Intrapartum NCLEX questions

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: 1.Hematoma 2.Placenta previa 3.Uterine atony 4.Placental separation

4. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? 1.Disseminated intravascular coagulation 2.Chronic hypertension 3.Infection 4.Hemorrhage

4. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? 1.Placing the client on complete bed rest 2.Continuous electronic fetal monitoring 3.An IV infusion of antibiotics 4.Placing a code cart at the client's bedside

2. Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: 1.Breech 2.Transverse 3.Occiput anterior 4.Occiput posterior

4. A persistent occiput-posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? 1.Encourage the client's coach to continue to encourage breathing exercises 2.Encourage the client to continue pushing with each contraction 3.Continue monitoring the fetal heart rate 4.Notify the physician or nurse mid-wife

4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified.

A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes

2. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: 1.Not yet engaged 2.Entering the pelvic inlet 3.Below the ischial spines 4.Visible at the vaginal opening

3. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.

When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: 1.Stop the oxytocin infusion 2.Change the client's position 3.Prepare for immediate delivery 4.Take the client's blood pressure

2. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.

After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: 1.Above the umbilicus at the midline 2.Above the umbilicus on the left side 3.Below the umbilicus on the right side 4.Below the umbilicus near the left groin

3. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.

A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? A. Biophysical profile B. Amniocentesis C. Maternal serum alpha-fetoprotein (MSAFP) D. Transvaginal ultrasound

D. Transvaginal ultrasound An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women, whose thick abdominal layers cannot be penetrated adequately with the abdominal approach. Option A: A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. Option B: An amniocentesis is performed after the fourteenth week of pregnancy. Option C: A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal)

The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: 1.Blowing 2.Slow chest 3.Shallow 4.Accelerated-decelerated

1. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.

1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A.The client begins to expel clear vaginal fluid B.The contractions are regular C.The membranes have ruptured D.The cervix is dilated completely

1.4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

A female adult patient is taking a progestin-only oral contraceptive or mini pill. Progestin use may increase the patient's risk for: A. Endometriosis B. Female hypogonadism C. Premenstrual syndrome D. Tubal or ectopic pregnancy

D. Tubal or ectopic pregnancy Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Option A: Progestins are widely regarded as effective treatments for the symptoms of endometriosis despite not all being indicated for the treatment of the disease. It is not yet fully understood how progestins relieve the symptoms of endometriosis, but they probably work by suppressing the growth of endometrial implants in some way, causing them to gradually waste away. Option B: Hypogonadism is a condition in which the male testes or the female ovaries produce little or no sex hormones. Treatment may involve estrogen and progesterone pills or skin patches, GnRH injections, or HCG injections. Option C: Premenstrual syndrome is defined as the recurrence of psychological and physical symptoms in the luteal phase, which remit in the follicular phase of the menstrual cycle. The rationale for the use of progesterone and progestogens in the management of premenstrual syndrome is based on the unsubstantiated premise that progesterone deficiency is the cause.

A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? 1.Fetal heart rate of 180 beats per minute 2.White blood cell count of 12,000 3.Maternal pulse rate of 85 beats per minute 4.Hemoglobin of 11.0 g/dL

1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: 1.An acceleration 2.An early elevation 3.A sonographic motion 4.A tachycardic heart rate

1. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician

1. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.

A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: 1.Over the fetus that is most anterior to the mothers abdomen 2.Over the fetus that is most posterior to the mothers abdomen 3.So that each fetal heart rate is monitored separately 4.So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

3. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? 1.Absence of abdominal pain 2.A soft abdomen 3.Uterine tenderness/pain 4.Painless, bright red vaginal bleeding

3. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? 1.Prepare the client for an ultrasound 2.Obtain equipment for external electronic fetal heart monitoring 3.Obtain equipment for a manual pelvic examination 4.Prepare to draw a Hgb and Hct blood sample

3. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia

Which behaviors would be exhibited during the letting-go phase of maternal role adaptation. Select all that apply. A. Emergence of the family unit. B. Dependent behaviors. C. Sexual intimacy continues. D. Defining one's individual roles. E. Being talkative and excited about becoming a mother.

A, C, & D The emergence of family unit, sexual intimacy relationship continuing and defining one's individual roles represent interdependent behaviors associated with the letting-go phase. During the letting go phase, the woman finally accepts her new role and gives up her old roles like being a childless woman or just a mother of one child. Option B: Dependent behaviors are exhibited in the taking-in phase. The taking-in phase is the time of reflection for the woman because within the 2 to 3 day period, the woman is passive. Option E: Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors. The woman starts to initiate actions on her own and makes decisions without relying on others.

The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A. "Nausea and vomiting can be decreased if I eat a few crackers before rising." B. "If I start to leak colostrum, I should cleanse my nipples with soap and water." C. "If I have a vaginal discharge, I should wear nylon underwear." D. "Leg cramps can be alleviated if I put an ice pack on the area."

A. "Nausea and vomiting can be decreased if I eat a few crackers before arising" Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. Option B: Colostrum is a milky fluid that's released by mammals that have recently given birth before breast milk production begins. Option C: Cotton underwear is breathable and absorbent, which can help prevent yeast infections. Option D: A heating pad or hot pack may help relieve tight muscles in leg cramps.

Which of the following is the most common kind of placental adherence seen in pregnant women? A. Accreta B. Placenta previa C. Percreta D. Increta

A. Accreta Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. Option B: In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Option C: Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Option D: Placenta increta leads to deep penetration of the myometrium.

While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client's fundus to: A. Prevent uterine inversion. B. Promote uterine involution. C. Hasten the puerperium period. D. Determine the size of the fundus.

A. Prevent uterine inversion Using both hands to assess the fundus is useful for preventing uterine inversion. The recent uterine inversion with placenta already separated from it may often be replaced by manually pushing up on the fundus with the palm and fingers in the direction of the long axis of the vagina. Option B: Involution is the process by which the uterus is transformed from pregnant to non-pregnant state. This period is characterized by the restoration of ovarian function in order to prepare the body for a new pregnancy. Option C: The puerperium, or postpartum period, generally lasts 6 weeks and is the period of adjustment after delivery when the anatomic and physiologic changes of pregnancy are reversed, and the body returns to the normal, nonpregnant state. Option D: A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimeters from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimeters.

While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack? A. Yogurt B. Cereal with milk C. Vegetable soup D. Peanut butter cookies

A. Yogurt In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids. Option B: Most institutions would only allow clear liquids for clients in early labor. This prevents gastrointestinal problems during labor and delivery. Option C: Vegetables may cause gastric discomfort for the woman during labor. Option D: Fluids are mostly recommended during this stage of labor, instead of solids, to avoid dehydration.

A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count (DFMC). Which instructions could be included in the plan of care? Select all that apply. A. The fetal alarm signal is reached when there are no fetal movements noted for 5 hours. B. The patient can monitor fetal activity once daily for a 60-minute period and note activity. C. Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted. D. Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.

B, C, & D The fetal alarm signal is reached when no fetal movements are noted for a period of 12 hours. Fetal movement is one show of a baby's health in the womb. Each woman should learn the normal pattern and number of movements for her own baby. A change in the normal pattern or number of fetal movements may mean the baby is under stress. And it's not normal for a baby to stop moving with the start of labor. Option A: In general, the woman should feel 10 movements in 2 hours. Sit or lie on the side in a comfortable spot during a time of day when the baby is usually active. This may be after eating or moving around. If the woman lies down, lie on the left side, since the baby will have better circulation.

