exam 3 maternal
The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? -Repeating the assessment every 5 minutes for up to 20 minutes
-Repeating the assessment every 5 minutes for up to 20 minutes
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? -The client requires a rubella immunization following delivery.
-The client requires a rubella immunization following delivery.
A nonstress test (NST) is ordered on a pregnant woman at 37 weeks of gestation. Which are the most appropriate teaching points to include when explaining the procedure to the client? Select all that apply.
-Vibroacoustic stimulation may be used during the test. -Drinking orange juice before the test is appropriate. -Two sensors are placed on the abdomen to measure contractions and fetal heart tones
Which assessment should alert the nurse to withhold the scheduled dose of methylergonovine maleate (Methergine) for a postpartum client and notify the health care provider? 1. Blood pressure 142/86 2. Apical pulse 56 3. Blood type O positive 4. Mother is planning to breastfeed
1
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.
2
A patient is admitted for possible preterm labor. The nurse receives a prescription for a transvaginal ultrasound to be performed by the radiology department. The nurse should understand that this test is used for which primary purpose? A. To detect a shortened cervical length B. To evaluate the presenting fetal part C. To evaluate cervical dilation D. To evaluate the fetal structure
A
Regarding vaginal birth after cesarean (VBAC), which of the following statements is true? a. Misoprostol is contraindicated in women attempting a VBAC. b. After one successful VBAC, there remains an increased risk of neonatal and maternal complications in subsequent attempts. c. Research shows no significant correlation between maternal weight and successful VBAC. d. Healthcare costs are considerably higher for women who have a VBAC than for those who have a repeat cesarean birth.
A
RhoGAM is given to Rh-negative women to prevent maternal sensitization. In addition to pregnancy, Rh-negative women would also receive this medication after which of the following? a. Therapeutic or spontaneous abortion b. Head injury from a car accident c. Blood transfusion after a hemorrhage d. Unsuccessful artificial insemination procedure
A
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates an appropriate understanding of the information presented? a. "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." b. "During labor, the nurse will regularly check my cervix by doing a pelvic exam." c. "During labor, the nurse will verify that my contractions are strong but not too close together." d. "During labor, the nurse will look at the color and amount of bloody show that I have."
A
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? a. Beginning continuous fetal heart rate monitoring b. Changing the client's position in bed c. Administering oxygen at 2L per minute d. Notifying the healthcare provider that birth is imminent
A
Which of the following women should receive RhoGAM postpartum? a. Nonsensitized Rh-negative mother with a Rh-negative newborn b. Nonsensitized Rh-negative mother with a Rh-positive newborn c. Sensitized Rh-negative mother with a Rh-positive newborn d. Sensitized Rh-negative mother with a Rh-negative newborn
A
A nurse is preparing a presentation for a health fair focusing on prevention of congenital neuromuscular disorders. Which of the following would the nurse emphasize as most important in preventing neural tube defects? a) Ultrasound screening at 16 weeks' gestation b) Folic acid supplementation c) Genetic testing for gene identification d) Maternal serum α-fetoprotein levels screening
B
A pt who is pregnant for the first time and at 12 weeks gestation is concerned that her fetus is not growing normally. She states, "I have not felt the baby move yet." Which of the following responses by the nurses is more appropriate? a. I will need to report this to your primary care provider immediately. b. Fetal movement is usually felt for the first time around the 20th week. c. It is not unusual to have no fetal movement until labor begins. d. If you have not felt the fetus move by the 22nd week, we will need to perform an amniocentesis.
B
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: A) Amount of lochia B) Blood pressure C) Deep tendon reflexes D) Uterine tone
B
In palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. What action should the nurse take first? A) Contact the client's nurse midwife to notify the midwife of this condition. B) Have a nursing colleague reexamine the client to verify the nurse's finding. C) Have the client void to empty the bladder and then remeasure fundal height. D) Catheterize the woman to empty the bladder and then remeasure fundal height.
C
When administering magnesium sulfate to a woman with severe preeclampsia, which finding would alert the nurse to the development of magnesium toxicity? a) Serum magnesium level of 6.5 mEq/L b) Elevated liver enzymes c) Diminished reflexes d) Seizures
C
The nurse is providing care to a pregnant client and her spouse. The client requires an amniocentesis. Which client statement indicates an appropriate understanding of the information presented? a. "If the test determines our baby has Down syndrome, we will not need to take childbirth classes." b. "The test has to be done before the 14th week of pregnancy." c. "It is not unusual for amniocentesis to misdiagnose a problem with the baby." d. "The results of the amniocentesis will take up to 2 weeks"
D
A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data? Nausea
Nausea
The nurse is reiterating prior teaching given to parents about antepartum testing. Which statements should the nurse include? Select all that apply.
"A nonstress test may be used to measures fetal heart rate."
The nurse is educating a group of pregnant women about the importance of folic acid supplementation in the diet. Which suggestion given by the nurse is appropriate?
"Foods rich in folic acid prevent the development of neural tube defects."
