LP 10, CH8 & CH9 Success Q's

A 38-week-gestation woman is in labor and delivery with a painful, board-like ab- domen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds

1. A fetal heart check is the appropriate assessment. The clinical scenario is indicative of a placental abruption. Since the only oxygenation available to the fe- tus is via the placenta, the appropriate action by the nurse at this time is to de- termine the well-being of the fetus.

A 32-week-gestation client was last seen in the prenatal client at 28 weeks' gesta- tion. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? 1. Weight change from 128 pounds to 138 pounds. 2. Pulse rate change from 88 bpm to 92 bpm. 3. Blood pressure change from 120/80 to 118/78. 4. Respiratory rate change from 16 rpm to 20 rpm.

1. A weight gain of 10 pounds in a 4-week period is worrisome. The rec- ommended weight gain during the second and third trimesters is approx- imately 1 pound per week. A weight gain above that which is recommended can be re- lated to a few things, including preeclampsia, excessive food intake, or multiple gestations. The midwife should be advised of the weight gain in order to identify the reason for the increase and to intervene accordingly

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

1. An order for oxytocin administration should be questioned. Since the stem states that this woman has symptomatic pla- centa previa, the test taker can conclude that the woman is bleeding vaginally. It would be appropriate to monitor the fetal heart for any signs of distress, to weigh pads to determine the amount of blood loss, and to assess the hematocrit and hemoglobin to check for anemia. Labor, however, is contraindicated since vaginal delivery is contraindicated.

A client with 4 protein and 4 reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1. Clients with severe preeclampsia are high risk for seizure. A client who is diag- nosed with severe preeclampsia is high risk for becoming eclamptic. Clients who become eclamptic have had at least one seizure.

The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.

1. Induction is contraindicated in trans- verse lie. A baby in the transverse lie is in a scapular presentation. The baby is incapable of being birthed vaginally. Whenever a vaginal birth is contraindi- cated, induction is also contraindicated.

Which of the following clients is at highest risk for developing a hypertensive ill- ness of pregnancy? 1. G1P0000, age 44 with history of diabetes mellitus. 2. G2P0101, age 27 with history of rheumatic fever. 3. G3P1102, age 25 with history of scoliosis. 4. G3P1011, age 20 with history of celiac disease.

1. This primigravid client—age 44 and with a history of diabetes—is very high risk for preeclampsia. Preeclampsia is a vascu- lar disease of pregnancy. Although any woman can develop the syndrome, women who are highest risk for the dis- ease are primigravidas, those with multi- ple gestations, women who are younger than 17 or older than 34, those who had preeclampsia with their first pregnancy, and women who have been diagnosed with a vascular disease like diabetes mel- litus or chronic hypertension.

The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2 proteinuria. 3. Decrease in plasma protein. 4. 3 patellar reflexes.

1. Weight loss is a positive sign

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hyper- tension and oligohydramnios. She is contracting q 3 min 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart brady- cardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip. Oxytocin stimulatesthe contractility of the uterine muscle. When the muscle is contracted, the blood flow to the placenta is reduced. Whenever there is evidence of fetal com- promise and oxytocin is being infused, the intravenous should be stopped immediately in order to maximize placental perfusion.

A gravid client, 27 weeks' gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? 1. Oral hypoglycemic agents. 2. Diet control with exercise. 3. Regular insulin injections. 4. Inhaled insulin.

2. About 95% of gestational diabetic clients are managed with diet and ex- ercise alone.

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has oc- curred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her hips. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2. Flexing the woman's hips sharply toward her shoulders, called McRoberts' maneuver, is appropriate. Flexing the woman's hips sharply toward her shoulders in- creases slightly the diameter of the pelvic outlet which often enables the practi- tioner to successfully deliver the baby. It is especially important to note that fundal pressure is contraindicated be- cause it may actually magnify the prob- lem by wedging the shoulders into the pelvis even more deeply. Suprapubic pressure, on the other hand, is often helpful in assisting with the delivery.

The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick counts.

2. Positive fetal fibronectin levels are seen in clients who deliver preterm Fetal fibronectin (fFN) is a substance that is metabolized by the chorion. Although positive during the first half of pregnancy, it is very rare to see positive results between 24 and 34 weeks' gestation unless the client's cervix begins to efface and dilate. It is an excellent predictor of preterm labor (PTL); therefore, many practitioners as- sess the cervical and vaginal secretions of women at high risk for PTL for the presence of fFN.

A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appro- priate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

2. The nurse should assess the client's blood pressure. Headache is a symptom of preeclampsia. Preeclampsia, a serious complication, is a hypertensive disease of pregnancy. In order to determine whether or not the client is preeclamptic, the next action by the nurse would be to assess the woman's blood pressure.

The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and head board. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2. The side rails of eclamptic clients' beds should be padded.

A diabetic client is to receive 5 units regular and 15 units NPH insulin at 0800. In order to administer the medication appropriately, what should the nurse do? 1. Draw 5 units regular in one syringe and 15 units NPH in a second syringe and inject in different locations. 2. Draw 5 units regular first and 15 units NPH second into the same syringe and inject. 3. Draw 15 units NPH first and 5 units regular second into the same syringe and inject. 4. Mix 5 units regular and 15 units NPH in a vial before drawing the full 20 units into a syringe and inject.

2. This is the appropriate method. The regular insulin should be drawn up first and then the NPH insulin in the same syringe.

Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order. The test taker should remember that beta agonists stimulate the "fight or flight" response. The client's heart rate will increase precipi- tously and there is a possibility that the potassium levels of the client may fall. These side effects place the client with heart disease at risk of heart failure and/or dysrhythmias. The client is also at high risk for pulmonary edema and con- gestive heart failure so lung field assess- ments should be done regularly.

