is done on inpatient basis."

1. "A stitch is placed in the cervix to prevent a spontaneous abortion or premature birth."

A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? 1. A soaked perineal pad since the last 15-minute check 2. An edematous perineum 3. The client experiencing tremors 4. A fundus located at the umbilicus

1. A soaked perineal pad since the last 15-minute check If the perineal pad becomes soaked in a 15-minute period or if blood pools under the buttocks, continuous observation is necessary. As long as the woman remains in bed during the first hour, bleeding should not exceed saturation of one pad.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: 1. Assess for hypovolemia and notify the health care provider 2. Begin hourly pad counts and reassure the client 3. Begin fundal massage and start oxygen by mask 4. Elevate the head of the bed and assess vital signs

1. Assess for hypovolemia and notify the health care provider Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the client to change position. 2. Apply oxygen to the client at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid.

1. Assist the client to change position The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava.

Two hours ago, a client at 39 weeks' gestation was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every 5 minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40-50 seconds' duration and intensity of 40 mmHg. What would the priority intervention be? 1. Begin oxytocin after assessing for CPD. 2. Give terbutaline to stop the preterm labor. 3. Start oxygen at 8 L/min. 4. Have the anesthesiologist give the client an epidural.

1. Begin oxytocin after assessing for CPD. The client is having hypertonic contractions. Cephalopelvic disproportion (CPD) must be excluded. If CPD exists, oxytocin (Pitocin) augmentation should not be used. Oxytocin is the drug of choice for labor augmentation or labor induction.

The labor nurse is caring for a client at 38 weeks' gestation who has been diagnosed with symptomatic placenta previa. Which physician order should the nurse question? 1. Begin oxytocin drip rate at 0.5 milliunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1. Begin oxytocin drip rate at 0.5 milliunits/min.

Risk factors for tachysystole include which of the following? Select all that apply. 1. Cocaine use 2. Placental abruption 3. Low-dose oxytocin titration regimens 4. Uterine rupture 5. Smoking

1. Cocaine use 2. Placental abruption 4. Uterine rupture

The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowler's position.

1. Document the fetal heart rate. The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary.

Upon assessing the FHR tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Select all that apply. 1. Early fetal hypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 4. Fetal sleep cycle 5. Infection

1. Early fetal hypoxia 2. Prolonged fetal stimulation 3. Fetal anemia 5. Infection

Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? 1. Massage the fundus until firm 2. Express retained clots 3. Increase the intravenous solution 4. Call the physician

1. Massage the fundus until firm When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm.

The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following? Select all that apply. 1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 4. Central nervous system malformation 5. Late fetal asphyxia

1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 5. Late fetal asphyxia

A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for? 1. Oxytocin induction of labor 2. Amnioinfusion 3. Increased intravenous infusion 4. Cesarean section

1. Oxytocin induction of labor Oxytocin is the drug of choice for labor augmentation or labor induction and may be administered as needed for hypotonic labor patterns.

Which of the following behaviors characterizes the PP mother in the taking in phase? 1. Passive and dependent 2. Striving for independence and autonomy 3. Curious and interested in care of the baby 4. Exhibiting maximum readiness for new learning

1. Passive and dependent During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.

A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be? 1. Perform a vaginal exam. 2. Notify the physician. 3. Place the client in a left lateral position. 4. Administer oxygen at 2 L per nasal cannula.

1. Perform a vaginal exam. A drop in fetal heart rate accompanied by variable decelerations is consistent with a prolapsed cord. The nurse would assess for prolapsed cord via vaginal examination.

Which of the following conditions would predispose a client for thrombophlebitis? 1. Severe anemia 2. Cesarean delivery 3. Anorexia 4. Hypocoagulability

1. Severe anemia

During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make? 1. The client appears interested in learning about neonatal care 2. The client talks a lot about her birth experience 3. The client sleeps whenever the neonate isn't present 4. The client requests help in choosing a name for the neonate.

1. The client appears interested in learning about neonatal care The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for independence and is eager for her neonate. The other options describe the phase in which the mother relives her birth experience.