A gravida 2 para 1 client in the 10th week of her pregnancy says to the nurse, "I've never urinated as often as I have for the past three weeks." Which response would be most appropriate for the nurse to make? -"By the time you are 12 weeks pregnant, this frequent urination should no longer be a problem, but it is likely to return toward the end of your pregnancy."
-"By the time you are 12 weeks pregnant, this frequent urination should no longer be a problem, but it is likely to return toward the end of your pregnancy."
Before discharging a client from the Antepartum Triage Unit, the nurse reinforces the teaching plan about the difference between Braxton Hicks contractions and true labor contractions. Which statement by the client indicates the teaching has been effective? -Braxton Hicks contractions begin in the abdomen and remain irregular.
-Braxton Hicks contractions begin in the abdomen and remain irregular.
A client at 43 weeks gestation has just given birth to an infant with typical post-maturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.)
-Cracked and peeling skin -Long scalp hair and fingernails -Creases covering the neonate's full soles and palms
A woman at 37 weeks' gestation presents to the labor and delivery area with symptoms of abruptio placentae. Which action should the nurse prioritize? -Ensure large bore IV access is obtained
-Ensure large bore IV access is obtained
The nurse provides care to a client who is experiencing nausea and vomiting during the first trimester of pregnancy. Which actions by the nurse are appropriate based on this data? Select all that apply. Teach the client that ginger may relieve her symptoms. Suggest the client use acupressure to pressure points on the wrist.
-Teach the client that ginger may relieve her symptoms. -Suggest the client use acupressure to pressure points on the wrist.
When providing education to parents about care of the umbilical cord, what information should be included? (Select all that apply.)
1.Cleaning the cord with an alcohol swab 2. Keeping the diaper folded below the cord
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.
2
A client is requiring a rubella vaccination before discharge following cesarean section delivery of a 34-week gestation female infant. The infant is in the Neonatal Intensive Care Unit. The nurse is explaining why the immunization is required. What should be included in the explanation? 1.Rubella vaccine is given to parents of premature infants. 2.The mother must not have been vaccinated as a child. 3.The mother's blood work demonstrated a non-immune status. 4.This is a normal booster vaccine given to all adults.
3
Quickening is usually first noticed first: 1. Between 8 and 12 weeks gestation 2. Between 12 and 16 weeks gestation 3. Between 16 and 20 weeks gestation 4. Between 20 and 24 weeks gestation
3
The nurse is caring for a female patient who recently had an abortion after learning that the fetus had a neural tube defect. The patient wants to conceive again and asks the nurse for advice. What suggestion is best to prevent neural tube defects in future pregnancies? 1 "Take 15 mg of iron every day." 2 "Take 46 g of protein every day." 3 "Take 4 mg of folic acid every day." 4 "Take 1300 mg of calcium every day.
3
A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? 1 "I will need to have a full bladder for the test to be done accurately." 2 "I should have my husband drive me home after the test because I may be nauseated." 3 "This test will help to determine if the baby has Down syndrome or a neural tube defect." 4 "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."
4
4. The nurse is reviewing exercises with a pregnant woman to help the client maintain physical fitness and appropriate weight gain throughout the pregnancy. After the teaching session, the client tells the nurse that she was taught never to reach over the head because this will harm the baby. Based on this data, which action by the nurse is appropriate? a. Assure the client that reaching over the head will not harm the baby b. Provide alternative activities to do instead of exercise c. Tell the client to just perform the exercises that do not require her to reach over her head d. Provide dietary instruction instead to ensure the client does not gain excessive weight
A
A nurse is assessing a postpartum client who delivered via c-section for a placental abruption. What assessment finding would be the MOST concerning? A. Oozing from the IV site B. Abdominal cramping C. IV fluids running at 125 ml/hr D. Vaginal bleeding
A
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. Which teaching points are appropriate for this client based on her current diet? Select all that apply. A. Eat up to 12 ounces a week of a variety of fish and shellfish. B. Do not eat more than 6 ounces per week of albacore tuna C. Avoid shrimp, salmon, and catfish because these have higher mercury levels. D. Eat plenty of fish such as king mackerel while pregnant. E. Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
A,B
Medications used to manage postpartum hemorrhage include (choose all that apply): A. Pitocin B. Methergine C. Terbutaline D. Hemabate E. Magnesium sulfate
A,B,D
The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply. A. "Leopold's maneuvers are used to determine fetal position. B. "Leopold's maneuvers are used to determine actual fetal heart rate. C. "Leopold's maneuvers are used to determine duration of contractions. D. "Leopold's maneuvers are used to determine frequency of contractions. E. "Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part. F." Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen.
A,E,F
What are the signs and symptoms of an ectopic pregnancy?
Abrupt unilateral lower-quadrant abdominal pain with or without vaginal bleeding
How should the nurse explain ectopic pregnancy
An ectopic pregnancy involves a fertilized ovum outside of the uterus that cannot be transferred to the uterus."
A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation
Apply ice packs in the perineum
When teaching parents how to bathe their baby, which point should the nurse stress?