With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that: A. In the first trimester, diseases or abnormalities result in asymmetric IUGR. B. Infants with asymmetric IUGR have the potential for normal growth and development. C. In asymmetric IUGR, weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA. D. Symmetric IUGR occurs in the later stages of pregnancy.

B. Infants with asymmetric IUGR have the potential for normal growth and development. The infant with asymmetric IUGR has the potential for normal growth and development. SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Option A: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities. Option C: Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits). Option D: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities.

What is an appropriate indicator for performing a contraction stress test? A. Increased fetal movement and small for gestational age. B. Maternal diabetes mellitus and postmaturity. C. Adolescent pregnancy and poor prenatal care. D. History of preterm labor and intrauterine growth restriction.

B. Maternal diabetes mellitus and postmaturity. The contraction stress test helps predict how the baby will do during labor. The test triggers contractions and registers how the baby's heart reacts. A normal heartbeat is a good sign that the baby will be healthy during labor. Option A: Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator. Option C: Although adolescent pregnancy and poor prenatal care are risk factors for poor fetal outcomes, they are not indicators for performing a contraction stress test. Option D: Intrauterine growth restriction is an indicator; history of a previous stillbirth, not preterm labor, is another indicator.

While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review the events and her behavior during the process of labor and birth. B. Exhibit a reduced attention span, limiting readiness to learn. C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D. Have reestablished her role as a spouse or partner.

C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. One week after birth the woman should exhibit behaviors characteristic of the dependent-independent or taking-hold stage. She still has needs for nurturing and acceptance by others. Option A: Wanting to discuss the events of her labor and delivery are characteristics of the taking-in stage; this stage lasts from the first 24 hours until 2 days after delivery. Option B: A reduced attention span and limiting readiness to learn is also characteristic of the taking-in stage. This dependence is mainly due to her physical discomfort from hemorrhoids or the after pains, from the uncertainty of how she could care for the newborn, and also from the extreme tiredness she feels that follows childbirth. Option D: Having reestablished her role as a spouse reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? A. Notify the neonate's pediatrician immediately. B. Check the diaper and circumcision again in 30 minutes. C. Secure the diaper tightly to apply pressure on the site. D. Apply gentle pressure to the site with a sterile gauze pad.

D. Apply gentle pressure to the site with a sterile gauze pad If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. Option A: Immediate nursing intervention and assessment should be done first before notifying the physician. Option B: 30 minutes is a long time to reassess. Addressing the bleeding immediately may save it from getting worse. Option C: Tightening the diaper may elicit a case of diaper rash. Applying direct pressure on the bleeding site is more effective.

After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? A. Decreased peristalsis B. Increase heart rate C. Dry mucous membranes D. Nausea and Vomiting

D. Nausea and Vomiting Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Bethanechol directly stimulates cholinergic receptors in the parasympathetic nervous system while stimulating the ganglia to a lesser extent. Option A: Peristalsis is increased rather than decreased. Stimulation of muscarinic receptors in the GI tract restores peristalsis, increases motility, and increases the resting lower esophageal sphincter pressure. Option B: With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased the force of cardiac contraction, which may cause hypotension. Option C: Salivation or sweating may gently increase because of its cholinergic effects.

The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? A. Doppler blood flow analysis B. Contraction stress test (CST) C. Amniocentesis D. Daily fetal movement counts

Doppler blood flow analysis Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high-risk pregnancy due to intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Option B: Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm. Option C: Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of the pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Option D: Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although it may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.

During the period of induction of labor, a client should be observed carefully for signs of: 1.Severe pain 2.Uterine tetany 3.Hypoglycemia 4.Umbilical cord prolapse

2. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? 1.Early decelerations 2.Variable decelerations 3.Late decelerations 4.Short-term variability

2. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.

The nurse in-charge is reviewing a patient's prenatal history. Which finding indicates a genetic risk factor? A. The patient is 25 years old. B. The patient has a child with cystic fibrosis. C. The patient was exposed to rubella at 36 weeks' gestation. D. The patient has a history of preterm labor at 32 weeks' gestation.

B. The patient has a child with cystic fibrosis Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Option A: Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. Option C: Maternal exposure to rubella during the first trimester may cause congenital defects. Option D: Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects.

Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? A. Taking in B. Letting go C. Taking hold D. Resolution

C. Taking hold Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills. Option A: The taking-in phase usually sets 1 to 2 days after delivery. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role. Option B: During the letting go phase, the woman finally accepts her new role and gives up her old roles like being a childless woman or just mother of one child. Option D: The resolution phase or ending phase is the final stage of the nurse-client relationship. After the client's problems or issues are addressed, the relationship needs to be completed before it can be terminated.

A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase

D. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient. Option B: The latent phase extends from 0 to 3 cm; it is mild in nature. Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation. B. Is an invasive test; however, contractions are stimulated. C. Is considered to have a negative result if no late decelerations are observed with the contractions. D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.

C. Is considered to have a negative result if no late decelerations are observed with the contractions. No late decelerations indicate a positive CST result. Option A: Vibroacoustic stimulation is sometimes used with NST. Vibroacoustic stimulation (VAS) of the fetus has been used as both a primary and adjunctive method of FHR testing. This device produces a broadband acoustic signal and a complex vibratory component. Option B: CST is invasive if stimulation is performed by IV oxytocin but not if by nipple stimulation. Option D: CST is contraindicated if the membranes have ruptured.

A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admitted to cocaine use during the pregnancy. Which of the following persons must the nurse notify? A. Nursing unit manager so appropriate agencies can be notified. B. Head of the hospital's security department. C. Chaplain in case the fetus dies in utero. D. Physician who will attend the delivery of the infant.

D. Physician who will attend the delivery of the infant. The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the client's cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client's care. Option A: Informing the nursing unit manager would be inappropriate since the physician would be the one who will have the knowledge on how to manage the fetus. Option B: The knowledge should only be used in relation to the client's care. Notifying the head of the security department is unnecessary and would be against the data privacy act. Option C: Informing the physician first of the cocaine use would most likely save the fetus' life in utero.

During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies? A. Amniocentesis B. Chorionic villi sampling C. Fetoscopy D. Ultrasound

D. Ultrasound Ultrasound is used between 18 and 40 weeks' gestation to identify normal fetal growth and detect fetal anomalies and other problems. Option A: Amniocentesis is done during the third trimester to determine fetal lung maturity. Option B: Chorionic villi sampling is performed at 8 to 12 weeks' gestation to detect genetic disease. Option C: Fetoscopy is done at approximately 18 weeks' gestation to observe the fetus directly and obtain a skin or blood sample.

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1.Stop of Pitocin infusion 2.Perform a vaginal examination 3.Reposition the client 4.Check the client's blood pressure and heart rate 5.Administer oxygen by face mask at 8 to 10 L/min

1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? 1.Document the findings and tell the mother that the monitor indicates fetal well-being 2.Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. 3.Notify the physician or nurse mid-wife of the findings. 4.Reposition the mother and check the monitor for changes in the fetal tracing

1. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.