The nurse has received end-of-shift reports in the high-risk maternity unit. Which client should the nurse see first? 1. The client at 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 2. The client at 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. The client at 35 weeks' gestation with grade I abruptio placentae in labor who has a strong urge to push 4. The client at 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously

1. The client at 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement Assessment of the woman with placenta previa must be ongoing to prevent or treat complications that are potentially lethal to the mother and fetus. Painless, bright red vaginal bleeding is the best diagnostic sign of placenta previa. This client is the highest priority.

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done? 1. To contract the uterus and minimize bleeding 2. To decrease breast milk production 3. To decrease maternal blood pressure 4. To increase maternal blood pressure

1. To contract the uterus and minimize bleeding

A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect? 1. Blood pressure 2. Temperature 3. Pulse 4. Respiration

2. Temperature Rupture of membranes places the mother at risk for infection. The temperature is the primary and often the first indication of a problem.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? 1. A temperature of 100.4*F 2. An increase in the pulse from 88 to 102 BPM 3. An increase in the respiratory rate from 18 to 22 breaths per minute 4. A blood pressure change from 130/88 to 124/80 mm Hg

2. An increase in the pulse from 88 to 102 BPM During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.

A patient has a nonreassuring fetal status occurring with a tachysystole contraction pattern. Which intrauterine resuscitation measures are warranted? Select all that apply. 1. Position the woman on her right side. 2. Apply oxygen via face mask. 3. Call for anesthesia provider for support. 4. Increase intravenous fluids by at least 700 mL bolus. 5. Call the physician/CNM to the bedside.

2. Apply oxygen via face mask. 3. Call for anesthesia provider for support. 4. Increase intravenous fluids by at least 700 mL bolus.

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: 1. Amount of lochia 2. Blood pressure 3. Deep tendon reflexes 4. Uterine tone

2. Blood pressure Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: 1. Every 30 minutes during the first hour and then every hour for the next two hours. 2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. 3. Every hour for the first 2 hours and then every 4 hours 4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

The nurse is preforming an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm3

2. Fetal heart rate of 180 beats/minute

The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Encourage the husband to remain in the room. 2. Keep the client on bed rest at this time. 3. Apply an internal fetal scalp electrode. 4. Obtain a clean-catch urine specimen.

2. Keep the client on bed rest at this time. Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on assessment? 1. Proteinuria of 3+ 2. Respirations of 10 breaths per minute 3. Presence of deep tendon reflexes 4. Serum magnesium level of 6 milliequivilents per liter

2. Respirations of 10 breaths per minute

During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be? 1. To help the fetal head descend faster 2. To use gravity and manipulation to relieve compression on the cord 3. To facilitate dilation of the cervix with prostaglandin gel 4. To prevent head compression

2. To use gravity and manipulation to relieve compression on the cord The top priority is to relieve compression on the umbilical cord to allow blood flow to reach the fetus. It is because some obstetric maneuvers to relieve cord compression are complicated that cesarean birth is sometimes necessary.

The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? 1. "I'll get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I'll bring you an extra so that you can change it when you are ready."

3. "You need to leave it off for at least 20 minutes and then reapply."

A client is admitted to the labor and delivery unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. What is this client at risk for? 1. Gestational diabetes 2. Placenta previa 3. Abruptio placentae 4. Placenta accreta

3. Abruptio placentae Abruptio placentae is more frequent in pregnancies complicated by smoking, premature rupture of membranes, multiple gestation, advanced maternal age, cocaine use, chorioamnionitis, and hypertension.

The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? 1. Late decelerations 2. Early decelerations 3. Accelerations 4. Fetal dysrhythmia

3. Accelerations A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the FHR.

Five clients are in active labor in the labor unit. Which women should the nurse monitor carefully for the potential of uterine rupture? Select all that apply. 1. Age 15, in active labor 2. Age 22, with eclampsia 3. Age 25, last delivery by cesarean section 4. Age 32, first baby died during labor 5. Age 27, last delivery 11 months ago

3. Age 25, last delivery by cesarean section 5. Age 27, last delivery 11 months ago

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature? 1. Every hour 2. Every 2 hours 3. Every 4 hours 4. Every shift

3. Every 4 hours Maternal temperature is taken every 4 hours unless it is above 37.5°C. If elevated, it is taken every hour.

