N144 Week 4 Elsevier Skills Modules

7. A patient has just been admitted for induction of labor after being diagnosed with a fetal demise in the office at 36 weeks' gestation. The nurse is talking with the patient and the family. What is an appropriate comment to say to the patient and the family? A. "How are you doing with all of this?" B. "You are young; you can have others." C. "Now you have an angel in heaven." D. "This happened for the best."

A. "How are you doing with all of this?" Rationale: The nurse can acknowledge the patient's and the family's feelings and encourage expression of them by asking, "How are you doing with all of this?" Remarks such as "You are young; you can have others," "Now you have an angel in heaven," and "This happened for the best" express an opinion by the nurse and trivialize the patient's and family's pregnancy loss.

2. The nurse instructs the patient to remove all jewelry in preparation for a cesarean delivery. The patient asks whether a metal clitoris ring should be removed. How should the nurse respond? A. "Leaving the metal ring in your clitoris may result in a burn injury." B. "Leaving the metal ring in your clitoris may result in a chemical reaction injury." C. "Leaving the metal ring in your clitoris is appropriate during surgery, but it must be removed in recovery." D. "We need to remove it for the surgery, but we can reinsert it immediately after delivery."

A. "Leaving the metal ring in your clitoris may result in a burn injury." Rationale: Safety measures before a cesarean delivery include removal of dentures, nail polish, and jewelry (including piercing jewelry). Any metal object in contact with the patient's skin during the use of electrical cutting and cauterizing devices may result in inadvertent electrical burns, not a chemical reaction. Reinsertion of the clitoris ring in the OR after delivery is not a clinical priority.

7. When disinfecting the connection surface and sides of a needleless connector using mechanical scrubbing for a minimum of 5 to 15 seconds per the organization's practice, which disinfecting solutions may be used? A. 70% isopropyl alcohol or alcohol-based chlorhexidine B. Alcohol-based chlorhexidine or ethyl alcohol C. Alcohol-based chlorhexidine or 10% povidone-iodine D. Ethyl alcohol or iodophor

A. 70% isopropyl alcohol or alcohol-based chlorhexidine Rationale: In order to disinfect the connection surface and sides of a needleless connector using mechanical scrubbing for a minimum of 5 to 15 seconds, 70% isopropyl alcohol or alcohol-based chlorhexidine suitable for use with medical devices should be used. Sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab may be used for disinfecting vial by cleansing the access diaphragm using friction. Povidone-iodine is an iodophor, so it may be used for disinfecting vials, but not needleless connectors.

2. The nurse is discussing the process of parental grief with a family who has experienced an unexpected newborn death. While explaining that there is no specific order or timeline that families commonly experience, what reactions after the loss of a newborn should the nurse point out? A. Acute distress, intense grief, reorganization B. Anger, denial, acceptance C. Bargaining, depression, acceptance D. Intense grief, acute distress, and acceptance

A. Acute distress, intense grief, reorganization Rationale: Acute distress, intense grief, and reorganization are specific to the loss of the parent-child relationship. They differ from the manifestations of grief such as denial, anger, bargaining, depression, and acceptance that are based on the response to a terminal illness.

2. During preparation of a patient for a cesarean delivery, where should the nurse place the dispersive grounding pad for the electrocautery device? A. As close to the surgical site as possible, avoiding bony prominences B. Around the area of skin to be prepared for incision to prevent pooling of solutions under the patient C. On a bony prominence D. As close to the anesthesia provider as possible so the pad can be monitored closely

A. As close to the surgical site as possible, avoiding bony prominences Rationale: The dispersive grounding pad for the electrocautery device should be placed as close to the surgical site as possible, usually on the thigh. The pad's placement should not be in an area where pooling of prep solutions will occur because pooling will impede the functionality of the machine and increase the likelihood of burns to the patient. Fatty tissue or tissue directly over bone may also impede the return flow of electrosurgical current, and a dispersive grounding pad placed over such an area should be replaced with a new pad over a muscular area, which is more conductive. The dispersive grounding pad does not require monitoring by the anesthesia provider.

6. A patient at 38 weeks' gestation who has chronic hypertension with superimposed preeclampsia is having labor induced. What are contraindications to labetalol? A. Asthma, greater than first-degree AV block, and heart failure B. Asthma, maternal tachycardia, and marijuana use C. Asthma, heart failure, and marijuana use D. Asthma, heart failure, and maternal tachycardia

A. Asthma, greater than first-degree AV block, and heart failure Rationale: Asthma, greater than first-degree AV block, and heart failure are contraindications to labetalol. Marijuana use and maternal tachycardia are not considered contraindications to labetalol.

10. A student nurse asks the nurse which routes are safe for calcium gluconate administration. How should the nurse respond? A. Calcium gluconate is for IV use only. B. The subcutaneous and IV routes are safe for calcium gluconate administration. C. Calcium gluconate can be given by the IV or intramuscular route. D. Calcium gluconate can be given by the IV, intramuscular, or subcutaneous route.

A. Calcium gluconate is for IV use only. Rationale: Calcium gluconate is for IV use only. Subcutaneous or intramuscular injection may cause tissue necrosis, ulceration, and secondary infection.

4. A multipara with preeclampsia is hospitalized for a 23-hour observation period. The practitioner orders IV hydralazine. The order says to administer an initial dose of 50 mg IV for BP over 160/110 mm Hg. Based on this order, what should the nurse do? A. Clarify the practitioner's order. B. Administer the hydralazine as soon as possible. C. Assume that the practitioner meant to order labetalol 50 mg. D. Assume that the practitioner intended to order oral hydralazine 50 mg.

A. Clarify the practitioner's order. Rationale: The nurse should never administer a medication with an unusual dosage or an alternate medication without clarifying the practitioner's order. The recommended initial dosage of hydralazine is 5 mg IV or IM, followed by 5 to 10 mg IV every 20 to 40 minutes to a maximum total dose of 20 mg. An initial dose of labetalol is 20 mg IV, not 50 mg. An oral dose of hydralazine may be 50 mg for adults; however, the nurse should never administer an unusual dosage or use an alternate route of medication without first clarifying the order. IV hydralazine, not oral hydralazine, is recommended for first-line management of hypertension in pregnancy; the initial dose may be given IV or IM. Assuming that the practitioner meant anything other than what is written may lead to serious errors.

5. A patient at 31 weeks' gestation is receiving a magnesium sulfate infusion for preterm labor. The laboratory calls the nurses' station to report a serum magnesium level of 7.5 mEq/L. The nurse completes an assessment and finds that the patient's blood pressure is 110/66 mm Hg, respirations are 14 breaths/minute, and deep tendon reflexes are 1+ bilaterally. The patient reports mild generalized muscle weakness. The FHR is within normal limits. How should the nurse respond? A. Continue to monitor closely, because the patient is experiencing adverse reactions to magnesium sulfate therapy. B. Notify the practitioner that the patient is experiencing magnesium toxicity. C. Administer calcium gluconate for magnesium toxicity. D. Decrease the rate of magnesium sulfate administration to prevent magnesium toxicity.

A. Continue to monitor closely, because the patient is experiencing adverse reactions to magnesium sulfate therapy. Rationale: The patient is experiencing adverse reactions to magnesium sulfate therapy; the therapeutic range for treatment is 5 to 8 mEq/L. The patient is not exhibiting signs of magnesium toxicity, such as depressed respirations, absence of deep tendon reflexes, altered mental status, or muscle weakness, so notifying the practitioner is not necessary. Calcium gluconate administration is not necessary in the absence of magnesium toxicity. There is no need to decrease the magnesium sulfate infusion rate when the patient's serum level is within the therapeutic range.

7. A patient at 40 weeks' gestation has just started receiving magnesium sulfate for preeclampsia. Which medical condition can affect the metabolism and excretion of the medication and cause signs and symptoms of toxicity? A. Renal disease B. Respiratory disease C. Anemia D. Asthma

A. Renal disease Rationale: Renal disease can affect the metabolism and excretion of magnesium sulfate. Respiratory disease, anemia, and asthma do not affect the metabolism and excretion of magnesium sulfate.

4. A patient who is at 37 weeks' gestation is laboring and receiving IV magnesium sulfate therapy for severe preeclampsia. The nurse administered IV labetalol, 20 mg, 5 minutes ago for an elevated BP of 198/114 mm Hg. Now the patient is experiencing dizziness, mild nausea, and headache. The nurse obtains a new BP reading of 158/98 mm Hg, and the FHR characteristics fall within Category I (normal). Based on these assessments, what should the nurse do next? A. Continue to monitor the patient closely every 10 minutes. B. Notify the practitioner that the patient is having an allergic reaction to the medication. C. Reassure the patient that the symptoms are from the IV magnesium sulfate. D. Educate the patient regarding normal labor symptoms.

A. Continue to monitor the patient closely every 10 minutes. Rationale: Frequent monitoring should continue because the patient is at risk for a further decrease in BP given the concurrent administration of magnesium sulfate. The patient is experiencing recognized adverse effects of labetalol that are usually mild and temporary. Notifying the practitioner of an allergic reaction is not necessary because the patient is not experiencing signs of an allergic reaction such as difficulty breathing, rash, itching, or chest pain. Although magnesium sulfate may cause some of the same adverse effects as labetalol, the new onset of symptoms suggests that they are more likely associated with the recent administration of labetalol. The progression of labor can cause symptoms similar to those listed, but the new onset of symptoms also suggests that they are probably related to the recent administration of labetalol.