A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? 1.Swelling of the calf in one leg 2.Prolonged clotting times 3.Decreased platelet count 4.Petechiae, oozing from injection sites, and hematuria

1. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophebitis.

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? 1.Identifying the types of accelerations 2.Assessing the baseline fetal heart rate 3.Determining the frequency of the contractions 4.Determining the intensity of the contractions

2. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority.

A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver

2. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor.

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: 1.Complete bed rest for the remainder of the pregnancy 2.Delivery of the fetus 3.Strict monitoring of intake and output 4.The need for weekly monitoring of coagulation studies until the time of delivery

2. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.

A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? 1.Keeping the significant other informed of the progress of the labor 2.Providing comfort measures 3.Monitoring fetal heart rate 4.Changing the client's position frequently

3. The priority is to monitor the fetal heart rate.

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? 1.Medication that will provide sedation 2.Increased hydration 3.Oxytocin (Pitocin) infusion 4.Administration of a tocolytic medication

3. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.

The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: 1.Clear and dark amber in color 2.Milky, greenish yellow, containing shreds of mucus 3.Clear, almost colorless, and containing little white specks 4.Cloudy, greenish-yellow, and containing little white specks

3. by 36 weeks' gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? 1.The umbilical cord shortens in length and changes in color 2.A soft and boggy uterus 3.Maternal complaints of severe uterine cramping 4.Changes in the shape of the uterus

4. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping. I am going to look more into this answer. According to our book on page 584, this is not one of our options.

A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure? Select all that apply. A. Perform ultrasound to determine fetal positioning. B. Observe the patient for possible uterine contractions. C. Administer RhoGAM to the patient if she is Rh-negative. D. Perform a mini catheterization to obtain a urine specimen to assess for bleeding.

B & C Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of the transabdominal needle. RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. RhoGAM is administered by intramuscular (IM) injection. RhoGAM is purified from human plasma containing anti-Rh (anti-D). Option A: The position of the baby in the uterus is called the presentation of the fetus. Ideally for labor, the baby is positioned head-down, facing the mother's back with the chin tucked to its chest and the back of the head ready to enter the pelvis. This position is called cephalic presentation. Option D: There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.

A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? A. Placing the client in bed to begin fetal monitoring. B. Preparing for immediate delivery. C. Checking for ruptured membranes. D. Providing comfort measures.

B. Preparing for immediate delivery. This question requires an understanding of station as part of the intrapartum assessment process. Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority. Option A: Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. Option C: The membranes can break by themselves. This is called a spontaneous rupture of the membranes. It most often happens after active labor has started. Option D: Comfort measures may be given to the woman after ensuring all necessary measures to help her deliver successfully.

An adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: A. Return preovulatory basal body temperature. B. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle. C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. D. Breast tenderness and mittelschmerz.

C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. Option A: A return to the preovulatory body temperature indicates a safe period for sexual intercourse. Option B: A slight rise in basal temperature early in the cycle is not significant. Ovulation may cause a slight increase in basal body temperature. Option D: Breast tenderness and mittelschmerz are not reliable indicators of ovulation. Mittelschmerz is one-sided, lower abdominal pain associated with ovulation. It occurs midway through a menstrual cycle.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation. B. Alteration in comfort related to nausea and abdominal distention. C. Impaired bowel motility related to pain medication and immobility. D. Fatigue related to cesarean delivery and physical care demands of infant.

C. Impaired bowel motility related to pain medication and immobility Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Option A: Altered nutrition is also an appropriate diagnosis since the woman was not able to eat adequately since the surgery, hindering her ability to breastfeed. However, it can be managed and is not the priority at the time. Option B: The woman's comfort is also altered due to nausea and bloating, but it is not considered a priority. Option D: After cesarean delivery, fatigue may overcome the client's desire to eat and breastfeed her infant. This is a correct diagnosis but it does not take priority over impaired bowel motility.

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseated." C. "This test will help to determine whether the baby has Down syndrome or a neural tube defect." D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements. Option A: An ultrasound requires a full bladder. A full bladder creates a reservoir fluid that enhances the movement of sound waves through the abdominal cavity. This creates a clearer view of the structures that need to be observed. Option B: An amniocentesis is a test after which a pregnant woman should be driven home. Option C: A maternal serum alpha-fetoprotein test is used in conjunction with unconjugated estriol levels and human chorionic gonadotropin helps to detect Down syndrome.

A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: A. Weekly fetal movement counts are made by the mother. B. Contraction stress testing is performed weekly. C. Induction of labor begins at 34 weeks' gestation. D. Nonstress testing is performed weekly until 32 weeks' gestation.

D. Nonstress testing is performed weekly until 32 weeks' gestation For most clients with type 1 diabetes mellitus, non-stress testing is done weekly until 32 weeks' gestation and twice a week to assess fetal well-being. Option A: Increased fetal activity may minimize the impact of hyperglycemia on subsequent birth weight. The inactive fetus appears to be at a higher risk for glucose-mediated macrosomia. Option B: Contraction stress test may be done weekly with reassuring results of no heart rate deceleration in response to 3 contractions in 10 minutes. Option C: Nonstress test may be done twice a week with reassuring results of 2 heart rate acceleration in 20 minutes.

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation. C. Between 21 and 23 weeks' gestation. D. Between 24 and 26 weeks' gestation.

B. Between 16 and 20 weeks' gestation. A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Option A: Before 16 weeks, the fetus is not developed enough for the woman to detect movement. Option C: After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. Option D: After 24 weeks, the fetus might be able to respond to familiar sounds such as its mother's voice, with movement. It is spending most of its sleep time in rapid eye movement (REM).

In the past, factors to determine whether a woman was likely to have a high-risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category? A. Biophysical B. Psychosocial C. Geographic D. Environmental

C. Geographic The fourth category is correctly referred to as the sociodemographic risk category. Several risk factors for high-risk pregnancy were present before pregnancy, including multiple pregnancies, maternal age under 16 or over 35 years, and interval between pregnancies less than one year. Option A: A fetal biophysical profile is a prenatal test used to check on a baby's well-being. The test combines fetal heart rate monitoring (nonstress test) and fetal ultrasound to evaluate a baby's heart rate, breathing, movements, muscle tone and amniotic fluid level. Option B: A pregnancy may be determined to be at high risk because of obstetric factors in previous pregnancies or the present one; conditions that are, themselves, psychosocial: anxiety disorders (GAD, OCD, panic disorder, PTSD), mood disorders, and schizophrenia, all of which are a background for a disturbed pregnancy and might complicate a pregnancy denominated high risk for some other reason. Option D: Environmental factors that have been implicated in adverse pregnancy outcomes include smoking, video display terminals, anesthetic gases, antineoplastic drugs and exposure to lead, selenium and inorganic mercury.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis

C. Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Option A: Antibiotics do not work for viruses like herpes. Taking antibiotics when they are not really needed increases the risk of getting infection later that resists antibiotic treatment. Option B: Trichomoniasis can be cured with a single dose of prescription antibiotic medication (either metronidazole or tinidazole), pills that can be taken by mouth. Option D: A single intramuscular injection of long-acting Benzathine penicillin G (2.4 million units administered intramuscularly) will cure a person who has primary, secondary, or early latent syphilis. Three doses of long-acting Benzathine penicillin G (2.4 million units administered intramuscularly) at weekly intervals is recommended for individuals with late latent syphilis or latent syphilis of unknown duration. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest. B. Platelet infusion. C. Immediate cesarean delivery. D. Labor induction with oxytocin.

A. Activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding. Option B: The greatest risk of placenta previa is hemorrhage. Bleeding often occurs as the lower part of the uterus thins during the third trimester of pregnancy in preparation for labor. This may require blood transfusion during Cesarean section. Option C: In general, there is a higher Cesarean rate associated with placental edge-to-cervical os distances of less than 2 cm. Option D: Labor induction is the stimulation of uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth. It is not an option for placenta previa.

A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices: A. Blurred vision B. Hemorrhoids C. Increased vaginal mucus D. Shortness of breath on exertion

A. Blurred vision Blurred vision or other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Option B: Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Hemorrhoids occur when the external hemorrhoidal veins become varicose (enlarged and swollen), which causes itching, burning, painful swellings at the anus, dyschezia (painful bowel movements), and bleeding. Option C: Almost all women have more vaginal discharge in pregnancy. This is normal, and helps prevent any infections travelling up from the vagina to the womb. Towards the end of pregnancy, the amount of discharge increases further. In the last week or so of pregnancy, it may contain streaks of sticky, jelly-like pink mucus. Option D: Dyspnea can begin before any upward displacement of the diaphragm, suggesting that factors other than mechanical pressure may be involved. It probably results from the subjective awareness of hyperventilation that is universally present in pregnancy. Hyperventilation in pregnancy is predominantly due to an increase in the depth of the tidal volume, with little change in the respiratory rate

The multigravida mother with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" Which of the following would be the nurse's first action? A. Inspect the perineum. B. Time the contractions. C. Auscultate the fetal heart rate. D. Contact the birth attendant.

A. Inspect the perineum When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques. Option B: The woman has a history of rapid labor and is already experiencing true labor contractions. There is no need to time the contractions experienced. Option C: Fetal heart rate monitoring is being consistently monitored during labor. The client's concerns about the delivery of the baby must be prioritized. Option D: Before contacting a birth attendant or the physician, validate the client's claims first. If she is not yet delivering, instruct about breathing techniques that may ease her discomfort.

When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: A. Prevent seizures. B. Reduce blood pressure. C. Slow the process of labor. D. Increase diuresis.

A. Prevent seizures The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper-stimulated neurologic system by interfering with signal transmission at the neuromuscular junction. Option B: Magnesium sulfate may attenuate blood pressure by decreasing the vascular response to pressor substances. Option C: Since the primary therapeutic goal of tocolysis is to delay preterm delivery within 48 hours from the initiation of steroid prophylaxis, little evidence suggests that extended MgSO4 therapy is beneficial. Option D: There are rare cases of pregnant women who develop polyuria after receiving intravenous therapy of magnesium sulfate. It can be considered as another cause of solute diuresis.

Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A. Applying cold to limit edema during the first 12 to 24 hours. B. Instructing the client to use two or more peri pads to cushion the area. C. Instructing the client on the use of sitz baths if ordered. D. Instructing the client about the importance of perineal (Kegel) exercises.

B. Instructing the client to use two or more peri pads to cushion the area Using two or more peripads would do little to reduce the pain or promote perineal healing. A fourth-degree perineal laceration is the injury to the perineum involving the anal sphincter complex and anorectal mucosa. Option A: Ice packs can help reduce pain and swelling in the perineum. Use ice cubes in a clean, disposable glove. Wrapped in a damp cloth or place the ice pack inside a pad. Never apply directly on skin. Apply for 10-20 minutes. Repeat every 2-3 hours until pain and swelling decrease. Option C: Hot sitz bath may help speed up the healing process. Use sitz baths a few times a day, 24 hours after giving birth. Sit in water that covers the vulvar area. Option D: The muscles lie deep in the pelvis and support the pelvic organs and control the bladder and bowel function. The pelvic floor muscles attach to the pubic bone at the front, tail bone at the back, and from one sitting bone to the other sitting bone. It is important to retrain the muscles after a tear, to prevent problems such as incontinence.

After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: A. Apply warm compresses to her nipples just before feeding. B. Lubricate her nipples with expressed milk before feeding. C. Dry her nipples with a soft towel after feeding. D. Apply soap directly to her nipples, and then rinse.

B. Lubricate her nipples with expressed milk before feeding Measures that help relieve nipple soreness in a breastfeeding patient include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples. Option A: Cold compresses are applied instead of warm because it reduces swelling and pain. Use a piece of fabric between the skin and the cold compress. Never apply an ice pack directly to the skin. Option C: Air drying prevents the clothing from sticking to and irritating the breast. Option D: Soap removes the nipples' natural lubricants and will dry them out.

While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? A. Calcium gluconate B. Protamine sulfate C. Methylergonovine (Methergine) D. Nitrofurantoin (Macrodantin)

B. Protamine sulfate Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose. Option A: Calcium gluconate is the calcium salt of gluconic acid, an intravenous medication used to treat conditions arising from calcium deficiencies such as hypocalcemic tetany and hypocalcemia. Option C: Methylergonovine is used to prevent or treat bleeding from the uterus that can happen after childbirth or an abortion. Option D: Nitrofurantoin is used to treat urinary tract infections. It is an antibiotic that works by killing bacteria that cause infection.

A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta. B. The ultrasound identifies blood flow through the umbilical cord. C. The test will determine where to insert the needle. D. The ultrasound locates a pool of amniotic fluid.

B. The ultrasound identifies blood flow through the umbilical cord. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. Option A: As early as 10 weeks, the placenta can be detected by an ultrasound. The normal placenta is discoid with uniform echogenicity and rounded margins. It is usually located along the anterior or posterior uterine walls, extending into the lateral walls. Option C: Ultrasound is done before and during amniocentesis to ensure that the needle can safely pass through the walls of the abdomen and womb. Option D: The sample of amniotic fluid is removed through a fine needle inserted into the uterus through the abdomen, under ultrasound guidance.

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A Place the mother in the supine position B Document the findings and continue to monitor the fetal patterns C Administer oxygen via face mask D Increase the rate of pitocin IV infusion

C Administer oxygen via face mask Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.

A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting, the nurse might ask which question? A. "Are you planning to have epidural anesthesia?" B. "Have you begun prenatal classes?" C. "What changes have you made at home to get ready for the baby?" D. "Can you tell me about the meals you typically eat each day?"

C. "What changes have you made at home to get ready for the baby?" During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. Option A: The type of anesthesia planned doesn't reflect the client's preparation for parenting. Option B: The client should have begun prenatal classes earlier in the pregnancy. Option D: The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide a formula for the infant until he becomes calm, and then offer the breast again.

C. Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Option A: Concern about pacifiers for breastfeeding infants focuses on "nipple confusion"—that is, that pacifiers (and supplemental bottles) do not facilitate effective breast sucking and may contribute to incorrect latch. Findings from earlier observational studies suggest that early exposure to pacifiers leads to cessation of exclusive breastfeeding by 3 to 6 months and an end to all breastfeeding by 12 months. Option B: Option B would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated. Option D: When using an average baby bottle, babies don't have to work as hard because gravity and the nipple cause the milk flow to be more continuous for the baby. Nipple confusion occurs when the baby switches back to breast, and doesn't understand why the milk flows differently than it did with the bottle.