A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for: 1. Dysuria, ecchymosis, and vertigo 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and epistaxis 4. Hematuria, ecchymosis, and vertigo

3. Hematuria, ecchymosis, and epistaxis The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

A nurse is assessing a client who is 6 hours post-partum after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Elevate the client's legs. 2. Determine the hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn infant to the client until the feelings of faintness and dizziness have subsided.

3. Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.

Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? 1. Mediolateral 2. Episiorrhaphy 3. Midline 4. Medical

3. Midline

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured 3. The cervix is completely dilated 4. The client starts to expel clear vaginal fluid

3. The cervix is completely dilated

A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? 1. Latent phase 2. Active phase 3. Transition phase 4. Fourth stage

3. Transition phase The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense.

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy & how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling her that: 1.Return to prepregnant weight is usually achieved by the end of the postpartum period 2.Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight loss 3.The expected weight loss immediately after birth averages about 11 to 13 pounds 4.Lactation will inhibit weight loss since caloric intake must increase to support milk production

3.The expected weight loss immediately after birth averages about 11 to 13 pounds Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? 1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." 2. "I can use analgesics to assist in alleviating some of the discomfort." 3. "I need to wear a supportive bra to relieve the discomfort." 4. "I need to stop breastfeeding until this condition resolves."

4. "I need to stop breastfeeding until this condition resolves." In most cases, the mother can continue to breast feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? 1. Change the client's position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring.

4. Begin continuous fetal heart rate monitoring.

A postpartum nurse is taking the vital signs of a client who delivered a healthy infant 4 hours ago. The nurse notes that the client's temperature is 100.2 degrees Farenheit. Which of the following actions would be appropriate? 1. Notify the physician. 2. Document the findings. 3. Retake the temperature in 15 minutes. 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor.

During a maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in what quadrant? 1. Right upper quadrant 2. Left upper quadrant 3. Right lower quadrant 4. Left lower quadrant

4. Left lower quadrant The fetal heart rate (FHR) is heard most clearly at the fetal back. Thus, in a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen.

On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? 1. Depression phase 2. Letting-go phase 3. Taking-hold phase 4. Taking-in phase

4. Taking-in phase The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives. The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as the infants care. The letting-go phase begins several weeks later, when the mother incorporates the new infant into the family unit.

After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression

4. Umbilical cord compression Variable decelerations occur when there is umbilical cord compression

Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? 1. Cervical laceration 2. Clotting deficiency 3. Perineal laceration 4. Uterine subinvolution

4. Uterine subinvolution Late postpartum bleeding is often the result of subinvolution of the uterus. Retained products of conception or infection often cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may also have an immediate PP hemorrhage if the deficiency isn't corrected at the time of delivery.

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a. "I may not have a bowel movement until the 2nd postpartum day." b. "If I breastfeed and supplement with formula, I won't need any birth control." c. "I know my normal pattern of bowel elimination won't return until about 8 to 10 days." d. "If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband."

ANS: B "If I breastfeed and supplement with formula, I won't need any birth control." For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.

The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 4- to 6-inch stain on the peripad c. 1- to 4-inch stain on the peripad d. Less than a 1-inch stain on the peripad

ANS: B 4- to 6-inch stain on the peripad Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: · Scant—less than a 1-inch stain on the peripad · Light—1- to 4-inch stain · Moderate—4- to 6-inch stain · Heavy—saturated peripad · Excessive—saturated peripad in 15 minutes

47. The nurse is administering fentanyl (Sublimaze) to a client in labor. The health care provider's prescription reads fentanyl (Sublimaze), 100 mcg IV stat. The medication vial reads fentanyl (Sublimaze), 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Record your answer as a whole number.

ANS: 2 mL Desired/available ´ volume = milliliters per dose 100 mcg/50 mcg ´ 1 mL = 2 mL/dose

Which of the following factors would affect pain perception or tolerance for the laboring client? a. Right occiput posterior fetal position during labor b. Bishop score of 10 prior to the induction of labor c. Gynecoid pelvis d. Absence of Ferguson's reflex

ANS: A Right occiput posterior fetal position during labor A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Ferguson's reflex occurs when a contraction is stimulated as a result of vaginal stimulation.

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

ANS: A Distended bladder The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus.

Rho(D) immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative

ANS: A Mother Rh-negative, baby Rh-positive An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.