7. A primigravida who is laboring at 39 weeks' gestation has a prolonged deceleration (9 minutes). The obstetrician calls for an emergency cesarean delivery. An internal fetal electrode is on the fetal head to monitor the FHR. The nurse attempts to remove the internal lead but is unsuccessful. What is the nurse's next action in this emergency? A. Cut the lead wire as close as possible to the introitus. B. Disconnect the lead wire from the leg plate. C. Keep trying to remove the lead wire. D. Have the obstetrician attempt to remove the lead wire.

A. Cut the lead wire as close as possible to the introitus. Rationale: If the lead cannot be removed, it should be cut as close as possible to the introitus so the remainder can be pulled up through the vagina and out through the abdominal incision during delivery of the newborn. Leaving the entire lead wire to be pulled through the incision increases the risk of contamination. In an emergency cesarean delivery, having the obstetrician attempt to remove the lead or having the nurse keep trying to remove it would be inappropriate.

10. While preparing a patient who is gravida 4, para 3 at term for surgery in the OR, the nurse prewarms the patient with warm blankets before receiving an epidural. What are some of the evidence-based benefits of prewarming the patient before anesthesia administration? A. Decreased postoperative pain and reduced surgical site infections B. Shortened length of stay in the postanesthesia care unit and decreased VTE risk C. Decreased stress-response-altered mental status and higher Apgar scores D. Decreased blood loss and decreased VTE risk

A. Decreased postoperative pain and reduced surgical site infections Rationale: Benefits of prewarming include decreased postoperative pain, decreased stress-response-altered mental status, decreased blood loss, shortened length of stay in the perianesthesia care unit, reduced surgical site infections, and overall decreased mortality. Evidence also suggests that prewarming the patient before anesthesia administration reduces the risk of subsequent hypothermia. Higher Apgar scores and decreased VTE risk are not evidenced-based benefits of prewarming.

6. A patient at 39 weeks' gestation has just been admitted in labor. Which factors place the patient at risk of a prolapsed umbilical cord? A. Hydramnios, breech presentation, small fetus B. Breech presentation, oligohydramnios, small fetus C. Hydramnios, preeclampsia, transverse lie D. Oligohydramnios, transverse lie, small fetus

A. Hydramnios, breech presentation, small fetus Rationale: Factors that place the patient at risk of a prolapsed umbilical cord include hydramnios, malpresentation of the fetus such as breech presentation and transverse lie, small fetus, long umbilical cord, and high station associated with SROM or AROM. Oligohydramnios and preeclampsia are not associated with a prolapsed umbilical cord.

1. What is the primary risk of umbilical cord prolapse to the fetus? A. Hypoxia B. Bone injury C. Subdural hematoma D. Facial lacerations

A. Hypoxia Rationale: Prolonged cord compression (occlusion of blood flow to and from the fetus for longer than 5 minutes) leads to fetal hypoxia, usually resulting in CNS damage or fetal death. Bone injury, subdural hematoma, and facial lacerations are not likely risks of umbilical cord prolapse but may occur as a result of an emergency cesarean delivery.

4. During a cesarean delivery, bright red blood appears in the drainage bag of the indwelling urinary catheter. What should the circulating nurse do? A. Immediately inform the physician and anesthesia provider of the findings. B. Verify that the indwelling catheter is patent. C. Reassure the support person that red urine is a normal finding. D. Whisper the findings to the anesthesia provider so the support person does not hear the conversation.

A. Immediately inform the physician and anesthesia provider of the findings. Rationale: Although trauma may cause blood-tinged urine, frank bleeding into the urinary catheter is not a normal finding and should be reported immediately to the physician and anesthesia provider. The catheter is patent because it continues to drain fluid. Whispering to the anesthesia provider only creates concern and anxiety for the mother and support person. The physician and anesthesia provider can be notified discreetly to investigate the source of bleeding.

10. A student nurse asks the patient's nurse what it means to have an occult cord prolapse. How does the nurse reply? A. In an occult cord prolapse, the cord is hidden, often next to but not in front of the fetal head. B. In an occult cord prolapse, the cord is in front of the fetal head. C. In an occult cord prolapse, the cord is in the vagina. D. In an occult cord prolapse, the cord is outside the vagina.

A. In an occult cord prolapse, the cord is hidden, often next to but not in front of the fetal head. Rationale: When the prolapse is occult, the cord is hidden, often next to but not in front of the fetal head. A cord in front of the fetal head, in the vagina, or outside the vagina is not considered an occult prolapse.

6. A primigravida is about to undergo a cesarean delivery. The surgical team calls a time-out. The patient is worried that this indicates that something is wrong. What should the nurse tell the patient about the time-out? A. It is performed immediately before the start of the procedure to make a final verification of the correct patient, procedure, and site. B. It is performed immediately before the start of the procedure so the patient can review her decision. C. It is performed immediately before the procedure to conduct a count of the surgical instruments. D. It is performed immediately before long surgeries so the delivery team can take a break.

A. It is performed immediately before the start of the procedure to make a final verification of the correct patient, procedure, and site. Rationale: A time-out immediately before a procedure is a patient safety measure conducted as a final verification of the correct patient, correct procedure, and correct site. The nurse should reassure the patient that a time-out does not mean that something is wrong. The obstetric practitioner would have conducted a thorough discussion and review of clinical factors while obtaining the patient's informed consent for the cesarean delivery before the patient's transfer into the delivery room. Surgical instrument counts are initially done when the OR is prepared for the patient's arrival. A time-out is not a break for the delivery team.

3. The nurse prepares to document the implementation of a magnesium sulfate infusion in the patient's record, but the space for documentation is limited. How should the nurse refer to the drug? A. Magnesium sulfate B. MgSO4, which is the medical abbreviation for magnesium sulfate C. MSO4, which is recognized as an abbreviation for magnesium sulfate D. MS, the chemical abbreviation for magnesium sulfate

A. Magnesium sulfate Rationale: Magnesium sulfate must be spelled out in orders and documentation per the standards set by The Joint Commission. No abbreviations are approved for magnesium sulfate, so MS, MSO4, and MgSO4 are not acceptable for medical documentation.

8. A nurse who is training a new nurse on the labor and delivery unit explains the different uses for magnesium sulfate in labor and delivery. What should the nurse tell the new nurse? A. Magnesium sulfate can be used to treat preeclampsia, eclampsia, and preterm labor and to provide fetal neuroprotection. B. Magnesium sulfate can be used to treat preeclampsia, eclampsia, preterm labor, and anemia. C. Magnesium sulfate can be used to treat preeclampsia, eclampsia, preterm labor, and anemia and to provide fetal neuroprotection. D. Magnesium sulfate can be used to treat preeclampsia, eclampsia, and preterm labor and to provide electrolyte replacement.

A. Magnesium sulfate can be used to treat preeclampsia, eclampsia, and preterm labor and to provide fetal neuroprotection. Rationale: Magnesium sulfate is used in the labor and delivery unit to treat preeclampsia, eclampsia, and preterm labor and to provide fetal neuroprotection. Magnesium sulfate is not used to treat anemia, and although it can be used for electrolyte replacement when appropriate, electrolyte replacement is not a common use for magnesium sulfate in the labor and delivery unit.

5. A patient at 28 weeks' gestation is admitted to the antepartum unit in preterm labor, and the practitioner starts magnesium sulfate therapy for neuroprotection of the fetus. Four hours after the magnesium sulfate infusion is initiated, the nurse obtains a specimen for a serum magnesium level. The laboratory calls to report a "critical magnesium value" of 6.2 mEq/L. What is the most appropriate intervention by the nurse? A. Notify the practitioner that a therapeutic level of magnesium has been achieved. B. Notify the practitioner of a critical level of magnesium. C. Stop the magnesium infusion because the patient has a toxic level of magnesium. D. Continue the magnesium infusion but reduce the rate by half.

A. Notify the practitioner that a therapeutic level of magnesium has been achieved. Rationale: The therapeutic level of magnesium in obstetric patients is between 4 and 7 mEq/L; therefore, the nurse should notify the practitioner that the therapeutic level has been reached. The laboratory reports the results as critical because of reporting standards and normal values not associated with magnesium therapy in obstetric patients. Because 6.2 mEq/L falls within the therapeutic range, the nurse should not stop the infusion or reduce the rate without a practitioner's order.

6. A primigravida at 40 weeks' gestation with preeclampsia is having labor induced. The patient has received magnesium sulfate for the past 2 days. In the past 2 hours, the patient has been showing signs of magnesium toxicity, with a magnesium level that is now at 10 mEq/L. Which antidote to magnesium sulfate should the practitioner order? A. One gram of calcium gluconate (10 ml of 10% solution) intravenously over several minutes B. One gram of calcium gluconate (10 ml of 20% solution) intravenously over several minutes C. One gram of calcium gluconate (10 ml of 10% solution) intravenously over 1 minute D. Two grams of calcium gluconate (10 ml of 10% solution) intravenously over several minutes

A. One gram of calcium gluconate (10 ml of 10% solution) intravenously over several minutes Rationale: One gram of calcium gluconate (10 ml of 10% solution) may be administered intravenously over several minutes as an antidote to magnesium sulfate. A 20% solution is too high. Administering the calcium gluconate over 1 minute is too fast. Two grams of calcium gluconate is too much.