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? 1.Three contractions occurring within a 10-minute period 2.A fetal heart rate of 90 beats per minute 3.Adequate resting tone of the uterus palpated between contractions 4.Increased urinary output

2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring

2. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.

A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: 1.A form of biofeedback to enhance bearing down efforts during delivery 2.Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus 3.The application of pressure to the sacrum to relieve a backache 4.Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

2. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.

A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? 1.Hypotonic contractions 2.Forceps delivery 3.Schultz delivery 4.Weak bearing down efforts

2. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.

At 38 weeks' gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: 1.Discontinue the catheter, if the reading is not above 80% 2.Discontinue the catheter, if the reading does not go below 30% 3.Advance the catheter until the reading is above 90% and continue monitoring 4.Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

4. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.

A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? 1.A loud mouth 2.Low self-esteem 3.Hemorrhage 4.Postpartum infections

4. Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Having a loud mouth is only related to the person typing up this test.

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: 1.Auscultating the fetal heart 2.Taking an obstetric history 3.Asking the client when she last ate 4.Ascertaining whether the membranes were ruptured

1. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is: 1.1 cm above the ischial spine 2.1 fingerbreadth below the symphysis pubis 3.1 inch below the coccyx 4.1 inch below the iliac crest

1. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion

3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: 1.Until the time it is completely over 2.To the end of a second contraction 3.To the beginning of the next contraction 4.Until the time that the uterus becomes very firm

3. This is the way to determine the frequency of the contractions

. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: 1.Noting if the heart rate is greater than 140 BPM 2.Placing the diaphragm of the Doppler on the mother abdomen 3.Performing Leopold's maneuvers first to determine the location of the fetal heart 4.Palpating the maternal radial pulse while listening to the fetal heart rate

4. The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: 1.Trendelenburg's position with the legs in stirrups 2.Semi-Fowler position with a pillow under the knees 3.Prone position with the legs separated and elevated 4.Supine position with a wedge under the right hip

4. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus.

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A Place the client in Trendelenburg's position B Call the delivery room to notify the staff that the client will be transported immediately C Gently push the cord into the vagina D Find the closest telephone and stat page the physician

A Place the client in Trendelenburg's position When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.

A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense: A. Around the pelvic girdle B. Around the pelvic girdle and in the upper arms C. Around the pelvic girdle and at the perineum D. At the perineum

A. Around the pelvic girdle During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. The pain of early labor is referred to T10-T12 dermatomes such that the pain is felt in the lower abdomen, sacrum, and back. This pain is dull in character and is not always sensitive to opioid drugs. Option B: Upper arm pain is not common during any stage of labor. With each uterine contraction, pressure is transmitted to the cervix causing stretching and distension and activating excitatory nociceptive afferents. Option C: Pain arises due to afferents that innervate the vaginal surface of the cervix, perineum, and vagina and occurs as a result of stretching, distention, ischemia, and injury of the pelvic floor, perineum, and vagina. Option D: During the late part of the second stage and childbirth, intense pain occurs at the perineum. Somatic pain occurs closer to delivery, is sharp in character and easily localized to the vagina, perineum, and rectum. It radiates to the adjacent dermatomes T10 and L1 and compared to visceral pain, is more resistant to opioid drugs.

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? A. At the beginning of each fetal movement. B. At the beginning of each contraction. C. After every three fetal movements D. At the end of fetal movement.

A. At the beginning of each fetal movement An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. Option B: The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. The Non-Stress Test (NST) is an assessment tool used from 32 weeks of gestation to term to evaluate fetal health through the use of electronic fetal monitors that continuously record the fetal heart rate (FHR). Option C: Pushing the control button after every three fetal movements wouldn't allow accurate comparison of fetal movement and FHR change. Fetal activity may be recorded by the patient using an event marker or noted by the staff performing the test. Option D: The presence of fetal heart rate acceleration with fetal movement is the principle behind the non-stress test. It is vital to start monitoring the moment the client recognizes a fetal movement. The NST recognizes the coupling of fetal neurological status to cardiovascular reflex responses. It is one of the factors that tends to disappear earliest during progressive fetal compromise.

The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A. Change the client's position. B. Prepare for an emergency cesarean section. C. Check for placenta previa. D. Administer oxygen.

A. Change the client's position. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side-lying may immediately correct the problem. Option B: An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Option C: Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent. It does not include placenta previa. Option D: Administering oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression. The fetus already has a surplus of oxygen due to high basal blood flow to its organs and vascular shunts.

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? A. Endometritis B. Endometriosis C. Salpingitis D. Pelvic thrombophlebitis

A. Endometritis Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Symptoms include swelling of the abdomen, abnormal vaginal bleeding or discharge, fever, discomfort with bowel movement, and pain in the lower abdomen or pelvic region.

Immediately after delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding? A. Fetal body flexion or extension B. Maternal age, body frame, and weight C. Maternal and paternal ethnic backgrounds D. Maternal parity and gravidity

A. Fetal body flexion or extension Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head of a neonate. Option B: When a baby is born in a cephalic position, pressure on the head in the birth canal may mold the head into an oblong shape. The mother's age, body frame, and weight do not affect the pressure. Option C: There is research that indicates that infant head molding, the application of pressure or bindings to cranial bones to alter their shapes, is prevalent among various Caribbean, Latino, European, African American, Asian, and Native American groups. Option D: Infants born by primiparous women showed significantly higher degrees of molding of the head than those born by multiparous women.

A client tells the nurse, "I think my baby likes to hear me talk to him." When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? A. High-pitched speech with tonal variations. B. Low-pitched speech with a sameness of tone. C. Cooing sounds rather than words. D. Repeated stimulation with loud sounds.

A. High-pitched speech with tonal variations Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than about 55 decibels. Option B: Low pitched speech is less effective for neonates because they can hear all sounds louder than about 55 decibels. Option C: At about two months, the infant may start cooing and repeating vowel sounds. Imitate his cooing while also adding simple words and phrases over the first four to six months. Option D: A baby's hearing is very sensitive and can be easily damaged by loud sounds. It is recommended to keep sounds around the infant quieter than 60 decibels.

Which change would the nurse identify as a progressive physiological change in the postpartum period? A. Lactation B. Lochia C. Uterine involution D. Diuresis

A. Lactation Lactation is an example of a progressive physiological change that occurs during the postpartum period. Lactation is the process of milk production. Option B: Lochia is the vaginal discharge a woman has after a vaginal delivery. It has a stale, musty odor like menstrual discharge. Lochia for the first 3 days after delivery is dark red in color. For the fourth through tenth day after delivery, the lochia will be more watery and pinkish to brownish color. From about the seventh to tenth day through the fourteenth day after delivery, the lochia is creamy or yellowish in color. Option C: Involution is the process by which the uterus is transformed from pregnant to non-pregnant state. This period is characterized by the restoration of ovarian function in order to prepare the body for a new pregnancy. Option D: Diuresis is increased urination and the physiologic process that produces such an increase. It involves extra urine production in the kidneys as part of the body's homeostatic maintenance of fluid balance.

Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why should the nurse monitor the patient's fluid intake and output closely during oxytocin administration? A. Oxytocin causes water intoxication. B. Oxytocin causes excessive thirst. C. Oxytocin is toxic to the kidneys. D. Oxytocin has a diuretic effect.

A. Oxytocin causes water intoxication. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. In addition, oxytocin may cause water intoxication via an antidiuretic hormone-like activity when administered in excessive doses with electrolyte-free solution. Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. Option C: Oxytocin, when given in rapid bolus, produces marked but short-lived hypotension and tachycardia. Sometimes, this abrupt and severe hemodynamic depression may need to be distinguished from placental abruption, myocardial infarction, or a pulmonary embolism in patients undergoing delivery. Option D: Oxytocin is known to possess antidiuretic properties. It can function physiologically as an antidiuretic hormone, mimicking the short-term action of vasopressin on water permeability, albeit with somewhat lower potency.

The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? A. Risk for deficient fluid volume related to hemorrhage. B. Risk for infection related to the type of delivery. C. Pain related to the type of incision. D. Urinary retention related to periurethral edema.

A. Risk for deficient fluid volume related to hemorrhage Hemorrhage jeopardizes the client's oxygen supply — the first priority among human physiological needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over-diagnoses of Risk for Infection, Pain, and Urinary retention. Option B: Episiotomy infections are classically reported as being rare at a rate of 0.1% and increasing up to 2% if a third or fourth-degree tear occurs. Option C: Episiotomy pain may be relieved by an ice pack, warm or cold shallow baths or sitz baths, or medicated creams or local numbing sprays. Option D: Postpartum urinary retention (PPUR) is an upsetting condition that has no standard literature definition. It has been variably defined as the abrupt onset of aching or inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or not to void spontaneously within 6 hours of vaginal delivery.

After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective? A. Shortens the second stage of labor. B. Enlarges the pelvic inlet. C. Prevents perineal edema. D. Ensures quick placenta delivery.

A. Shortens the second stage of labor An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieve pressure on the rectum. Tearing may still occur. Option B: The pelvic inlet or superior aperture of the pelvis is a planar surface that defines the boundary between the pelvic cavity and the abdominal cavity. It is not involved during an episiotomy. Option C: To prevent perineal edema, ice packs may be applied in the first 24 hours after birth to decrease swelling and pain. Option D: Placenta delivery may be sped up by either pulling the cord gently with one hand while pressing and kneading the uterus with the other, or exerting downward pressure on the top of the uterus, asking the woman to push at the appropriate time.

When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? A. Startle reflex B. Babinski reflex C. Grasping reflex D. Tonic neck reflex

A. Startle reflex The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months. Option B: Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toe fan out. Option C: Palmar grasp reflex appears around 16 weeks of gestation and can be elicited in preterm infants as young as 25 weeks of postconceptional age. To elicit the reflex, the infant is laid in a symmetrical supine and the examiner strokes the palm of the infant with his or her index finger. The response to this stimulus comprises two phases: finger closing and clinging. Option D: When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. The tonic neck reflex lasts until the infant is about 5 to 7 months old.

A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: A. Tailor sitting B. Leg lifting C. Shoulder circling D. Squatting exercises

A. Tailor sitting Tailor sitting is an excellent exercise that helps to strengthen the client's back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. Option B: The leg raise is a great way to strengthen the abdominal muscles. It targets the lower abdominal muscles and hip muscles. Option C: This exercise can warm up the shoulders, specifically the muscles in the rotator cuff. Option D: During pregnancy, squats are an excellent resistance exercise to maintain strength and range of motion in the hips, glutes, core, and pelvic floor muscles.

For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? A. The membranes must rupture. B. The fetus must be at 0 station. C. The cervix must be dilated fully. D. The patient must receive anesthesia.

A. The membranes must rupture. Internal fetal heart rate monitoring uses an electronic transducer connected directly to the fetal skin. A wire electrode is attached to the fetal scalp or other body parts through the cervical opening and is connected to the monitor. Internal EFM can be applied only after the patient's membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. Option B: An electrode will be attached to the part of the infant's body that is closest to the cervical opening. Option C: Dilation of at least 2 cm is adequate enough to insert the electrode through the cervical opening. Option D: Although the patient may receive anesthesia, it is not required before application of an internal EFM device.

When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breastfeeding success? A. "It's contraindicated for you to breastfeed following this type of surgery." B. "I support your commitment; however, you may have to supplement each feeding with formula." C. "You should check with your surgeon to determine whether breast-feeding would be possible." D. "You should be able to breastfeed without difficulty."

B. "I support your commitment; however, you may have to supplement each feeding with formula." Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breastfeeding after surgery is possible. Still, it's good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother's ability to meet all of her baby's nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client's psychological adaptation to mothering may be dependent on how successfully she breast-feeds. Option A: While there is evidence that both breastfeeding and breast reduction surgery are beneficial, it is unknown whether breast reduction surgery impacts breastfeeding and whether any breast reduction technique differentially preserves the ability to breastfeed. Option C: Women considering breast reduction surgery should be told not only the name of the proposed breast reduction technique but its characteristics, including the extent the column of subareolar parenchyma will be preserved and pedicle width, to allow them to gain a better understanding of its impact on breastfeeding. Option D: Breast reduction techniques have been in a continuous state of development since the early 1900s, with new techniques developed, refined, and modified by subsequent plastic surgeons. This has led to many diverse breast reduction techniques. Its effect on breastfeeding remains entirely unclear, so telling the client that she could breastfeed without difficulty would give her a false sense of reassurance.

When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? A. "I'll report increased frequency of urination." B. "If I have blurred or double vision, I should call the clinic immediately." C. "If I feel tired after resting, I should report it immediately." D. "Nausea should be reported immediately."

B. "If I have blurred or double vision, I should call the clinic immediately." Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. It can affect the visual pathways, from the anterior segment to the visual cortex. Option A: Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. The anatomical and physiological changes affecting the lower urinary tract in pregnancy, as well as the hormonal milieu of pregnancy, have been postulated to underlie the pathogenesis of lower urinary symptoms in pregnancy Option C: Clients generally experience fatigue during pregnancy. Pregnancy is accompanied by several psychological, emotional, and physical changes that may predispose the woman to fatigue, which can range from mild tiredness to severe exhaustion. Option D: The pathophysiology of nausea and vomiting during early pregnancy is unknown, although metabolic, endocrine, GI, and psychologic factors probably all play a role. Estrogen may contribute because estrogen levels are elevated in patients with hyperemesis gravidarum.

A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effect." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."

B. "No, it can initiate premature uterine contractions." Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Option A: Castor oil is a harsh stimulant laxative that relieves constipation by forced bowel movements. Side effects may include nausea, stimulation of uterine activity, meconium-stained fluid, and amniotic fluid embolism. Option C: There is no evidence that suggests that castor oil can promote sodium retention. Option D: Castor oil is not known to increase absorption of fat-soluble vitamins, although laxatives, in general, may decrease absorption if intestinal motility is increased.