Which adverse effects can be seen in response to administration of oxytocin (Pitocin) for induction of labor? (Select all that apply.) a. Maternal hyponatremia b. Uterine tachysystole c. Maternal hypotension d. Reassuring fetal heart pattern e. Decreased variability on fetal tracing

ANS: A, B, C The administration of Pitocin can lead to a decrease in maternal serum sodium levels because of water intoxication. With regard to uterine effects, Pitocin can cause hyperstimulation or uterine tetany to occur, along with maternal hypotension. In terms of fetal response, Pitocin administration can lead to a nonreassuring fetal heart rate pattern manifested as bradycardia, tachycardia, and/or late decelerations and a decrease in variability, resulting in fetal compromise.

The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas

ANS: A, C, D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

The nurse is teaching a non-breastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended . d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

ANS: A, D, E The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production.

The labor nurse is developing a plan of care for a patient admitted in active labor with spontaneous rupture of the membranes 6 hours prior to admission with clear fluid. On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 99° F [37.2° C]. What is the priority nursing action for this patient? a. Fetal acoustic stimulation b. Assess temperature every 2 hours c. Change absorption pads under her hips every 2 hours d. Review white blood cell count (WBC) drawn at admission

ANS: B Assess temperature every 2 hours The woman's temperature should be assessed at least every 2 to 4 hours after the membranes rupture. Elevations above 38° C (100.4° F) should be reported. A rising FHR and fetal tachycardia (above 160 bpm) may precede maternal fever. The fetal heart rate is at the high end of the acceptable range and the maternal temperature is slightly above normal. These parameters warrant watching closely with more frequent vital signs. The WBC is often falsely elevated in labor, largely related to the stress of labor. The FHR with a baseline of 150 to 160 bpm demonstrates moderate variability, and fetal acoustic stimulation is not warranted. Amniotic fluid is emitted from the vagina at variable rates and the underpad needs to be changed as needed.

A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration? a. Oxytocin (Pitocin) b. Naloxone (Narcan) c. Bromocriptine (Parlodel) d. Oxygen

ANS: B Naloxone (Narcan) Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression.

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus is palpable two fingerbreadths above the umbilicus. The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum, but is still appropriate.

You are preparing a client for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.) a. Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement. b. Have ephedrine available at bedside during catheter placement. c. Monitor blood pressure of client frequently during catheter insertion and for the first 15 minutes of epidural administration. d. Insert a Foley catheter prior to epidural catheter placement. e. Monitor the client for hypertension in response to epidural insertion.

ANS: B, C A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is.

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38° C (100.4° F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

ANS: C Firm fundus, but excessive lochia Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38° C (100.4° F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

42. After birth, the nurse monitors the mother for postpartum hemorrhage secondary to uterine atony. What would increase the nurse's concern about this risk? a. Hypovolemia b. Iron deficiency anemia c. Prolonged use of oxytocin d. Uteroplacental insufficiency

ANS: C Prolonged use of oxytocin Postpartum uterine atony is more likely if she has received oxytocin for a long time because the uterine muscle becomes fatigued and does not contract effectively to compress vessels at the placental site.

To relieve a mild postdural puncture headache, the nurse should encourage the intake of: a. milk. b. orange juice. c. tea or coffee. d. beef or chicken bouillon.

ANS: C tea or coffee. Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine.

A client asks the nurse, "What can I do to avoid an episiotomy during birth?" Which responses should the nurse give? (Select all that apply). a. "Using the lithotomy position during pushing may be beneficial." b. "Using prolonged breath-holding when pushing may help stretch the tissue." c. "Beginning at 36 weeks, a daily 10-minute perineal massage may help stretch the tissue." d. "Using an open glottis technique when pushing can promote gradual perineal stretching." e. "Delaying pushing until the urge is felt can gradually distend the soft tissues of the pelvic floor."

ANS: C, D, E Daily perineal massage and stretching by the woman from 36 weeks until birth has been shown to reduce the risk for perineal trauma during birth. Pushing with an open glottis technique rather than prolonged breath-holding when pushing promotes gradual perineal stretching. Delaying pushing until the urge is felt gradually distends the soft tissues of the pelvic floor. An upright position while pushing promotes gradual stretching of the woman's perineum, not the lithotomy position.