8. A primigravida in labor and delivery has persistent seizure activity despite being given repeated loading doses of magnesium sulfate. Which anticonvulsant can the labor and delivery nurse give this patient? A. Phenytoin B. Calcium gluconate C. Hydralazine D. Propofol

A. Phenytoin Rationale: Phenytoin may be given to this patient. Calcium gluconate is not an anticonvulsant but is given to reverse magnesium toxicity. Hydralazine is used to treat severe hypertension. Propofol is a sedative-hypnotic that is given on an organization-specific basis by an anesthesia provider, not by a labor and delivery nurse.

8. A patient undergoing an emergency cesarean delivery has just been placed on the OR table. What does the circulating nurse do to ensure the safety of the patient? A. Place safety straps on the upper and lower extremities. B. Verify the patient's NPO status. C. Monitor the FHR. D. Drape the patient.

A. Place safety straps on the upper and lower extremities. Rationale: To ensure the safety of the patient, the nurse should place safety straps on the upper and lower extremities. The patient may not have been NPO in labor, so verification of NPO status may not be possible. Monitoring the FHR in the OR does not ensure the safety of the patient. The surgical team for the emergency cesarean delivery, not the circulating nurse, drapes the patient.

4. The health care team member has received a patient after cesarean delivery. The health care team member assesses the patient's vital signs and records a blood pressure of 101/60 mm Hg, pulse 96 beats per minute, respiratory rate 24 breaths per minute, temperature 35.1°C (95.2°F), and pulse oximetry reading 98% on room air. The patient reports feeling nauseated. What should the health care team member do first? A. Provide a warming device or warm blankets and warmed IV fluids as needed. B. Offer the patient warmed clear fluids to drink until the nausea passes. C. Increase the IV rate to 200 ml/hr with warm fluids for the next 2 hours. D. Initiate warmed and humidified supplemental oxygen at 2 L/min via nasal cannula.

A. Provide a warming device or warm blankets and warmed IV fluids as needed. Rationale: The patient's temperature is below normal, so early intervention, such as provision of a warming device or warm blankets and warmed IV fluids, will prevent adverse effects from hypothermia. If the patient is receiving oxygen, it needs to be humidified and warmed; however, the patient's pulse oximetry reading is 98% on room air, so there is no need for supplemental oxygen at this time. Many operative patients experience hypothermia because of the stress of the operative procedure and the effects of anesthesia. Oral intake should not be offered until the patient is stable without nausea and vomiting. Increasing the IV rate or administering supplemental oxygen does not address the hypothermia.

1. A laboring patient who is about to undergo a cesarean delivery has a large amount of lower abdominal and pubic hair. The FHR is approximately 105 beats per minute with minimal variability. The amount of bloody show is moderate. What is the most appropriate action? A. Remove the hair at the surgical site selectively with electric or battery-operated clippers or a depilatory method. B. Leave the lower abdominal hair in place but remove the pubic hair. C. Shave the surgical site with a razor. D. Scrub the hair with povidone-iodine solution or other organization-approved solution.

A. Remove the hair at the surgical site selectively with electric or battery-operated clippers or a depilatory method. Rationale: If pubic or lower abdominal hair will interfere with the surgical site, it should be removed selectively with electric or battery-operated clippers or depilatory methods that minimize injury to the skin. Leaving the hair in place is preferred to prevent skin trauma from hair removal or a surgical site infection; however, if the hair will interfere with the surgical site, it should be selectively removed. Removing the hair with a razor may cause abrasions to the skin surface and enhance microbial growth; research studies have found that shaving is associated with an increased rate of surgical site infection. Cleansing the skin to decrease bacteria at the surgical site should occur after excess hair has been removed.

2. A patient at 36 weeks' gestation with preeclampsia has been admitted. Which position should the nurse recommend for this patient in the teaching plan? A. Right or left side-lying position B. Upright in a rocking chair C. Walking to stimulate the natural progression of labor D. Supine with a wedge under the knees

A. Right or left side-lying position Rationale: Patients with preeclampsia are encouraged to maintain the side-lying position to decrease BP and increase perfusion to the uterus and kidneys. Preeclampsia can compromise placental blood flow. Sitting upright in a rocking chair and walking are not recommended for the pregnant patient with preeclampsia. The supine position is not recommended because it applies pressure to the vena cava and can cause maternal hypotension and decrease uterine blood flow.

4. A patient is experiencing postpartum hemorrhage 2 hours after a vaginal delivery. The nurse notices blood clots on the patient's perineal pad and a 1200-ml QBL after weighing the perineal pads and underpads. The practitioner has ordered blood products; however, the situation becomes critical very rapidly as the patient becomes hypotensive with a blood pressure of 80/40 mm Hg, diaphoretic, and pale. Which condition should the nurse suspect? A. Severe hypovolemia B. Mild hypovolemia C. Cardiogenic shock D. DIC

A. Severe hypovolemia Rationale: Hypotension is a late sign of hypovolemia and should be treated urgently or the patient may enter an irreversible stage of shock in which death is imminent. Mild hypovolemia does not produce hypotension due to the increased blood volume in pregnancy. Because of the patient's recent postpartum hemorrhage, with clots observed, the nurse should first suspect hypovolemic shock and not cardiogenic shock or DIC.

8. A patient's postoperative bleeding is being assessed by the postoperative nurse. To accurately assess the patient's vaginal bleeding and estimate blood loss, what should be measured, weighed, and noted in the postoperative area? A. Sheets, towels, and pads, including a description of clots B. Sheets, towels, and the patient's urine output C. Blood clots, pads, and any blood products administered D. Amount, color, consistency of lochia, and presence of clots

A. Sheets, towels, and pads, including a description of clots Rationale: To accurately assess vaginal bleeding, weigh sheets, towels, and pads, and include a description of clots. The patient's urine output and blood products administered are not included in the amount for postoperative bleeding assessment. The amount, color, and consistency of lochia and presence of clots are important factors when determining postoperative bleeding, but the patient's sheets, towels, and pads all need to be weighed to accurately assess vaginal bleeding.

3. A postcesarean patient reports pain in the abdomen while coughing. What is a nonpharmacologic measure that the health care team member may instruct the patient to perform? A. Splint the incision. B. Apply heat to the incision. C. Apply ice to the incision. D. Use the patient-controlled analgesia pump.

A. Splint the incision. Rationale: The health care team member should always instruct the postoperative patient regarding splinting of the incision when turning or coughing to decrease pain. Heat or ice is not routinely used in the immediate postcesarean period and should not be applied to the incision without a practitioner's order. Administration of medication via patient-controlled analgesia is a pharmacologic intervention rather than a nonpharmacologic intervention.

9. A patient at 39 weeks' gestation is being induced for preeclampsia. Twenty minutes ago, the patient had a seizure. The patient is now alert and oriented, and the FHR tracing is a Category I. What is the priority for the nurse? A. Stay with the patient. B. Administer an anticonvulsant. C. Stop the magnesium sulfate therapy. D. Administer calcium gluconate.

A. Stay with the patient. Rationale: After a patient experiences a seizure, the nurse should not leave the patient unattended because of the risk of recurring seizures, disorientation, or coma. Delivery of the fetus may be imminent. During a seizure, breathing is affected and the blood oxygen level decreases. The uterus may become hypertonic, and the increase in abdominal pressure from the seizure activity may rupture the amniotic membrane and dilate the cervix. An anticonvulsant should have been administered at the time of the seizure. Magnesium sulfate should be continued to help prevent more seizures. Administering calcium gluconate would not be appropriate because it is used to counteract magnesium toxicity.

4. A patient with preeclampsia is on seizure precautions and receiving a maintenance dose of 2 g of magnesium sulfate per hour. The nurse observes that the patient is lethargic and has respirations of 6 breaths per minute. What should the nurse do first? A. Stop the magnesium infusion and prepare to administer calcium gluconate. B. Assess DTRs and decrease stimulation in the room. C. Prepare for emergency delivery. D. Administer 2 L of oxygen via nasal prongs and notify the practitioner.

A. Stop the magnesium infusion and prepare to administer calcium gluconate. Rationale: Because magnesium sulfate may depress the respiratory and cardiac systems, the nurse's priorities are to stop the infusion, prepare to administer calcium gluconate for magnesium toxicity as necessary, and then notify the practitioner. DTRs are assessed to gauge the patient's risk of possible seizure activity, but this assessment does not address the current symptoms. Although decreasing stimulation may help prevent seizures, it would not address the patient's current symptoms, which require an immediate response. An emergency delivery is not indicated because the patient has not had a seizure, and the priority is to alleviate the patient's lethargy and slow respiration rate. Oxygen administration would not improve the patient's symptoms, which are caused by an electrolyte imbalance rather than a lack of oxygen.

6. A nurse is caring for a mother undergoing a repeat cesarean delivery at 39 weeks' gestation. The nurse should know that which maternal risk factors are associated with cesarean delivery? A. Surgical wound infection, VTE, and potential for hemorrhage requiring a blood transfusion B. Surgical wound infection, VTE, and perineal laceration C. VTE, potential for hemorrhage requiring blood transfusion, and cervical lacerations D. Surgical wound infection, potential for hemorrhage requiring blood transfusion, and perineal hematoma

A. Surgical wound infection, VTE, and potential for hemorrhage requiring a blood transfusion Rationale: Maternal risks associated with cesarean delivery include surgical wound infection, the potential for hemorrhage requiring blood transfusion, VTE, increased health care costs related to longer hospital stays, and fetal injury. Cervical lacerations, vaginal hematoma, and perineal lacerations are risk factors associated with vaginal delivery.