What is the approximate time that the blastocyst spends traveling to the uterus for implantation? A. 2 days B. 7 days C. 10 days D. 14 weeks

B. 7 days The blastocyst takes approximately 1 week to travel to the uterus for implantation. Implantation is a process in which a developing embryo, moving as a blastocyst through a uterus, makes contact with the uterine wall and remains attached to it until birth. Option A: The zygote moves through the fallopian tube and undergoes cell division, a process called cleavage. These cell divisions produce the inner cell mass (ICM), which will become the embryo, and the trophoblast, which surrounds the ICM and interacts with maternal tissues. Together, the ICM and the trophoblast are called the blastocyst. Option C: A blastocyst successfully implants in the uterus when, as the zona pellucida exits the fallopian tube, the blastocyst leaves the zona pellucida and binds to the endometrium. Option D: 14 weeks is too long a time to wait for implantation. If the blastocyst does not implant within 7 days, the pregnancy may not occur at all.

A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? A. Placenta previa B. Abruptio placentae C. Ectopic pregnancy D. Spontaneous abortion

B. Abruptio placentae The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae. The hypertension and increased levels of catecholamines caused by cocaine abuse are thought to be responsible for a vasospasm in the uterine blood vessels that causes placental separation and abruption. Option A: A pregnant woman who uses cocaine experiences a constriction of the blood vessels throughout her body. A fetus needs this blood flow for its oxygen supply. After cocaine abuse, the heart rate of the fetus goes up along with the blood pressure, but it may suffer a lack of oxygen (hypoxia). This restricted blood supply can also permanently damage sections of the placenta which can result in loss of the baby. Option C: Ectopic pregnancy (EP) is defined as the implantation and development of a fertilized ovum anywhere outside of the uterine cavity. Such a pregnancy may lead to tubal rupture and intra abdominal hemorrhage and represents the major cause of maternal death in the first trimester. Option D: Cocaine use early in pregnancy decreases uterine and placental blood flow by inhibiting the reuptake of norepinephrine, which causes arterial vasoconstriction. In most, but not all, previous studies of cocaine use during pregnancy and spontaneous abortion, the women's current use of cocaine, as assessed by self-reports or urine analysis, was related to their history of spontaneous abortion.

A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? A. Every 5 minutes. B. Every 15 minutes. C. Every 30 minutes. D. Every 60 minutes.

B. Every 15 minutes During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. Option A: Second stage of labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered. At this stage, the patient feels an uncontrollable urge to push. Monitoring every 5 minutes would be too frequent and inconvenient for the laboring mother. Option C: After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. The fetus passes through the birth canal via 7 movements known as the cardinal movements. These include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. These movements may occur in a few minutes, so 30 minutes might be too long to assess for contractions. Option D: Monitoring hourly would be too long and the nurse might miss the important details of assessment.

A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient? A. Knowledge deficit B. Fluid volume deficit C. Anticipatory grieving D. Pain

B. Fluid volume deficit If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Blood volume expands during pregnancy, and a considerable portion of the weight of a pregnant woman is retained water. Option A: Knowledge deficit is an appropriate nursing diagnosis because the woman might not have any knowledge on how to manage her symptoms. However, this is not a priority diagnosis. Option C: Anticipatory grieving is the name given to the tumultuous set of feelings and reactions that occur when someone is expecting the death of a loved one. Option D: Pain may be felt due to abdominal cramping accompanied by bleeding. This is not a cause of alarm since true labor pain includes strong and regular contractions and lower back pain.

A client makes a routine visit to the prenatal clinic. Although she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: A. An empty gestational sac. B. Grapelike clusters. C. A severely malformed fetus. D. An extrauterine pregnancy.

B. Grapelike clusters. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually, no embryo (and therefore no fetus) is present because it has been absorbed. Option A: An anembryonic pregnancy is characterized by a gestational sac that forms and grows while an embryo fails to develop. Etiologies include morphological abnormalities of an embryo that prevents implantation or prevents long term survival of the embryo after implantation; chromosomal abnormalities that collectively include autosomal trisomy, polyploidy, sex chromosomal polysomy, and monosomy X likely represent the most common etiologies for early pregnancy loss; and other genetic and chromosomal abnormalities include translocations, inversions, single-gene perturbations, and placental mosaicism. Option C: Congenital anomalies are also known as birth defects, congenital disorders or congenital malformations. Congenital anomalies can be defined as structural or functional anomalies (for example, a severely malformed fetus) that occur during intrauterine life and can be identified prenatally, at birth, or sometimes may only be detected later in infancy, such as hearing defects. Option D: Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.

While the client is in active labor with twins and the cervix is 5 cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? A. Note the fetal heart rate patterns. B. Notify the physician immediately. C. Administer oxygen at 6 liters by mask. D. Have the client pant-blow during the contractions.

B. Notify the physician immediately. The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists. Option A: A baby's heart rate during labor should be between 110 and 160 beats per minute, but it may fluctuate above and below this rate for a variety of reasons. Option C: Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate non-reassuring fetal heart rate patterns. However, there are only two randomized trials investigating the use of maternal oxygen supplementation in laboring women. These studies did not find that supplementation is likely to benefit the fetus and may even be harmful. Option D: During active labor, breathing should be as slow as possible, but it can be sped up as the intensity of the contraction increases. As the contraction peaks and the breathing rate increases, switch to light breathing both in and out the mouth, about one breath per second.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following? A. The vaccine prevents a future fetus from developing congenital anomalies. B. Pregnancy should be avoided for 3 months after the immunization. C. The client should avoid contact with children diagnosed with rubella. D. The injection will provide immunity against the 7-day measles.

B. Pregnancy should be avoided for 3 months after the immunization After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccine's toxic effects to the fetus. Option A: The role of the vaccine postpartum is to protect the mother against rubella in the future pregnancies as well as measles and mumps, since it is given together. Option C: Protection against measles, mumps, and rubella starts to develop around 2 weeks after having the MMR vaccine. Option D: One dose of MMR vaccine is 93% effective against measles, 78% effective against mumps, and 97% effective against rubella.

Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Tetanic uterine contractions D. Premature rupture of membranes

B. Rigid, board-like abdomen The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. Option A: It's possible for the blood to become trapped inside the uterus, so even with a severe placental abruption, there might be no visible bleeding. Option C: Uterine contractions are a common finding with placental abruption. Contractions progress as the abruption expands, and uterine hypertonus may be noted. Contractions are painful and palpable. Option D: Increased frequency of placental abruption was found in patients with early rupture of membranes. The incidence was 50% and 44% when rupture of the membranes occurred before 20 weeks or between 20-24 weeks of pregnancy, respectively.

Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? A. "Do you have any chronic illness?" B. "Do you have any allergies?" C. "What is your expected due date?" D. "Who will be with you during labor?"

C. "What is your expected due date?" When obtaining the history of a patient who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons. Option A: After asking for the expected due date, obtain the client's problems during this or previous pregnancies. Option B: Asking about any known allergies may be done after inquiring about prior ultrasonographic examinations and results, and bleeding during pregnancy or labor. Option D: This may be asked if the client's health history and present health history, which are some of the most important details, are already obtained.

After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at (-1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: A. 1 cm below the ischial spines. B. Directly in line with the ischial spines. C. 1 cm above the ischial spines. D. In no relationship to the ischial spines.