The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) a. Encourage the client to drink fluids. b. Place the client in a Trendelenburg position. c. Administer a normal saline bolus as prescribed. d. Administer oxygen at 8 to 10 L/min per face mask. e. Administer IV ephedrine in 5- to 10-mg increments as prescribed.

ANS: C, D, E If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client.

Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? a. Narcotics b. Spinal block c. Epidural anesthesia d. Breathing and relaxation techniques

ANS: D . Breathing and relaxation techniques Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn.

To monitor for potential hemorrhage in the client who has just had a cesarean birth, which action should the recovery room nurse implement? a. Monitor her urinary output. b. Maintain an intravenous infusion at 1 mL/hr. c. Assess the abdominal dressings for drainage. d. Assess the uterus for firmness every 15 minutes.

ANS: D Assess the uterus for firmness every 15 minutes. Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room.

Which documentation in the client's chart on the 14th postpartum day indicates a normal involution process? a. Breasts firm and tender b. Episiotomy slightly red and puffy c. Moderate bright red lochial flow d. Fundus below the symphysis and not palpable

ANS: D Fundus below the symphysis and not palpable The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

ANS: D Uterine fundus 2 cm above the umbilicus By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client.

A gravida 2, para 1 client is admitted to the labor and birth unit in labor. She states that she had a cesarean birth with her first pregnancy. The most critical information the nurse must obtain at this point is: a. the onset of contractions. b. her estimated date of birth. c. when the client ate last and what she consumed. d. the type of uterine incision with the first pregnancy.

ANS: D the type of uterine incision with the first pregnancy. A vertical incision creates a greater risk of uterine rupture in a subsequent labor than a transverse incision. The onset of labor is not the most important information that is needed at this point. This is important information to prepare for a fetus that may not be term. However, it is not the most critical question. If a cesarean birth is necessary this information is needed but not as critical as the type of previous incision.

A pregnant woman develops hypertension. The nurse monitors the client's blood pressure closely at subsequent visits because the nurse is aware that hypertension is associated with what complication? a. Abruptio placentae b. Cardiac abnormalities in the neonate c. Neonatal jaundice d. Reduced placental blood flow

ANS: D. Reduced placental blood flow Hypertension associated with pregnancy is associated with reduced placental blood flow. Abruptio placentae, cardiac abnormalities in the neonate, and neonatal jaundice are not directly related to maternal hypertension.

For which client should the oxytocin (Pitocin) infusion be discontinued immediately? a. A client in transition with contractions every 2 minutes lasting 90 seconds each b. A client in early labor with contractions every 5 minutes lasting 40 seconds each c. A client in active labor with contractions every 3 minutes lasting 60 seconds each d. A client in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each

ANS: a. A client in transition with contractions every 2 minutes lasting 90 seconds each This client's contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this client's contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this client's contractions. There is an appropriate resting period between this client's contractions for her stage of labor.

The nurse is aware of the different breathing techniques that are used during labor. Why are breathing techniques used during labor? Select all that apply. 1. They are a form of anesthesia. 2. They are a source of relaxation. 3. They increase the ability to cope with contractions. 4. They are a source of distraction. 5. They increase a woman's pain threshold.

Answer: 2, 3, 4, 5

Which of the following potential problems would the nurse consider when planning care for a client with a persistent occiput posterior position of the fetus? Select all that apply. 1. Increased fetal mortality 2. Severe perineal lacerations 3. Ceasing of labor progress 4. Fetus born in posterior position 5. Intense back pain during labor

Answer: 2, 3, 4, 5 Explanation: 2. The woman can have third- or fourth-degree perineal laceration or extension of a midline episiotomy. 3. Sometimes labor progress ceases if the fetus fails to rotate to an occiput anterior position. 4. Occiput posterior positions are associated with a higher incidence of vacuum-assisted births. 5. The woman usually experiences intense back pain in the small of her back throughout labor.

Which of the following symptoms would be an indication of postpartum blues? Select all that apply. 1. Overeating 2. Anger 3. Mood swings 4. Constant sleepiness 5. Crying

Answer: 2, 3, 5 Explanation: 2. Anger would be a symptom of postpartum blues. 3. Mood swings would be a symptom of postpartum blues. 5. Weepiness and crying would be a symptom of postpartum blues.