9. A patient at 40 weeks' gestation has just delivered vaginally. While the practitioner is delivering the placenta, a uterine inversion occurs. The uterus can be seen outside the vaginal introitus. What medications can be used to help relax the uterus before it can be replaced? A. Terbutaline, magnesium sulfate, halogenated general anesthetics, or nitroglycerin B. Terbutaline, oxytocin, halogenated general anesthetics, or nitroglycerin C. Terbutaline, magnesium sulfate, misoprostol, or nitroglycerin D. Terbutaline, magnesium sulfate, halogenated general anesthetics, or methylergonovine

A. Terbutaline, magnesium sulfate, halogenated general anesthetics, or nitroglycerin Rationale: Tocolytics, such as terbutaline, magnesium sulfate, halogenated general anesthetics, and nitroglycerin, can be used to help relax the uterus when a uterine inversion occurs. Oxytocin, misoprostol, and methylergonovine have the opposite effect and will cause the uterus to contract.

10. The nurse is preparing to take photographs of a deceased newborn. What should the nurse do first? A. Wrap the newborn in plastic wrap to protect the skin. B. Complete the required documentation for fetal or newborn death. C. Take footprints and handprints of the newborn. D. Ensure that the newborn is bathed and dressed.

A. The nurse should explain how the newborn will look to prepare the patient. Rationale: The best response by the nurse is to explain to the patient how the newborn will look so the patient is prepared. Although it is all right for the patient not to see the newborn, the patient should be encouraged to see the newborn if willing. Telling the patient that it is better to see how the newborn looks at birth does not answer the patient's question about how the newborn will look and does not help prepare the patient. If the nurse does not have an idea of how the newborn will look at birth, another nurse who does know how the newborn will look should talk with the patient. The nurse should never express uncertainty to the patient about how the newborn will look because this does not help prepare the patient.

7. A student nurse is asking about the causes of postpartum hemorrhage. What should the mentor nurse say is the most common cause of hemorrhage in a patient with a primary postpartum hemorrhage? A. Uterine atony B. Infection C. Retained placental fragments D. Perineal laceration

A. Uterine atony Rationale: The mentor nurse should explain that primary postpartum hemorrhage, which occurs within the first 24 hours after birth, is most often associated with uterine atony. Infection and retained placental fragments are associated with secondary postpartum hemorrhage, which occurs 24 hours to 6 weeks after birth. Bleeding from a perineal laceration would be associated with primary postpartum hemorrhage, but perineal laceration is not the most common cause of primary postpartum hemorrhage.

10. What is the medication classification of hydralazine? A. Vasodilator B. Calcium-channel blocker C. Combined alpha and beta blocker D. Angiotensin-converting enzyme inhibitor

A. Vasodilator Rationale: Hydralazine is a peripheral vasodilator that relaxes the arteriolar smooth muscle. It is not classified as a calcium-channel blocker, combined alpha and beta blocker, or angiotensin-converting enzyme inhibitor.

10. Antimicrobial prophylaxis should be administered for all cesarean deliveries. Within what time frame should the antibiotic be administered? A. Within 60 minutes before the incision is made B. Within 90 minutes before the incision is made C. Within 90 minutes after the incision is made D. Within 60 minutes after the incision is made

A. Within 60 minutes before the incision is made Rationale: For all cesarean deliveries, antimicrobial prophylaxis should be administered within 60 minutes before the incision is made or as soon as possible after the incision is made, unless the patient is already receiving appropriate antibiotics (e.g., for intraamniotic infection). Administering the antibiotic 90 minutes before the incision is made is too early. Administering the antibiotic within 60 to 90 minutes after surgery is not recommended.

7. The nurse is preparing a patient who is gravida 3, para 2 at 39.5 weeks' gestation for a cesarean delivery. The patient has a history of two cesarean deliveries. A student nurse asks if the patient has an increased risk of any health conditions because of the prior cesarean deliveries. How should the nurse respond? A. "There is no increased risk for a patient with a prior cesarean delivery." B. "A patient with a prior cesarean delivery has an increased risk of placenta previa, placenta accreta spectrum, and uterine rupture." C. "Patients with a prior cesarean delivery have an increased risk of preeclampsia." D. "Patients with a prior cesarean delivery have an increased risk of gestational diabetes."

B. "A patient with a prior cesarean delivery has an increased risk of placenta previa, placenta accreta spectrum, and uterine rupture." Rationale: A patient who has had one or more cesarean deliveries is at higher risk for conditions such as placenta previa, placenta accreta spectrum, uterine rupture, and adhesions. This patient does not have an associated increased risk for preeclampsia or gestational diabetes.

5. Which terms are appropriate to facilitate grieving when a patient has experienced pregnancy loss? A. "Loss" and "passed" B. "Death" and "miscarriage" C. "Moved on" and "in a better place" D. "With the angels" or "with God"

B. "Death" and "miscarriage" Rationale: To assist the patient and family with accepting the reality of their pregnancy loss, the nurse should use realistic words such as "death," "died," or "miscarriage." Other words or phrases that attempt to disguise the reality of the death are not appropriate.

10. A patient has just delivered a healthy newborn at 40 weeks' gestation. During labor, the patient was on magnesium sulfate for seizure prophylaxis because of a history of preeclampsia. How long should the magnesium sulfate be continued after delivery? A. 12 hours B. 24 hours C. 48 hours D. 36 hours

B. 24 hours Rationale: For seizure prophylaxis, magnesium sulfate should be continued for at least 24 hours after delivery. Twelve hours is not long enough. Depending on the patient's condition, the practitioner may order the magnesium sulfate therapy to be continued beyond 24 hours.

9. A patient receiving magnesium sulfate for preeclampsia has just delivered a term newborn. After the delivery, magnesium sulfate is usually continued for how long to prevent seizures? A. 48 hours B. 24 hours C. 36 hours D. 12 hours

B. 24 hours Rationale: Magnesium sulfate is usually continued for 24 hours after delivery. Continuing magnesium sulfate therapy for 36 to 48 hours is unusual unless the symptoms of preeclampsia are not improving. Discontinuing therapy 12 hours after delivery is too soon; such an early end to therapy could lead to a seizure.

3. The practitioner orders an emergency cesarean delivery. Which important patient information should the nurse obtain and communicate to the perioperative team? A. Allergies to medications and substances and nonstress test results B. Allergies to medications and substances and the date and time of last oral intake C. Bleeding times, blood type, and date and time of last oral intake D. Chosen method of newborn feeding and nonstress test results

B. Allergies to medications and substances and the date and time of last oral intake Rationale: Allergic reactions to medications and substances (e.g., latex) must be communicated to the perioperative team to help determine the anesthetics to use, the supplies needed in the OR, and the practitioner's orders for preoperative and postoperative medications. Last oral intake is also an important concern for the anesthesia team because recent intake predisposes a patient to the risk of vomiting and aspiration during surgery. Nonstress test results, blood type, and the feeding method of choice may be noted, but this information is not essential to the surgical procedure. Bleeding times generally are not a concern unless the patient has a known clotting disorder or has recently been receiving an anticoagulant.

2. The physician has explained to the patient that her baby needs to be delivered by an emergency cesarean delivery. The patient is crying because she wanted to deliver her baby "naturally." What is the most appropriate nursing action? A. Continue preparing the patient for the cesarean delivery and tell her to calm down because her crying does not help the baby. B. Allow the patient to express her feelings and address them as time permits. C. Stop preoperative preparations and ask the patient if she is refusing to have a cesarean delivery. D. Tell the support person that this is a normal feeling and that the patient will get over it during the postpartum period.

B. Allow the patient to express her feelings and address them as time permits. Rationale: The patient is experiencing normal feelings related to having an unexpected cesarean delivery. Depending on the urgency of the situation, the nurse may not be able to stop and give full attention to the patient; however, the nurse can encourage the patient to express these feelings as preparations are being made and address concerns as the situation allows. Telling the patient to calm down because crying does not help the baby only worsens a sense of disappointment and anxiety. Preparations must continue to facilitate the delivery and mode of delivery based on the timing that best addresses maternal and fetal risks and benefits. The nurse should not assume that a patient is refusing treatment due to disappointment about the change in expectations. The patient may or may not "get over it" during the postpartum period; however, feelings should be addressed as soon as possible.

3. A patient who was receiving a magnesium sulfate infusion to treat eclampsia experienced magnesium toxicity and has just received an IV dose of calcium gluconate. The nurse should monitor this patient for which potentially life-threatening adverse reactions to calcium gluconate? A. Respiratory depression, hypotension, and absence of deep tendon reflexes B. Bradycardia, cardiac arrhythmias, and cardiac arrest C. Severe hypertension and seizures D. Renal failure and disseminated intravascular coagulation

B. Bradycardia, cardiac arrhythmias, and cardiac arrest Rationale: Bradycardia, cardiac arrhythmias, and cardiac arrest are potentially life-threatening adverse reactions caused by a rapid IV injection of calcium gluconate. Respiratory depression, hypotension, and absence of deep tendon reflexes are signs of magnesium toxicity. Severe hypertension and seizures are symptoms of eclampsia. Renal failure and disseminated intravascular coagulation may result from HELLP (Hemolytic anemia, Elevated Liver enzymes, and Low Platelet count) syndrome.

3. A patient's umbilical cord prolapses. Which is the correct sequence of interventions? A. Perform an SVE, change the patient's position, and call for help. B. Call for help, perform an SVE, and change the patient's position. C. Change the patient's position, call for help, and perform an SVE. D. Change the patient's position, perform an SVE, and call for help.

B. Call for help, perform an SVE, and change the patient's position. Rationale: Calling for help is always the first priority when caring for a patient with umbilical cord prolapse. Calling for help first is critical so preparation for an emergency cesarean delivery can begin immediately. Additional team members may assist with interventions such as changing the patient's position while an SVE is performed.

5. The nurse is caring for a patient with increasing vaginal bleeding and observes that the fundus is boggy, high, and displaced to the right of the umbilicus. What is the most likely cause of the bleeding? A. Perineal laceration B. Full bladder C. Retained placenta D. Hematoma

B. Full bladder Rationale: A full bladder displaces the uterus and prevents the uterus from contracting. Although perineal lacerations, retained placenta, and hematomas are causes of postpartum bleeding, they do not cause the uterus to become displaced because they do not cause any additional pressure to be exerted on the uterus.

5. During an initial assessment of a patient who underwent a cesarean delivery with a transverse abdominal incision, an area of sanguinous drainage 1 cm (0.4 inch) in diameter on the right side of the dressing is noted. What should the health care team member do first? A. Notify the practitioner immediately. B. Circle the drainage with a pen and indicate the date and time. C. Change the dressing immediately and continue to monitor for drainage. D. Continue the assessment because this is a normal finding.

B. Circle the drainage with a pen and indicate the date and time. Rationale: The health care team member should outline the perimeter of the drainage on the dressing using a black pen, write the time on the area, mark any changes, and note the patient's vital signs. The circle also allows for a comparison of drainage by subsequent health care team members who care for the patient. Then the health care team member can continue to monitor this because it is a small amount of drainage and is considered a normal finding following a cesarean delivery, but the amount should be marked to allow for future comparisons. Notifying the practitioner immediately is not necessary unless the amount of drainage is significant or the patient's overall status changes. A progressive increase in drainage or changes in drainage characteristics warrant a call to the practitioner as this may indicate a hemorrhage. The size, location, and depth of the wound influence the amount of drainage. A progressive increase in drainage or changes in drainage characteristics warrant a call to the practitioner as this may indicate a hemorrhage, so outlining the perimeter of the drainage on the current dressing is a better option than replacing the dressing immediately.

5. A primigravida at 39 weeks' gestation is laboring and receiving magnesium sulfate therapy for severe preeclampsia. The patient received IV hydralazine 10 minutes ago for an elevated BP of 201/116 mm Hg. The nurse completes an initial assessment. The patient's BP is now 172/96 mm Hg, the FHR is category I (normal), and the patient is reporting new-onset headache and palpitations. What should the nurse do? A. Notify the practitioner that the patient may be having an allergic reaction to the medication. B. Continue to monitor the patient closely because these are common adverse reactions to hydralazine. C. Reassure the patient that magnesium sulfate is causing these symptoms. D. Tell the patient that these symptoms are normal during labor.

B. Continue to monitor the patient closely because these are common adverse reactions to hydralazine. Rationale: The patient is experiencing common adverse reactions to hydralazine, which include headache, palpitations, tachycardia, and drug-induced lupus syndrome. However, the nurse should continue to monitor the patient closely to rule out more significant adverse effects. The patient is not experiencing signs of an allergic reaction, so notifying the practitioner is not necessary. Although magnesium sulfate may cause some of the same adverse effects as hydralazine, the new onset of symptoms suggests that the cause is more likely the hydralazine. Progression of labor may cause similar symptoms; however, the new onset of symptoms suggests that hydralazine is the more likely cause.

8. The nurse who is preparing to administer calcium gluconate to treat magnesium toxicity knows that the medication should not be given to which patients? A. Digitalized patients or those with hypocalcemia or ventricular fibrillation B. Digitalized patients or those with hypercalcemia or ventricular fibrillation C. Digitalized patients or those with hypermagnesemia or ventricular fibrillation D. Digitalized patients or those with hypercalcemia or bradycardia

B. Digitalized patients or those with hypercalcemia or ventricular fibrillation Rationale: The contraindications to calcium gluconate administration include digitalized patients and those with hypercalcemia or ventricular fibrillation. Hypocalcemia and bradycardia are not contraindications. Hypermagnesemia is a reason to give calcium gluconate.

9. A patient is concerned about feeling weak and drowsy while on magnesium sulfate for preeclampsia. Which is an appropriate response by the nurse? A. Explain that the symptoms are the normal effects of magnesium sulfate. B. Explain that the patient may need calcium gluconate because the patient's magnesium sulfate level may be too high. C. Explain that the practitioner will be notified. D. Explain that the patient should focus on getting better and not worry about the symptoms.

B. Explain that the patient may need calcium gluconate because the patient's magnesium sulfate level may be too high. Rationale: If feeling weak and drowsy while receiving magnesium sulfate, the patient may be experiencing magnesium toxicity. Explaining that the patient may need calcium gluconate because the magnesium sulfate level may be too high would be appropriate. Telling the patient that the symptoms are the normal effects of magnesium sulfate would be incorrect. Telling the patient that the practitioner will be notified does not address the patient's concerns, nor does explaining that the patient should focus on getting better and not worry about the symptoms; this is dismissive of the patient's concerns.

9. A primigravida with a BP of 180/110 mm Hg needs a dose of IV hydralazine. The patient does not want the hydralazine administered. What should the nurse do? A. State that the medication is best for both mother and baby and that the mother should take it. B. Explore the patient's concerns about the medication. C. Respect the patient's wishes and do not give the medication. D. Tell the patient that the medication is necessary, and administer it against the patient's wishes.

B. Explore the patient's concerns about the medication. Rationale: If the mother or support person expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified. Stating that the medication is best for the mother and the baby and that the mother should take it does not explain the rationale for the medication. The nurse should explain why the patient needs the medication and the possible complications of not taking it. Giving the medication without first explaining the potential complications is inappropriate. If the patient still does not want the hydralazine after the nurse explains the possible complications, the nurse must respect the patient's wishes. The nurse should not give the medication against the patient's wishes.

6. During labor, a multipara being treated with magnesium sulfate for preeclampsia receives a dose of IV hydralazine because her BP is 180/114 mm Hg. The combination of magnesium sulfate and hydralazine places the patient at an increased risk of which complication? A. Hypertension B. Hypotension C. Hyperreflexia D. Hyporeflexia

B. Hypotension Rationale: Antihypertensives administered with magnesium sulfate increase the risk of hypotension, not hypertension, and in turn, can lead to shock and placental abruption. Magnesium sulfate administration can cause hyporeflexia not hyperreflexia. The use of hydralazine does not impact the reflexes.

3. A pregnant patient with chronic hypertension is hospitalized for 23-hour observation to rule out preeclampsia. The practitioner orders labetalol 200 mg to be administered intravenously every 10 minutes if the patient's BP is more than 160/110 mm Hg. Based on this order, what should the nurse do? A. Administer the labetalol as soon as possible to reduce adverse effects from the elevated BP. B. Immediately clarify the practitioner's order. C. Assume that the practitioner intended to order hydralazine. D. Administer oral labetalol because 200 mg is the recommended oral dose.

B. Immediately clarify the practitioner's order. Rationale: The nurse should immediately clarify the practitioner's order because the recommended dose for IV labetalol usually starts at 20 mg, with increasing doses every 10 minutes up to 80 mg and to a maximum cumulative IV dose of 300 mg in 24 hours. Administering 200 mg of labetalol via the IV route could cause severe maternal hypotension and possibly lead to maternal or fetal injury or death. The nurse should never assume that the practitioner meant a medication other than what is written. A recommended oral dose of labetalol is 200 mg; however, the nurse should never administer an unusual dose or alternate the medication route without first clarifying the order with the practitioner.

7. Upon arrival in the PACU, a patient starts having shallow breathing, increased heart rate, and excessive sweating. When the anesthesia provider tries to administer oxygen via mask, masseter muscle rigidity is noticed. What is the best intervention? A. Monitor the patient's temperature every hour until hyperthermia is determined. B. Initiate the MH protocol. C. Assist the anesthesia provider with intubation. D. Have the patient drink cold clear liquids.

B. Initiate the MH protocol. Rationale: The patient is showing signs and symptoms of an MH crisis, so the best intervention is initiating the MH protocol. Signs and symptoms of malignant hyperthermia may vary and can occur during anesthesia or during recovery shortly after surgery. The patient's temperature should not be monitored every hour until hyperthermia is determined, as this could result in a poor outcome for the patient. The best intervention is to initiate the MH protocol first before helping the anesthesia provider with intubation, because the MH protocol will alert more health care team members to this emergent patient crisis, who can then assist with the intubation. During an MH crisis, the health care team member should not offer the patient cold liquids to drink as the patient is experiencing masseter muscle rigidity and cannot open the mouth. The patient should be cooled down by other means.

1. A patient who is at 39 weeks' gestation presents to the labor and delivery unit with chronic hypertension. The admission BP is 210/110 mm Hg, and the patient has no signs or symptoms of preeclampsia. The practitioner orders labetalol IV push. What is one advantage of labetalol administration over hydralazine administration that the nurse should know? A. Labetalol is more likely to cause tachycardia. B. Labetalol is less likely to cause excessive hypotension. C. Labetalol is a beta blocker, but hydralazine is a diuretic. D. Labetalol is available for IV administration.

B. Labetalol is less likely to cause excessive hypotension. Rationale: Labetalol is less likely than hydralazine to cause excessive hypotension, tachycardia, and rebound hypertension. Labetalol is a beta blocker, but hydralazine is a vasodilator, not a diuretic. Both medications are available for IV administration.

3. What guidelines should the nurse follow regarding mementos and keepsakes when caring for a mother and the mother's stillborn? A. Mementos and keepsakes should be obtained when the gestational age is older than 20 weeks. B. Mementos and keepsakes should be obtained regardless of gestational age. C. Mementos and keepsakes should be obtained only at the family's request. D. Mementos and keepsakes should not be obtained when congenital anomalies are present.

B. Mementos and keepsakes should be obtained regardless of gestational age. Rationale: Mementos and keepsakes should be obtained regardless of gestational age. Gestational age should not prevent an attempt at gathering possible mementos or keepsakes. The patient and family should not have to request mementos and keepsakes; these should be obtained and the patient and family should be asked whether they would like to have them. Congenital anomalies should not prevent the gathering of mementos and keepsakes, and photographs of the anomalies should be taken.

1. The nurse is reviewing the health history of a patient who is pregnant and for whom the practitioner has ordered IV hydralazine for elevated BP. Which condition in the patient's health history is a contraindication to hydralazine administration? A. Thyroid disease B. Mitral valve rheumatic heart disease C. Asthma D. Allergy to penicillin

B. Mitral valve rheumatic heart disease Rationale: Hydralazine is contraindicated for a patient with a history of mitral valve rheumatic heart disease. Hydralazine is not contraindicated for a patient with a history of thyroid disease, asthma, or an allergy to penicillin.

1. The health care team member is providing preoperative education to a patient who is having a planned cesarean delivery. The patient asks, "When will I be able to see my baby?" The health care team member is aware that promoting maternal bonding during the recovery period is especially important for postcesarean patients. Why is this true? A. Mothers have more problems with parenting skills. B. Mothers may be at increased risk for poor bonding with the newborn. C. Mothers cannot breastfeed right away. D. Mothers may resent the health care team member for keeping the newborn in the nursery.

B. Mothers may be at increased risk for poor bonding with the newborn. Rationale: Postcesarean patients may express a sense of failure because of the inability to have a "normal delivery" and may have difficulty bonding with the newborn. A cesarean delivery does not affect the patient's parenting skills, but postcesarean pain may inhibit the mother's active involvement in the newborn's care. Initiation of breastfeeding immediately after the birth is recommended if the patient is able to tolerate the feeding. The patient's attitude toward the health care team member is irrelevant in this case because the issue relates to the mother's desire to bond and interact with the newborn.

5. A patient is admitted for a cesarean delivery at 8:00 AM and states self-administering enoxaparin (Lovenox®) at 6:30 AM this morning. Which action should the nurse take? A. Prepare the patient for the 8:00 AM cesarean delivery. B. Notify the surgeon that enoxaparin was administered at 6:30 AM. C. Obtain a partial thromboplastin time to check the patient's bleeding time. D. Ensure that enoxaparin is ordered postoperatively.

B. Notify the surgeon that enoxaparin was administered at 6:30 AM. Rationale: The nurse should notify the surgeon that enoxaparin (an LMWH) was administered at 6:30 AM. According to California Maternal Quality Care Collaborative and ACOG recommendations, a patient who has been receiving an LMWH for anticoagulation during the antepartum period needs to wait 24 hours before receiving neuraxial anesthesia. Preparing the patient for the 8:00 AM cesarean delivery, obtaining a partial thromboplastin time, and ensuring that enoxaparin is ordered are inappropriate.

6. A mother has just delivered a stillborn newborn at 32 weeks' gestation. What is an appropriate measure to take to alert hospital employees about the mother's pregnancy loss? A. Stop everyone before entering the room to alert them. B. Place a card or symbol on the patient's door. C. Place an alert flag in the patient's computer chart. D. Alert the patient and family that some staff may not be aware.

B. Place a card or symbol on the patient's door. Rationale: Placing a card or symbol on the patient's door is the best method because doing so ensures that all staff entering the room will be aware of the patient's pregnancy loss. Stopping everyone before they enter the room is not feasible, and using this method could result in hospital employees entering the room while unaware of the patient's pregnancy loss. Placing an alert flag in the computer is not the best method because not all staff members have access to the patient's chart. Alerting the family that some of the staff may not be aware of their pregnancy loss is inappropriate and could lead to inappropriate comments made by well-meaning staff who are unaware that the patient has had a pregnancy loss.

9. To help prevent the patient from developing deep vein thrombosis as a result of surgery, the nurse should take which preventive action in the OR? A. Place a safety strap on the patient's lower extremities. B. Place a sequential compression device on the patient's lower extremities. C. Administer heparin in the OR. D. Position the patient with a wedge under the right or left hip.

B. Place a sequential compression device on the patient's lower extremities. Rationale: Placing a sequential compression device on the patient's lower extremities helps prevent deep vein thrombosis. Placing a safety strap on the lower extremities would not help to prevent deep vein thrombosis. Administering heparin in the OR would not be appropriate because excessive maternal bleeding may result. Positioning the patient with a wedge under the right or left hip will not prevent deep vein thrombosis.

6. When entering a pregnant patient's room, the nurse observes seizure activity. What should the nurse do in addition to protecting the patient from injury? A. Insert an oral airway. B. Position the patient side lying. C. Leave the room to get help. D. Administer oxygen.

B. Position the patient side lying. Rationale: The nurse should maintain a patent airway by turning the patient onto the side and providing oral suctioning as needed. Establishing a patent airway is always the first priority in seizure management, but mouth and teeth damage may occur if any device is placed between the patient's teeth during a seizure. During a seizure, breathing is affected and the blood oxygen level decreases; oxygen is administered after the seizure. The nurse should call for help but should not leave the patient to get help.

4. During the patient's admission assessment, a multipara states that she wants to have a vaginal birth because her last delivery was a cesarean delivery with postoperative complications. The nurse performs a physical assessment and reviews the patient's record to see whether the patient has any contraindications to VBAC. What should the nurse know is the most important contraindication for VBAC? A. Previous low transverse uterine incision B. Previous classic uterine incision C. Obesity D. Previous Pfannenstiel skin incision

B. Previous classic uterine incision Rationale: A previous classic uterine incision is the most important contraindication for VBAC. Three types of uterine incisions are possible: low transverse, low vertical, and classic. A classic cesarean incision is made vertically into the upper body of the uterus. Because the procedure is associated with a higher incidence of blood loss and uterine rupture in subsequent pregnancies, vaginal birth after a cesarean delivery utilizing a classic uterine incision is contraindicated. The low transverse uterine incision is more popular because it is easier to perform and is associated with less blood loss and likelihood of rupture in subsequent deliveries. Women who are obese may have a vertical skin incision and a low transverse uterine incision; however, obesity alone is not a contraindication for VBAC. The Pfannenstiel incision is one of two types of skin incisions for cesarean delivery; because the skin incision and uterine incision do not always match, its presence has no bearing on the decision to plan VBAC.

6. A patient requiring an emergency cesarean delivery has a metal tongue ball in place. What should the nurse do before surgery? A. Leave the metal tongue ball in place because there is not enough time to remove it. B. Remove the metal tongue ball before surgery. C. Notify the anesthesia provider that the patient has a mental tongue ball in place. D. Notify the obstetrician that the patient has a metal tongue ball in place.

B. Remove the metal tongue ball before surgery. Rationale: The patient should not wear anything containing metal in case cautery is used in the surgical field; the metal tongue ball should be removed. Otherwise, the patient could sustain a burn on the tongue. Notifying the anesthesia provider about the metal ball is appropriate; however, the ball still must be removed. Notifying the obstetrician is not necessary unless the circulating nurse cannot remove the metal tongue ball.

4. A patient with preeclampsia has been receiving magnesium sulfate at a rate of 2 gm/hr for the past 4 hours. On the last assessment, the nurse found that the patient was drowsy, patellar DTRs were 2+ bilaterally, BP was 118/66 mm Hg, pulse was 96 beats per minute, and respirations were 16 breaths per minute. Now the patient is reporting difficulty catching a breath; DTRs are absent; BP is 106/58 mm Hg, pulse is 112 beats per minute; and respirations are 10 breaths per minute. What is the most appropriate nursing intervention? A. Stop the magnesium sulfate infusion and administer a bolus of mainline fluid. B. Stop the magnesium sulfate infusion and notify the practitioner. C. Continue the infusion but notify the practitioner. D. Continue the infusion and reassure the patient that these are normal adverse effects of the medicine.

B. Stop the magnesium sulfate infusion and notify the practitioner. Rationale: The patient is exhibiting signs and symptoms of magnesium toxicity, which should be identified rapidly to prevent injury to the patient and fetus. The magnesium sulfate infusion must be discontinued immediately if the patient experiences respiratory distress or displays a decreased level of consciousness, and the practitioner should be notified. Administering a bolus of mainline fluid may inadvertently deliver a bolus of magnesium sulfate already in the line and may exacerbate pulmonary edema. Continuing the magnesium infusion when the patient is exhibiting signs and symptoms of magnesium toxicity and reassuring the patient without notifying the practitioner are both contraindicated because these actions could lead to magnesium levels sufficient to cause respiratory arrest.

2. A pregnant patient presents to the labor and delivery unit with severe preeclampsia, and a magnesium sulfate infusion is started. While completing an assessment after the initial bolus, the nurse realizes that the patient cannot answer questions. The nurse determines that the patient has slowed respirations, hypotension, and absent deep tendon reflexes, and that Category III (abnormal) characteristics are on the fetal monitor tracing. What should the nurse do immediately? A. Administer calcium gluconate and then contact the practitioner. B. Stop the magnesium sulfate infusion, administer oxygen, administer calcium gluconate as ordered, and contact the practitioner. C. Stop the magnesium sulfate infusion, administer oxygen, and contact the practitioner for further orders. D. Continue to monitor the patient for a worsening condition.

B. Stop the magnesium sulfate infusion, administer oxygen, administer calcium gluconate as ordered, and contact the practitioner. Rationale: The correct order of interventions is to stop the source of the magnesium toxicity, treat the hypoxemia resulting from depressed respirations, correct the cause of the symptoms (magnesium toxicity), and then contact the practitioner for further orders. Administering calcium gluconate and contacting the practitioner are appropriate interventions; however, the magnesium should first be discontinued to prevent additional toxicity, and the oxygen should be administered because it might not affect the FHR for as long as 10 minutes. If a patient is receiving magnesium sulfate, an order for calcium gluconate should be in place, and delaying treatment for further orders could result in respiratory arrest. Continuing to monitor the patient without taking other action will result in the condition worsening and may lead to a poor overall outcome.

7. The nurse has just given IV labetalol 20 mg to a patient at 40 weeks' gestation who is in labor with a BP of 200/110 mm Hg. The nurse is monitoring the patient's BP frequently. What are the onset and peak of action of labetalol? A. The onset of action is 10 minutes; the peak action occurs in 20 minutes. B. The onset of action is 2 to 5 minutes; the peak action occurs in 5 to 15 minutes. C. The onset of action is 5 minutes; the peak action occurs in 10 to 20 minutes. D. The onset of action is 7 minutes; the peak action occurs in 10 minutes.

B. The onset of action is 2 to 5 minutes; the peak action occurs in 5 to 15 minutes. 8. The nurse is preparing to administer a dose of labetalol IV push to a patient at 36 weeks' gestation who presented in the triage area 30 minutes ago. The patient had BP measured two times 15 minutes apart, and both readings were more than 160/110 mm Hg. Over which period of time should the nurse administer the IV push dose of labetalol?

10. An emergency cesarean delivery has just been ordered because of a Category III FHR tracing. The anesthesia provider asks the nurse to give the patient a bolus of lactated Ringer solution before surgery. What is the rationale for this action? A. To protect the patient in case she has excessive bleeding after delivery B. To help prevent hypotension associated with anesthesia C. To help prevent hypertension associated with anesthesia D. To ensure any IV medications administered reach the patient quickly

B. To help prevent hypotension associated with anesthesia Rationale: Administering a bolus of lactated Ringer solution before surgery helps prevent hypotension (not hypertension) associated with anesthesia. If a patient has excessive bleeding after surgery bolus of lactated Ringer solution should be administered at that time along with any indicated blood products. If an IV medication needs to reach the patient quickly, a bolus of the medication should be ordered.

9. A patient has just arrived in the recovery room after undergoing a primary cesarean section for labor dystocia. The health care team member places a sequential compression device on the patient's lower extremities. What is the purpose for placing this device? A. To replace the need for heparin treatment B. To prevent VTE C. To replace the need for coumadin treatment D. To prevent lower extremity muscle cramps

B. To prevent VTE Rationale: VTE is a leading cause of maternal morbidity and mortality during pregnancy and the postpartum period because of the patient's hypercoagulable state and venous stasis. The highest incidence of VTE during the postpartum period is the first 3 weeks following delivery. Cesarean delivery almost doubles the risk for VTE. A sequential compression device is used to prevent VTE formation, not to replace coumadin or heparin treatment. Coumadin and heparin can be used in the prevention and treatment of VTE. A sequential compression device is not used to prevent lower extremity muscle cramps.

3. A patient with preeclampsia has been admitted for observation. The practitioner orders monitoring of the patient for signs of placental abruption. What should the nurse monitor to evaluate placental well-being? A. DTRs B. Uterine tenderness and vaginal bleeding C. BP and CNS activity D. Previous seizure activity and family history

B. Uterine tenderness and vaginal bleeding Rationale: Assessment of placental well-being, including monitoring the patient for uterine tenderness and vaginal bleeding, is necessary to ensure that uteroplacental perfusion is adequate to continue the pregnancy. Patients with preeclampsia are at risk for placental abruption, which causes uterine tenderness and bleeding. DTRs are assessed to monitor the patient's risk of seizure activity. Monitoring BP and CNS activity is also indicated to assess the patient for the risk of seizures, not for placental well-being. Pregnant patients are prone to developing preeclampsia if they have a history in the family, but these details do not provide information on placental condition.

5. A patient about to have a cesarean delivery tells the nurse, "I'm so afraid." What is the nurse's best reply? A. "Surgery has some risks, but the likelihood of a problem is very low." B. "There's no reason to be afraid." C. "Tell me what you're afraid of." D. "You'll be just fine; don't worry."

C. "Tell me what you're afraid of." Rationale: The nurse should remain with the patient and encourage the patient to express specific fears. Therapeutic communication helps clarify concerns, so explanations to reduce anxiety can be effective; however, before providing explanations, the nurse needs to know more about the patient's fears. Discounting the patient's concerns is inappropriate and does not help allay the patient's anxiety. The obstetric practitioner should have thoroughly explained the surgical risks during the informed consent process. Because cesarean delivery does carry risks, telling the patient there is no reason to be afraid and will be just fine is inappropriate.

7. A primigravida is having a cesarean delivery for breech presentation. The patient requests that the newborn be placed skin-to-skin to promote breastfeeding while the patient is in the OR. What would be the appropriate response by the nurse? A. "We can bring the newborn to you in the recovery room to breastfeed." B. "We need to maintain sterility of the cesarean delivery; we will need to wait until you are leaving the OR." C. "We can place the newborn skin-to-skin to promote breastfeeding." D. "We will finish the assessment with the newborn on the warmer and provide formula supplementation until you are feeling better."

C. "We can place the newborn skin-to-skin to promote breastfeeding." Rationale: Studies have found that early skin-to-skin contact reduces crying, increases neonatal glucose levels, improves cardiorespiratory status among late preterm infants, promotes bonding, keeps the newborn warm, and enables breastfeeding success. Skin-to-skin contact reduces the need for formula supplementation if implemented in the OR.

4. A patient is receiving calcium gluconate IV for magnesium toxicity. A nurse enters the room to assist with the emergency and notices that the primary nurse is injecting the calcium gluconate rapidly. The assisting nurse should advise the primary nurse to administer the calcium gluconate at which rate? A. 10 mg/10 min B. 1 g/min C. 1 g/3 min D. 1 mg/min

C. 1 g/3 min Rationale: The recommended dosage of calcium gluconate for treating magnesium toxicity in a pregnant patient is 1 g (10 ml of a 10% solution) administered over 3 minutes.

6. A patient at 38 weeks' gestation is receiving magnesium sulfate for preeclampsia with severe features. The practitioner has ordered serum magnesium levels every 8 hours. What is the therapeutic target range for serum magnesium levels? A. 5 to 6 mEq/L B. 5 to 9 mEq/L C. 5 to 8 mEq/L D. 6 to 10 mEq/L

C. 5 to 8 mEq/L Rationale: The therapeutic target range for serum magnesium is 5 to 8 mEq/L. A lower level may result in seizures. A higher level may result in respiratory depression and could lead to cardiac arrest. Treatment with calcium gluconate would be indicated for a serum magnesium level above 8 mEq/L.

5. A patient requires an emergency cesarean delivery because of a prolapsed umbilical cord. The pediatrician and a nursery nurse are present for the delivery. When the newborn is delivered, resuscitation efforts are prolonged. What should the circulating nurse do? A. Continue attending to the surgical team's needs. B. Assist with resuscitative measures until the newborn is transferred to the nursery. C. Call for additional help and then assist as able. D. Run down the hall to get the resuscitation equipment.

C. Call for additional help and then assist as able. Rationale: The circulating nurse should call for help and then assist with resuscitative efforts until additional help arrives. After that, circulating nurse's duties may be resumed. The circulating nurse should not leave the surgical suite for any reason.

8. The nurse is preparing the surgical site for a patient who is gravida 2, para 1 at 40 weeks' gestation and is scheduled for a cesarean delivery. The patient's history includes a previous cesarean delivery. Which method should the nurse use to remove hair from the surgical site before surgery? A. Sharp razor B. Cordless electric clippers with a reusable head C. Cordless electric clippers with a disposable head D. Depilatory agent

C. Cordless electric clippers with a disposable head Rationale: Using cordless electric clippers with a disposable head reduces skin nicks that provide entry points for microorganisms and enhances the surgeon's view of the surgical site by clipping the hair. Studies show higher rates of surgical site infections in patients who have had hair removed with a razor compared with patients who have had hair removed with a depilatory agent or have had no hair removed. Using a cordless electric razor with a nondisposable head increases the risk of infection if the head of the razor is not adequately cleaned between patients. Not removing the hair can interfere with the surgeon's view of the surgical site.

2. The nurse is caring for a postpartum patient with severe preeclampsia who received magnesium sulfate during labor. While performing an assessment 60 minutes after the vaginal delivery, the nurse observes that the patient's fundus is firm, but bleeding has increased and is now a constant bright red flow. The nurse massages the patient's fundus and attempts to express clots but observes that there are none. The patient appears lethargic and diaphoretic, and the heart rate is 135 beats per minute. The nurse also notices some bleeding around the patient's IV site. Which maternal condition should the nurse suspect? A. Retained placenta B. Cervical laceration C. DIC D. Uterine inversion

C. DIC Rationale: Excessive bleeding without clotting, the presence of tachycardia, and unusual bleeding around the IV site are signs of DIC. Because magnesium sulfate was administered, the patient is at increased risk for postpartum hemorrhage. A cervical laceration may cause bright red bleeding, but some clotting should be present; furthermore, a cervical laceration would not explain bleeding around the IV site. A retained placenta may also result in some clotting and would not cause bleeding around the IV site. Uterine inversion would more likely cause signs of shock, and the nurse would not feel a firm fundus when examining the patient.