C. 1 cm above the ischial spines. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as -1, -2, or -3. Option A: A presenting part below the ischial spines, as +1, +2, or +3. Option B: 0 station is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis. Option D: If the head is high and not yet engaged in the birth canal, it may float away from the physician's fingers during the vaginal exam.

The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day. B. Wearing a supportive brassiere with nipple shields. C. Breastfeeding the neonate at frequent intervals. D. Decreasing fluid intake for the first 24 to 48 hours.

C. Breastfeeding the neonate at frequent intervals Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate's and mother's needs. Option A: A newborn feeds every 2 to 3 hours. They should be breastfed 8-12 times per day for about the first month. Frequent feedings help stimulate your milk production during the first few weeks. Option B: A nipple shield is usually meant to be used for a short time. When using a shield, help the baby to latch on by himself with a wide-open mouth. This will help the baby learn to breastfeed without a shield. Option D: Breastfeeding women are recommended to increase fluid intake by 800 ml/`day during the first 6 months postpartum

Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? A. Low room humidity B. Cold weight scale C. Cool incubator walls D. Cool room temperature

C. Cools incubator walls A common source of radiant heat loss includes cool incubator walls and windows. Radiant heat loss constitutes the transfer of heat from an infant's warm skin, via infrared electromagnetic waves, to the cooler surrounding walls that absorb heat. Option A: Low room humidity promotes evaporative heat loss. Evaporative heat loss occurs through the skin and the respiratory system. The driving force behind evaporation is the vapor pressure difference between the body surface and the environment. Option B: When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. Heat loss can occur by conduction of heat from the skin to the layer of still air around the body. Option D: A cool room temperature may lead to convective heat loss. Convective heat loss is the transfer of heat from a body to moving molecules such as air or liquid.

A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? A. Proteinuria, headaches, vaginal bleeding B. Headaches, double vision, vaginal bleeding C. Proteinuria, headaches, double vision D. Proteinuria, double vision, uterine contractions

C. Proteinuria, headaches, double vision A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Option A: Pre-eclampsia increases the risk for placental abruption, a condition in which the placenta separates from the inner wall of the uterus before delivery. Severe abruption can cause heavy bleeding, which can be life-threatening for both the baby and the mother. Option B: Any hypertensive disorder of pregnancy can result in preeclampsia. It occurs in up to 35% of women with gestational hypertension and up to 25% of those with chronic hypertension. The underlying pathophysiology that upholds this transition to, or superposition of, preeclampsia is not well understood; however, it is thought to be related to a mechanism of reduced placental perfusion inducing the systemic vascular endothelial dysfunction. Option D: Symptoms of preeclampsia may include visual disturbances, typically scintillations and scotomata, presumed to be due to cerebral vasospasm. The woman may describe new-onset headache that is frontal, throbbing, or similar to a migraine headache, and gastrointestinal complaints of sudden, new-onset, constant epigastric pain that may be moderate to severe in intensity and due to hepatic swelling and inflammation, with stretch of the liver capsule.

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? A. The fetus should be delivered within 24 hours. B. The client should repeat the test in 24 hours. C. The fetus isn't in distress at this time. D. The client should repeat the test in 1 week.

C. The fetus isn't in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits. Option A: The biophysical profile is a test used to evaluate the well-being of the fetus. It is commonly done at the last trimester of pregnancy, but it does not indicate that the fetus should be delivered within 24 hours. Option B: If the score is 6, the health care provider will likely repeat the test within 24 hours. Option D: The test is most commonly done when there's an increased risk of problems that could lead to complications or pregnancy loss. The health care provider will determine the necessity and timing of a biophysical profile based on whether the baby could survive if delivered early, the severity of the mother's condition, and the risk of pregnancy loss.

Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. A foul odor D. The complete absence of lochia

Correct Answer: A. Bright red blood Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia. Option B: The blood clots in the lochia should get smaller and happen less often as the bleeding gets less over the first few days. Option C: Lochia with offensive odor may indicate infection. Option D: Complete absence of lochia might be a sign of infection.

When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? A. Turn the neonate every 6 hours B. Encourage the mother to discontinue breastfeeding. C. Notify the physician if the skin becomes bronze in color. D. Check the vital signs every 2 to 4 hours.

D. Check the vital signs every 2 to 4 hours While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. Option A: Only one study reported the significance drop in serum bilirubin and shorter duration of phototherapy in the supine group. Keeping the jaundiced newborn in the supine position throughout phototherapy is as effective as turning them periodically based on appraised studies. Option B: The baby may be breastfed without interruption during phototherapy. Jaundice in breastfed babies is not a reason to stop breastfeeding as long as a baby is feeding well, gaining weight, and otherwise growing. Option C: Bronze baby syndrome is a rare complication seen in neonates with hyperbilirubinemia who are being treated with phototherapy. Affected neonates develop gray-brown skin, serum, and urine within a week of initiation of phototherapy.

A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first? A. Pad the side rails. B. Place a pillow under the left buttock. C. Insert a padded tongue blade into the mouth. D. Maintain a patent airway.

D. Maintain a patent airway The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Option A: Padding the side rails should be done as a precaution before a seizure, not during the seizure. Option B: The client should be placed on a flat, firm surface to avoid any injuries. Option C: There should be nothing inserted inside the client's mouth to maintain airway patency and prevent obstruction and aspiration.

A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? A. Back B. Abdomen C. Fundus D. Perineum

D. Perineum A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. Option A: A spinal anesthetic is given into the middle of the lower back and local anesthetic is injected through the needle into the fluid that surrounds the spinal cord. It numbs the nerves that supply the abdomen, hips, bottom, and legs. Option B: General or regional anesthesia can be appropriate for patients undergoing abdominal surgery. Balanced anesthesia with inhalational anesthetics, opioids, and neuromuscular blockers are used in general anesthesia for abdominal surgical procedures. Option C: Spinal anesthesia is one of the most preferred anesthetic methods during Cesarean section since it provides easy and rapid induction, effective sensory and motor block, and has little effect on the fetus.

Which of the following would be inappropriate to assess in a mother who's breastfeeding? A. The attachment of the baby to the breast. B. The mother's comfort level with positioning the baby. C. Audible swallowing. D. The baby's lips smacking.

D. The baby's lips smacking Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who's smacking his lips isn't well attached and can injure the mother's nipples. Option A: A good attachment shows much of the areola and the tissues underneath it, including the larger ducts, are in the baby's mouth; the breast is stretched out to form a long "teat", but the nipple only forms about one-third of the "teat"; the baby's tongue is forward over the lower gums, beneath the milk ducts; and the baby is suckling from the breast, not from the nipple. Option B: To be well attached at the breast, a baby and his or her mother need to be appropriately positioned. The mother can be sitting or lying down, or standing, if she wishes. However, she needs to be relaxed and comfortable, and without strain, particularly of her back. The baby can breastfeed in several different positions in relation to the mother: across her chest and abdomen, under her arm, or alongside her body. Option C: When the milk ejection reflex is triggered, the baby may swallow after every suck in order to handle the rapid flow of milk. You should hear suck, swallow, pause, suck, swallow, pause. Audible swallowing after every couple of sucks should continue for about ten minutes.

The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent phase D. Transitional phase

D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. Option B: The complete phase occurs during the second, not first, stage of labor. Option C: The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.