Avoid immersing the baby in water until after the umbilical cord has fallen off
A nurse is caring for a client who wants more information about fertility awareness-based contraceptive methods. Which statement made by the nurse provides the client with correct information? A. "The calendar method is the most reliable fertility awareness-based method of contraception." B. "To use the calendar rhythm method, a woman must record her menstrual cycles for 6 months to identify the shortest and longest cycles." C. "The calendar rhythm method is based on the assumption that ovulation tends to occur about 7 days before the start of a woman's next menstrual period." D. "For women, the fertility window occurs between days 19 and 26 of the menstrual cycle."
B
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus. C. Grasp lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence.
B
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? a. Assessing maternal temp. Every 1-2 hours after amniotic membranes have ruptured b. Assessing fetal HR every 5 minutes c. Administering antibiotics for a positive group beta strep d. Encouraging the client to void every 1-2 hours
B
A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which of the following would the nurse include? -Urinary frequency
urinary frequency
7. The nurse is teaching childbirth exercises to a pregnant client with a history of back pain. Which is most appropriate for this client? a. Exercise in the supine position throughout the pregnancy b. Perform the pelvic rock exercise while in the hands and knees position c. Perform the pelvic rock exercise only in the standing position d. Soak in a hot tub for approximately 30 minutes after exercise
C
A 32-week pregnant client arrives to the emergency department with severe abdominal pain and vaginal bleeding. What condition should the nurse be concerned for? A. Miscarriage B. Cervical effacement C. Placental abruption D. Placenta previa
C
If a woman had a pre-pregnancy daily requirement of 1800 calories and she decides to breastfeed her newborn, how many calories should the nurse recommend the woman take in each day? A. 2000 calories B. 1800 calories C. 2300 calories D. 2500 calories
C
In palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. What action should the nurse take first? A) Contact the client's nurse midwife to notify the midwife of this condition. B) Have a nursing colleague reexamine the client to verify the nurse's finding. C) Have the client void to empty the bladder and then remeasure fundal height. D) Catheterize the woman to empty the bladder and then remeasure fundal height.
C
Methylergonovine maleate Methergine) indications
used for the prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution
A nurse is assessing a pregnant client who is in labor. Which of the following symptoms would be indicative of a possible placental abruption? Select all that apply. A. Hypertension (hypotension) B. Maternal bradycardia (tachy) C. Non reassuring FHR D. Abdominal pain E. Bleeding
C,D,E
When trying to differentiate false labor from true labor, the nurse realizes which of the following statements regarding true labor is correct?
Contractions get stronger with ambulation.
. When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client? a. Notify the client's midwife of this condition. b. Perform a straight catheterization on the client and then reassess fundal height. c. Ask another nurse to assess the client to verify the findings. d. Ask the client to void and then reassess fundal height.
D
A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows fetal bradycardia, and a change is seen in the contour of the client's abdomen. What is the nurse's priority intervention? A) Checking the client's vital signs B) Placing the client on her left side C) Immediately placing an internal scalp electrode on the fetus D) Alerting others regarding the need for immediate cesarean delivery
D
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? a. Assisting the client into the Fowler position b. Applying oxygen via mask at 10 liters per minute c. Preparing for imminent delivery d. Documenting the fetal heart rate
D
The nurse has received a report about a woman in labor. The woman's last vaginal examination was recorded as 4, 80%, and -2. The nurse's interpretation of this assessment is that: A) The cervix is dilated 4 cm, it is effaced 80%, and the presenting part is 2 cm below the ischial spines B) The cervix is effaced 4 cm, it is dilated 80%, and the presenting part is 2 cm below the ischial spines. C) The cervix is effaced 4 cm, it is dilated 80%, and the presenting part is 2 cm above the ischial spines D) The cervix is 4 cm dilated, it is effaced 80%, and the presenting part is 2 cm above the ischial spines
D
A nurse is teaching the parents of a term newborn how to bathe him. Which of the following instructions should the nurse include?
Give him a sponge bath until his cord falls off.
A patient has been in the second stage of labor for 2 hours. The patient begins crying and states, "I am so tired. Can I just have a cesarean birth?
I cannot do this anymore." Which action by the nurse provides the most therapeutic response? Calmly providing reassurance and keeping the patient apprised of their progress
A nurse in a clinic is caring for a pt. who is post op following a salpingectomy due to ectopic pregnancy. Which of the following statement by the pt. requires clarification.
It's to good know that I won't have a tubal pregnancy in the future.
a nurse is completing an admission assessment of a client who is 38 weeks and has severe preeclampsia. What would be an expected finding.
Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
Monitor the FHR continuously
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?
Respiratory distress
A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?
Right upper quadrant
A nurse is calculating a client's expected date of birth using Negele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?
September 3rd November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up? Steady trickle of blood Firm fundus Fundus at the umbilical level Moderate lochia rubra
Steady trickle of blood
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following? Take a multivitamin each day.
Take a multivitamin each day
The nurse sees a fetal heart rate of 172 bpm on the monitor of a patient receiving continuous external monitoring. What is her priority action?
The nurse should continue to monitor the FHR. This may be a normal acceleration from baseline. To be classified as fetal tachycardia, the fetal heart rate must remain greater than 160 bpm for 10 minutes
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following response should the nurse make?
preterm newborns lack adequate temperature control mechanisms