A woman is to receive RhoGAM at 28 weeks' gestation. What action must the nurse take before giving the injection? 1. Validate that the baby is Rh negative. 2. Assess that the direct Coombs' test is positive. 3. Verify the identity of the woman. 4. Reconstitute the globulin with sterile water.

3. Although this is an important action that must be taken before the admin- istration of any medication, it is espe- cially critical in this situation. When RhoGAM is given, the nurse is administering Rh an- tibodies to Rh(-) mothers. If the nurse should make a mistake and administer the dosage to an Rh(+) mother, the client would then have been injected with antibodies that would act to destroy her own blood.

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G3P0020, 17 years of age. 2. G4P2101, cancer survivor. 3. G5P1211, cocaine abuser. 4. G6P0323, 27 weeks' gestation.

3. Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruption. It is very important that the test taker not read into any question or response. In the preceding question, all four of the women have had compli- cated pregnancies. The test taker should not presume the cause of the complica- tions when they are not stated but rather look for the answer that does absolutely place the client at high risk for the abruption.

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Low platelets are consistent with the diagnosis of HELLP syndrome. HELLP is the acronym for a serious complication of pregnancy and labor and delivery. The letters represent the following information: H, hemolysis; EL, elevated liver enzymes; LP, low platelets. When a client has HELLP syndrome, the nurse would, therefore, expect to see low hemoglobin and hematocrit levels, high aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, and low platelets, as seen in the scenario.

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this medication to be administered at this time. The client in the sce- nario is exhibiting signs that meet the criteria for preterm labor. The test taker should deduce, therefore, that a tocolytic agent may be ordered in this situation. The only tocolytic agent included in the choices is magnesium sulfate.

Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatiform mole)? 1. Protracted pain. 2. Variable fetal heart decelerations. 3. Dark brown vaginal bleeding. 4. Suicidal ideations.

3. The condition is usually diagnosed af- ter a client complains of brown vaginal discharge early in the "pregnancy." The most important thing to remember when answering questions about hydatiform mole is the fact that, even though a positive preg- nancy test has been reported, there is no "pregnancy." The normal conceptus de- velops into two portions—a blastocyst, which includes the fetus and amnion, and a trophoblast, which includes the fetal portion of the placenta and the chorion. In gestational trophoblastic disease (hydatiform mole), only the trophoblastic layer develops; no fetus develops. With the proliferation of the chorionic layer, the client is high risk for gynecological cancer.

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3. The most common difference be- tween placenta previa and placenta abruption is the absence or presence of abdominal pain. Because at least some of the blood from a placental abruption is trapped behind the placenta, women with that complication usually complain of intense, unrelenting pain. But because the blood from a symptomatic placenta previa flows freely through the vagina, the bleeding from that complication is virtually pain free.

A client, 37 weeks' gestation, has been advised that she is positive for group B strep- tococci. Which of the following comments by the nurse is appropriate at this time? 1. "The doctor will prescribe intravenous antibiotics for you. A visiting nurse will administer them to you in your home." 2. "You are very high risk for an intrauterine infection. It is very important for you to check your temperature every day." 3. "The bacteria are living in your vagina. They will not hurt you but we will give you medicine in labor to protect your baby from getting sick." 4. "This bacteria causes scarlet fever. If you notice that your tongue becomes very red and that you feel feverish you should call the doctor immediately."

3. This answer is correct. Exposure to group B strep is very dangerous for neonates. Group B strep can cause serious neonatal disease. Babies are at high risk for meningitis, sepsis, pneumonia, and even death. IV antibi- otics are administered to the laboring mother every 4 hours to decrease the colonization in the mother's vagina and rectum. In addition, the antibiotics cross the placenta and act as a prophylaxis for the baby.

A client has just been diagnosed with gestation diabetes. She cries, "Oh no! I will never be able to give myself shots!!" Which of the following responses by the nurse is appropriate at this time? 1. "I am sure you can learn for your baby." 2. "I will work with you until you feel comfortable giving yourself the insulin." 3. "We will be giving you pills for the diabetes." 4. "If you follow your diet and exercise you will probably need no insulin."

4. It is unlikely that this client will need any medication. Diet and exercise will probably control the diabetes.

Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia is an obstetric emergency.

A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures.

4. The absence of seizures is an ex- pected outcome related to magnesium sulfate administration.

A nurse is caring for four clients on the labor and delivery unit. Which of the fol- lowing actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.

4. The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency. Of the four choices above, prolapsed cord is life threatening to the fetus. None of the other situations, as stated in the question, is life threatening to either the mother or the fetus.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. Preeclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the uri- nalysis. By assessing the patellar reflexes first, however, the nurse can make a pre- liminary assessment of the severity of the preeclampsia. For example, if the reflexes are 2, the client would be much less likely to become eclamptic than a client who has 4 reflexes with clonus.

There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3P0020, in active labor. 2. Age 22, G1P0000, eclampsia. 3. Age 25, G4P3003, last delivery by cesarean section. 4. Age 32, G2P0100, first baby died during labor.

3. A woman, no matter what age, who has had a previous cesarean section is at risk for uterine rupture. When babies are birthed via cesarean section, the surgeon must create an incision through the uter- ine body. The muscles of the uterus have, therefore, been ligated and a scar has formed at the incision site. Scars are not elastic and do not contract and relax the way muscle tissue does. A vaginal birth after cesarean (VBAC) section can only be performed if the woman had a low flap (Pfannenstiel) incision in the uterus during her previous cesarean section.