Maternal risks of occiput posterior (OP) malposition include which of the following? Select all that apply. 1. Blood loss greater than 1000 mL 2. Postpartum infection 3. Anal sphincter injury 4. Higher rates of vaginal birth 5. Instrument delivery

Answer: 2, 3, 5 Explanation: 2. Postpartum infection is a maternal risk of OP. 3. Anal sphincter injury is a maternal risk of OP. 5. Instrument delivery is a maternal risk of OP.

The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? A. Mild B. Moderate C. Strong D. Weak

C. Strong

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: A. Avoid rotating breast-feeding positions. B. Stop nursing until the nipples heal C. Substitute a bottle-feeding until the nipples heal. D. Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother.

D. Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother. The nurse would suggest the mother position the infant in this manner. Rotating breast-feeding positions; breaking suction with the little finger; nursing frequently; begin feeding on the less sore nipple; not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness.

Which pt is most likely to be treated with amnioinfusion? a. A pt with variable decelerations for more than 10 minutes b. A pt with late decelerations for more than 10 minutes c. A pt with baseline FHR of 105 for more than 10 minutes d. A pt with baseline FHR of 170 for more than 10 minutes

a. A pt with variable decelerations Amnioinfusion is used during labor either to dilute meconium-stained amniotic fluid or to supplement the amount of amniotic fluid to reduce the severity of variable decelerations caused by cord compression.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: a. Change the woman's position b. Notify the health care provider c. Assist with amnioinfusion d. Insert a scalp electrode

a. Change the woman's position Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a. Latent phase b. Active phase c. Second stage d. Transition phase

a. Latent phase The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time.

A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurse's initial action should be to: a. Stop the oxytocin infusion b. Continue the infusion and report the findings to the physician c. Turn her on her left side and reassess the contractions d. Administer oxygen by mask

a. Stop the oxytocin infusion Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

Which client will most likely have increased anxiety and tension during labor? a. Gravida 2 who refused any medication b. Gravida 2 who delivered a stillborn baby last year c. Gravida 1 who did not attend prepared childbirth classes d. Gravida 3 who has two children younger than 3 years

b. Gravida 2 who delivered a stillborn baby last year If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect.

28. What correctly matches the type of deceleration with its likely cause? a. Early deceleration—umbilical cord compression b. Late deceleration—uteroplacental inefficiency c. Variable deceleration—head compression d. Prolonged deceleration—cause unknown

b. Late deceleration—uteroplacental inefficiency Late deceleration is caused by uteroplacental inefficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

Which fetal position may cause the laboring client more back discomfort? a. Left occiput anterior b. Left occiput posterior c. Right occiput anterior d. Right occiput transverse

b. Left occiput posterior In the left occiput posterior position, each contraction pushes the fetal head against the mother's sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position.

When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurse's best response would be to: a. stop the drip immediately. b. decrease the dose to 14 mU/min. c. reassess the patient at 5 minute intervals. d. reposition the patient to the left side-lying position.

b. decrease the dose to 14 mU/min. In the absence of any adverse fetal response, hypertonic stimulation can be managed by reducing the infusion rate by 1 to 2 mU/min until uterine hyperstimulation is resolved. Stopping the drip immediately is not necessary unless hyperstimulation continues and adverse fetal responses occur. Reassessing and repositioning are of no benefit in this situation.

The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)? a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the baby's neck e. Maternal supine hypotension

c. Placental abruption e. Maternal supine hypotension Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the umbilical cord is around the baby's neck, arm, leg, or other body part or when there is a short cord, a knot in the cord, or a prolapsed cord.

Fetal bradycardia is most common during: a. Intraamniotic infection. b. Fetal anemia. c. Prolonged umbilical cord compression. d. Tocolytic treatment using terbutaline.

c. Prolonged umbilical cord compression. Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n): a. local. b. epidural. c. pudendal. d. spinal block.

c. pudendal. A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

A patient in active labor requests an epidural for pain management. What is the nurse's priority action for this patient? a. Assess the fetal heart rate pattern over the next 30 minutes. b. Take the patient's blood pressure every 5 minutes for 15 minutes. c. Determine the patient's contraction pattern for the next 30 minutes. d. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hr over 30 minutes.

d. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hr over 30 minutes.

Which fetal heart rate (FHR) finding concerns the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations

d. Late decelerations Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected.