Maternal

36. A nurse is caring for a patient who is administering oxytocin to augment her labor. The oxytocin is mixed by the pharmacy 30 u in 500 mL Lactated Ringers. The nurse is titrating the oxytocin until the patient is in an active labor pattern. How many mL/hr will the nurse run to infuse at 8 mu/min?

8 mL/hr

31. A nurse is providing breast self examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective. (Select all that apply). a. "I don't have to lie down to check my breasts. I can stand in the shower." b. "If I feel a firm ridge in the lower curve of my breasts I should report this immediately." c. "It is important to use pressure when feeling my breasts to detect changes." d. "Since I no longer have periods, I can perform an examination at any time of the month." e. "I will make sure to feel for changes in my underarm area."

A C D E

25. The nurse is providing care in a woman's healthcare setting must be aware that which sexually transmitted disease (STD) can be cured? a. HIV b. Herpes c. Chlamydia d. Veneral Warts

Chlamydia

30. Appendicitis may be difficult to diagnose in pregnancy because the appendix is: a. Displaced upward and laterally, high and to the right. b. Displaced upward and laterally, high and to the left. c. Deep at McBurney point. d. Displaced downward and laterally, low and to the right.

Displaced upward and laterally, high and to the right

43. 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? a. Document the findings and tell the mother that the monitor indicates fetal well- being b. Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. c. Notify the physician or nurse mid-wife of the findings. d. Reposition the mother and check the monitor for changes in the fetal tracing

Document the findings and tell the mother that the monitor indicates fetal well- being

A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? A history of pelvic inflammatory disease. Abdominal bloating starting several days before menses. An atypical Papanicolaou smear at her last clinic visit. Dysmenorrhea that is unresponsive to NSAIDS.

Dysmenorrhea that is unresponsive to NSAIDS.

28. What results from the adaptation of the fetus to the size and shape of the pelvis? a. Lightening b. Lie c. Molding d. Presentation

Molding

When involved in prenatal teaching, the nurse should advise the client that an increase in vaginal secretions during pregnancy is called leukorrhea and is caused by increased: a. Production of estrogen b. Supply of sodium chloride to the cells of the vagina c. Metabolic rates d. Functioning of the Bartholin glands

Production of estrogen

19. A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess the fetal heart monitor tracing? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes

Rationale: FHTs should be assessed every 5 minutes during the 2nd stage of labor to ensure fetal stability during this stage until delivery

56. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. An intrauterine device (IUD) - an IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception b. An Oral contraceptive c. A male condom d. A diaphragm with spermicide

a. An intrauterine device (IUD) - an IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception

67. A nurse is speaking with a 35 year old client who has fibrocystic disease of the breasts. Which of the following times should the nurse inform the client that manifestations are most evident? a. Before menstruation begins b. During cold weather c. After menstruation ends d. During hot weather

a. Before menstruation begins

The breathing technique that the mother should be instructed to use as the fetus' his head is crowning is: a. Blowing b. Slow chest c. Shallow d. Accelerated-decelerated

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

A multiparous client who has been in labor for two hours states that she feels the urge to move her bowels. How should the nurse respond? a. Perform a pelvic examination b. Allow the client to use a bedpan c. Let the client get up ands the bathroom d. Check the fetal heart rate

a. Perform a pelvic examination

70. 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. Perineum b. Back c. Abdomen d. Fundus

a. Perineum

63. A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients blood pressure is 80/40 mmHg and the fetal heart rate is 140/min. Which of the following is a priority nursing action? a. Place the client in a lateral position b. Monitor vital signs every 5 minutes c. Notify the provider d. Elevate the clients legs

a. Place the client in a lateral position

A client who has been admitted to labor and delivery has the following assessment findings: gravida two para one, estimated 40 weeks gestation, contractions two minutes apart, nothing 45 seconds, vertex +4 station. Which of the following would be the priority at this time? a. Preparing for immediate delivery b. The client in bed for fetal monitoring c. Providing comfort measures d. For ruptured membranes

a. Preparing for immediate delivery Rationale: The question requires an understanding of station as part of the intrapartum assessment process. Based on the clients assessment findings, this client is ready for delivery, which is the nurses top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery

73. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was September 19, 2019. Using Naegele's rule, the nurse determines the estimated date of confinement as: a. July 12, 2020 b. June 25, 2020 c. June 12, 2020 d. July 26, 2020

b. June 25, 2020

Nutritional planning for a newly pregnant woman of average height and weighing 145 pounds should include: a. A decrease of 200 calories a day b. An increase of 300 calories a day (This is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy). c. An increase of 500 calories a day d. A maintenance of her present caloric intake per day

b. An increase of 300 calories a day (This is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy).

42. The nurse on the labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mmHg. Which of the following is the priority action for the nurse to take? a. Notify the provider of the findings. b. Position the client with one hip elevated. c. Ask the client if she needs pain medication. d. Have the client void.

b. Position the client with one hip elevated

27. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant of malignant cells is called: a. Bimanual palpation b. Rectovaginal palpation c. Papanicolaou test d. DNA testing

c. Papanicolaou test

Labor is a series of events affected by the coordination of the essential factors. One of these is the passenger (fetus). Which are the other 4 factors? a. Contractions, passageway, placental position and function, pattern of care b. Contractions, maternal response, placental position, psychological response c. Passageway, contractions, placental position and function, psychological response d. Passageway, placental position and function, paternal response, psychological response

c. Passageway, contractions, placental position and function, psychological response The five essential factors (5 P's) are passenger (fetus), passageway (pelvis), powers (contractions), placental position and function, and psyche (psychological response of the mother).

38. For a client was 40 weeks gestation and is an active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtained the clients blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? a. Prepare for a cesarean birth. b. Assist the client to an upright position. c. Prepare for an immediate vaginal delivery. d. Assist the client to turn onto her side.

d. Assist the client to turn onto her side

34. A nurse is caring for a client who's Papanicolaou test cytology results are abnormal. Which of the following procedures should the nurse anticipate for this client? a. Rectovaginal palpation by the provider b. Dilation and curettage c. Human chorionic gonadotropin (hCG) test d. Colposcopy

d. Colposcopy Rationale: The nurse should anticipate follow-up visit for a client who has an abnormal pap test to include colposcopy and directed biopsy. The specimen contained from endocervical testing is examined for abnormal cells.

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? a. Use a natural membrane condom rather than a polyurethane condom. b. You may use a condom more than once. c. Use an oil-based lubricant when you use a condom. d. Female condoms can help prevent transmission of sexually transmitted viruses.

d. Female condoms can help prevent transmission of sexually transmitted viruses

A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the clients preparation for parenting, the nurse might ask which question? a. "Are you planning to have epidural anesthesia?" b. "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?" d. "Have you begun prenatal classes?"

"What changes have you made at home to get ready for the baby Rationale: 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. The type of anesthesia plan doesn't reflect the client preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

35. A nurse is planning to administer diphenhydramine 30 mg IM stat to a client who is having an allergic reaction. Available is diphenhydramine 50 mg/1mL. How many mL should the nurse administer? (Round to the nearest tenth)

0.6 mL

49. 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 BPM lasting for 15 seconds this should be documented as: a. Tachycardic heart rate b. Acceleration c. Sonographic motion d. An early elevation

b. Acceleration

68. A nurse in a clinic is caring for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take? a. instruct the client about preventing reinfection by using a diaphragm b. Tell the client to expect some joint pain c. Obtain information about the client's recent sexual experiences d. Collect urine specimen from the client

c. Obtain information about the client's recent sexual experiences

The nurse teaches a pregnant woman to avoid lying on her back. The nurse has faced this statement on the knowledge that the supine position can: a. unduly prolong labor b. Cause decreased placental perfusion c. Interfere with free movement of the coccyx d. Lead to transient episodes of hypertension

b. Cause decreased placental perfusion

71. The nurse is aware that an adaption of pregnancy is an increase blood supply to the pelvic region that results in a purpleish discoloration of the vaginal mucosa, which is known as: a. Hegar's sign b. Chadwick's sign (a purplish color results from the increased vascularity of blood vessel engorgement of the vagina) c. Ladin's sign d. Goodell's sign

b. Chadwick's sign (a purplish color results from the increased vascularity of blood vessel engorgement of the vagina)

18. 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. "What is your expected due date?" b. "Who will be with you during labor?" c. "Do you have any chronic illnesses?" d. "Do you have any allergies?"

a. "What is your expected due date? Explanation: When obtaining the history of a client 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 illnesses, allergies, and support persons.

75. A woman's obstetric history indicates that she is pregnant for the fourth time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation what is her gravity and parity using the GTPAL system? a. 4-1-2-0-4 b. 4-0-3-0-3 c. 4-2-1-0-3 d. 3-1-1-1-3

a. 4-1-2-0-4

66. A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely will have: a. Amenorrhea. b. Positive pregnancy test. c. Chadwicks sign. d. Hegars sign.

a. Amenorrhea

10. A primigravida patient is admitted to the labor and delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense in which area

a. Around the pelvic girdle

37. The client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: a. Auscultating the fetal heart b. Obtaining an obstetric history c. Determining when the last meal was eaten d. Ascertaining whether the membranes have ruptured

a. Auscultating the fetal heart

65. Healthy people 2020 has established national health priorities that focus on a number of maternal - child health indicators. Nurses are assuming greater roles in assessing family health and providing care across the perinatal continuum. Therefore it is important for the nurse to be aware that significant progress has been made in: a. The reduction of fetal deaths and use of prenatal care. b. Low birth weight and preterm birth. c. Elimination of health disparities based on race. d. Infant mortality and the prevention of birth defects.

a. The reduction of fetal deaths and use of prenatal care

A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching? a. The urethral orifice is assessed by separating the labia minora b. A speculum is used to assess the perineum c. The cervix is assessed by spreading the labia majora d. The anal opening is assessed to visualize the Bartholin glands

a. The urethral orifice is assessed by separating the labia minora

48. 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. Transitional phase b. Complete phase c. Latent phase d. Active phase

a. Transitional phase

A nurse is teaching a client who has a new diagnosis of genital herpes. Which of the following statements by the client indicates the need for further teaching? a. Transmission of the disease will not occur when my lesions are gone b. Abstaining for sexual activity reduces the risk of transmission of the disease c. The use of condoms will reduce the risk of transmission d. Antiviral medications will not cure the infection

a. Transmission of the disease will not occur when my lesions are gone

41. For a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? a. Uteroplacental insufficiency b. Umbilical cord compression c. Fetal head compression d. Maternal bradycardia

a. Uteroplacental insufficiency

62. A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she answers which of the following patterns? a. Variable decelerations (occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus) b. Early decelerations c. Late decelerations. d. Accelerations

a. Variable decelerations (occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus)

64. A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asked about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that proceeds labor? a. a surge of energy b. weight gain of 0.5 to 1.5 kg c. urinary retention d. decreased vaginal discharge

a. a surge of energy

Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which one of the following is a correct interpretation of the data? a. fetal presenting part is 1 cm above the ischial spines b. effacement is 4 cm from completion c. dilation is 50% complete d. fetus has passed through the ischial spines

a. fetal presenting part is 1 cm above the ischial spines

57. A nurse is leading a discussion about contraception with a group of 14 year old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make? a. "Because of your age, i think that a barrier method would be the best choice." b. "Before i can help you, i need to know more about your sexual activity." c. "A provider can help you with that after a physical examination." d. "You are so young. Are you ready for the responsibilities of a sexual relationship?"

b. "Before i can help you, i need to know more about your sexual activity."

With regards to the structure and function of the placenta, the maternity nurse should be aware that: a. As the placenta widens, it gradually thins to allow easier passage of air and nutrients. b. As one of its early functions, the placenta acts as an endocrine gland. c. The placenta is able to keep out most potentially toxic substances such as cigarette smoke to which the mother is exposed. d. Optimal blood circulation is achieved through the placenta when the woman is lying on her back or standing.

b. As one of its early functions, the placenta acts as an endocrine gland Rationale: The placenta widens until week 20 and continues to grow thicker. The placenta produces four hormones necessary to maintain the pregnancy. Toxic substances such as nicotine and carbon monoxide readily cross the placenta into the fetus. Optimal circulation occurs when the woman is lying on her side.

47. 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 that much time? a. A.Between 10 and 12 weeks' gestation b. B.Between 16 and 20 weeks' gestation c. C.Between 21 and 23 weeks' gestation d. D.Between 24 and 26 weeks' gestation

b. B.Between 16 and 20 weeks' gestation

52. A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she's dilated to 3 cm. Her fetus is at 1+ station. The nurse is aware that the fetus's head is: a. Entering the pelvic inlet b. Below the ischial spines (a station 1+ indicates that the fetal head is 1 cm below the ischial spines) c. Not yet engaged d. Visible at the vaginal opening

b. Below the ischial spines (a station 1+ indicates that the fetal head is 1 cm below the ischial spines)

58. A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? a. Limit alcohol consumption b. Consume foods fortified with folic acid (increase consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy) c. Increase intake of iron-rich foods d. Avoid foods containing aspartame

b. Consume foods fortified with folic acid (increase consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy)

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

b. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus

32. You are a nurse in charge of setting up a community health fair for young adults. Which topic is least relevant to address at this fair? a. Alcohol and drug use b. Menopause and climacteric factors c. Smoking cessation d. Unplanned pregnancy

b. Menopause and climacteric factors

69. 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. Transitional phase c. Expulsive phase d. Latent phase

b. Transitional phase

53. 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? a. Early decelerations b. Variable decelerations c. Short-term variability d. Late decelerations

b. Variable decelerations

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion Pitocin. The woman is in side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: a. change the woman's position. b. stop the Pitocin. c. elevate the woman's legs. d. administer oxygen via a tight mask at 8 to 10 L/min.

b. stop the Pitocin Rationale: The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.

45. 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

72. The nurse recognizes that an expected change in the hematologic system that occurs during the second trimester of pregnancy is: a. A decrease in sedimentation rate b. In increase in hematocrit c. An increase in blood volume d. A decrease in WBC's

c. An increase in blood volume

Which of the following conditions is common in pregnant women in the second trimester of pregnancy? a. A decrease in WBC's b. In increase in hematocrit c. An increase in blood volume d. A decrease in sedimentation rate

c. An increase in blood volume Rationale: The blood volume increases by approximately 40-50% during pregnancy. The peak blood volume occurs between 30 and 34 weeks of gestation. The hematocrit decreases as a result of the increased blood volume

51. After doing Leopold's maneuvers, the determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: a. Above the umbilicus in the midline b. Above the umbilicus on the left side c. Below the umbilicus on the right side d. Below the umbilicus near the left groin

c. Below the umbilicus on the right side

33. You are working in an adolescent health center when a 15-year-old patient shares with you that she think she is pregnant and is worried that she may not have a sexually transmitted infection. Her pregnancy test was negative. What is your next priority of care? a. Contact her parents to alert them of her need for birth control b. Refer her to a primary health care provider to obtain a prescription for birth control c. Counsel her on safe sex practices d. Ask her to have her partner come to the clinic for STI testing

c. Counsel her on safe sex practices

29. The most important nursing intervention after the injection of epidural anesthesia is monitoring: a. Urinary output b. Contractions c. Maternal blood pressure d. Intravenous infusion rate

c. Maternal blood pressure

24. Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a patient with this condition should be aware that the optimal pharmacologic therapy for pain relief is: a. Acetaminophen. b. Oral contraceptives (OCPs). c. Nonsteroidal anti-inflammatory drugs (NSAIDs). d. Aspirin

c. Nonsteroidal anti-inflammatory drugs (NSAIDs

59. The nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching? a. "You will need to increase your calcium intake during breast feeding." b. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy." c. "Vitamin E requirements decline during pregnancy due to the increase in body fat." d. "You will need to double your intake of iron during pregnancy."

d. "You will need to double your intake of iron during pregnancy.

50. 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: a. Until the time it is completely over b. To the end of a second contraction c. To the beginning of the next contraction d. Until the time that the uterus becomes very firm

c. To the beginning of the next contraction

55. A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "my parents think I am a virgin. I don't think I can tell them I have this kind of infection." Which of the following responses should the nurse make? a. Give your parents a chance; they'll understand b. If you want me to, I can tell your parents for you c. You seem scared to talk to your parents (this is an open ended therapeutic statement that focuses on the adolescence concern and allows for further exploration of the clients fear of telling her parents that she is sexually active) d. Your parents will have to be told why you are being admitted

c. You seem scared to talk to your parents (this is an open ended therapeutic statement that focuses on the adolescence concern and allows for further exploration of the clients fear of telling her parents that she is sexually active)

74. The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of: a. arteries carry oxygenated blood to the fetus b. two umbilical veins and one umbilical artery c. two umbilical arteries and one umbilical vein d. Veins carrying deoxygenated blood to the fetus

c. two umbilical arteries and one umbilical vein

26. Which diagnostic test is used to confirm a suspected diagnosis of breast cancer? a. Ultrasound b. CA15-3 c. Core needle biopsy d. Mammogram

d. Mammogram

44. 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? a. Encourage the client's coach to continue to encourage breathing exercises b. Encourage the client to continue pushing with each contraction c. Continue monitoring the fetal heart rate d. Notify the physician or nurse mid-wife

d. Notify the physician or nurse mid-wife

A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: a. Breech b. Transverse c. Occiput anterior d. Occiput posterior

d. Occiput posterior Rational: 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.

39. A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locate the fetal heart tones above the clients umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? a. Frank breech b. Transverse c. Cephalic d. Posterior (with a posterior presentation, the fetal heart is generally below the level of the client's umbilicus)

d. Posterior (with a posterior presentation, the fetal heart is generally below the level of the client's umbilicus).

40. A nurse is assessing a client who is an active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical findings? a. The fetal head is in the left occiput posterior position. b. The largest fetal diameter has passed through the pelvic outlet. c. The posterior fontanel is palpable. d. The lowermost portion of the fetus is at the level of the ischial spines.

d. The lowermost portion of the fetus is at the level of the ischial spines.

22. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for a positive signs of pregnancy. Select all positive signs of pregnancy. a. Chadwick's sign b. Ballottment c. Braxton Hicks contractions d. Uterine enlargement e. Outline of fetus via radiograph or ultrasound f. Fetal heart rate detected by doppler device

d. Uterine enlargement e. Outline of fetus via radiograph or ultrasound f. Fetal heart rate detected by doppler device

Which of the following findings meets the criteria of a reassuring FHR pattern? a. FHR does not change as a result of fetal activity. b. Average baseline rate ranges between 100 and 140 beats/min. c. Mild late deceleration patterns occur with some contractions. d. Variability averages between 6 to 10 beats/min

d. Variability averages between 6 to 10 beats/min. Rationale: FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well- oxygenated fetus with a functioning autonomic nervous system.

61. A nurse is creating a plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following action should the nurse include in the plan of care? a. keep four side rails up while the client is in bed b. monitor FHR every hour c. insert indwelling urinary catheter d. check the cervix prior to analgesic administration

d. check the cervix prior to analgesic administration

60. A nurse receive report about a client who is in labor and is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. contractions that last for 60 seconds each with a 4-min rest between contractions b. contractions that last 45 seconds each with a 3 min rest between contractions c. a contraction that lasts 4 min followed by a period of relxation d. contractions that last for 60 seconds each with a 3 min rest between contractions

d. contractions that last for 60 seconds each with a 3 min rest between contractions

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: a. severe postpartum headache. b. limited perception of bladder fullness. c. increase in respiratory rate. d. hypotension

d. hypotension Rationale: Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic because it would be with a low spinal (saddle block) anesthetic. Limited perception of bladder fullness is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.

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

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