2. A laboring patient with severe preeclampsia has a BP of 198/112 mm Hg and is receiving IV magnesium sulfate and oxytocin. The practitioner orders 40 mg of labetalol to be administered intravenously. The nurse administers the medication as ordered. Ten minutes later, the nurse obtains a BP reading of 120/72 mm Hg and observes that the FHR pattern now has no variability and a new onset of late decelerations. What does the nurse know is the most likely cause of the change in FHR pattern? A. Severe preeclampsia B. Imminent delivery C. Decreased uteroplacental perfusion D. Decreased intravascular volume

C. Decreased uteroplacental perfusion Rationale: A sudden and marked decrease in BP may result in decreased uteroplacental perfusion, which may lead to decreased fetal oxygenation, as evidenced by the change in FHR variability and the onset of late decelerations. An imminent delivery is usually not the cause of absent variability and late decelerations. Severe preeclampsia may decrease overall placental perfusion to some extent, but the marked change in fetal status is more likely because of the sudden drop in maternal BP. The patient has not experienced a decrease in intravascular volume because there has been no aggressive diuretic action or bleeding to cause the decrease in BP.

1. A patient who has experienced pregnancy loss at 38 weeks' gestation is currently laboring. Which nursing measure should be taken when the newborn is delivered? A. Act as if nothing is out of the ordinary. B. Take the newborn to the nursery immediately. C. Dry the newborn and facilitate skin-to-skin care. D. Immediately obtain all newborn mementos.

C. Dry the newborn and facilitate skin-to-skin care. Rationale: The newborn should be cared for as in a live birth by being dried off and placed with the mother. The patient and family should be given the opportunity to hold the newborn before he or she is moved to the nursery or other designated area. The nurse should discuss and openly address the situation that the patient and family are experiencing in order to affirm their emotions. Newborn mementos and keepsakes should be obtained at a later time, after the patient and family have had the initial time to hold the newborn.

1. A multigravida is having a cesarean delivery. The patient has asked to be awake during the procedure, so the anesthesia provider plans to use regional anesthesia. The patient is extremely anxious about the procedure and expresses concern during the birth about feeling pressure and a pulling sensation. How should the nurse address the mother's anxiety? A. Inform the anesthesia provider that the patient needs additional anesthesia. B. Call a time-out and inform the obstetric practitioner that the patient is having doubts about the procedure. C. Explain that these sensations are normal and offer emotional support. D. Call a time-out for a count of surgical sponges because the sensations indicate loss of a sponge.

C. Explain that these sensations are normal and offer emotional support. Rationale: The nurse should reassure the patient that these sensations are normal. Offering emotional support to the patient undergoing a cesarean delivery is important because of the patient's concerns about the newborn's well-being and about having a surgical procedure. Explanations may help diminish the patient's anxiety about sensations the patient is experiencing, such as the coldness of the abdominal preparation solution or the normal pressure and pulling sensations during the birth. A time-out is called before the start of an invasive procedure, such as a cesarean delivery, not during the birth. The patient is describing typical sensations related to regional anesthesia during a cesarean delivery, so additional anesthesia is not required. A surgical count is conducted before the start of the procedure and before closure of the uterus, peritoneum, and skin incision. This scenario includes no signs of sponge loss during surgery.

1. A patient remains in the labor and delivery unit after a forceps delivery of a 10-lb, 8-oz healthy newborn. Thirty minutes after delivery, the patient is reporting severe perineal pain and pressure despite having an epidural. The patient's vital signs are normal except for a heart rate of 122 beats per minute. What is the primary assessment the nurse should make? A. Lacerations B. Perineal swelling C. Hematoma D. Anemia

C. Hematoma Rationale: Hematomas may cause severe perineal pain and pressure, and they occur more frequently with forceps delivery. The patient's elevated heart rate may be an initial sign of hemorrhage. Perineal swelling may be present from the birth but should not cause severe perineal pain and pressure. Lacerations may be present; however, with severe pain and pressure, a hematoma should be suspected first. Assessment of the patient's hematocrit level may be necessary to detect anemia, but the nurse should first assess for an actively bleeding or expanding hematoma.

7. The nurse has just received an order to administer magnesium sulfate to a patient in preterm labor at 31 weeks' gestation. Which condition would prompt the nurse to notify the practitioner because magnesium sulfate is contraindicated? A. Diabetes B. Preeclampsia C. Myasthenia gravis D. Anemia

C. Myasthenia gravis Rationale: Myasthenia gravis is a contraindication to magnesium sulfate because the drug can worsen the signs and symptoms of the disease, causing further muscle weakness and a myasthenic crisis. Preeclampsia is one of the indications for magnesium sulfate administration. Diabetes and anemia are not contraindications to magnesium sulfate administration.

8. A multipara with a breech presentation has just been placed on the OR table for a cesarean delivery. What action will support adequate blood flow to the fetus? A. Placement of a sequential compression device on the patient's legs B. Assessment of the FHR after induction of spinal or epidural anesthesia C. Placement of a wedge under the patient's hip to tilt the patient's uterus to the side D. Placement of a safety strap on the patient's upper thighs

C. Placement of a wedge under the patient's hip to tilt the patient's uterus to the side Rationale: Placement of a wedge under the patient's hip to tilt the patient's uterus to the side supports adequate blood flow to the fetus. Placement of a sequential compression device on the patient's legs decreases the risk of blood clots in the patient and is not done to improve blood flow to the fetus. Assessment of the FHR after induction of spinal or epidural anesthesia does not affect the blood flow to the fetus. Placement of a safety strap on the patient's upper thighs will prevent the patient's legs from falling off the OR table but has nothing to do with blood flow to the fetus.

1. Which condition is an indication for emergency cesarean delivery? A. Increased fetal movement B. Diabetes C. Placenta previa with hemorrhage D. Cephalopelvic disproportion

C. Placenta previa with hemorrhage Rationale: Emergency cesarean delivery may be performed because of umbilical cord prolapse or hemorrhage from placenta previa or abruptio placentae. Other indications for a cesarean delivery include hypertension, if prompt delivery is necessary; maternal diseases, such as heart disease and cervical cancer, if labor is not advisable; active genital herpes; previous uterine surgery, such as a classic cesarean incision and removal of fibroid tumors; and persistent indeterminate or abnormal FHR patterns. Not all these indications are emergent. Increased fetal movement is not an indication for cesarean delivery.

5. An 18-year-old primigravida at 36 weeks' gestation is transported to the unit after experiencing a seizure. The patient is awake and responsive upon arrival and reports not having had prenatal care. Which nursing action would signify that the nurse needs additional teaching? A. Obtaining venous access B. Assessing maternal and fetal status C. Placing the patient supine D. Implementing seizure precautions

C. Placing the patient supine Rationale: Placing the patient supine would indicate that the nurse needs additional teaching. This patient has experienced an eclamptic seizure. A side-lying position helps to keep the airway open, prevent aspiration of fluids or emesis, and perfuse the uterus and kidneys. The supine position places pressure on the vena cava from the uterus and decreases uterine blood flow. Although the patient is currently awake and responsive, there is a risk for another seizure; seizure precautions will be necessary from now through the postpartum period. Nursing assessment of the patient and fetus is critical to determine fetal status and the degree of maternal hypertension. Venous access is necessary to obtain laboratory studies, administer magnesium sulfate therapy, and prepare for delivery.

2. A laboring patient's water has spontaneously broken with a big gush. The FHR is 60 bpm. What should be the nurse's first concern? A. Vaginal bleeding B. Meconium-stained amniotic fluid C. Prolapsed umbilical cord D. Fetal station by means of SVE

C. Prolapsed umbilical cord Rationale: FHR decelerations from cord compression can indicate umbilical cord prolapse. The patient with ruptured membranes is at increased risk for prolapsed cord from the force of the fluid carrying the umbilical cord downward below the presenting part. Assessments for vaginal bleeding and meconium-stained amniotic fluid are important; however, in this situation, cord prolapse is the likely cause of the fetal deceleration. Assessment of fetal station is not important at this point, but an SVE should be performed to alleviate cord compression.

2. The nurse receives an order to administer magnesium sulfate to a patient with preterm labor to delay delivery and thus provide time for fetal lung maturity. Before initiating the infusion, the nurse should instruct the patient to report which sign or symptom? A. High fever B. Leg cramps C. Shortness of breath D. Decreased fetal movement

C. Shortness of breath Rationale: Magnesium sulfate carries an increased risk for fluid overload, which predisposes the patient to pulmonary edema. Therefore, the patient should be instructed to immediately report difficulty breathing or shortness of breath because of the possibility of respiratory depression. Reporting leg cramps is not specific to magnesium sulfate therapy. Subjective reports of high fever may reflect the flushing effect of magnesium sulfate but are not a priority. The fetus may exhibit decreased movement because of the magnesium in the patient's system, so fetal movement may not be a reliable indicator of fetal well-being.

10. A patient has just presented to the triage area at 37 weeks' gestation with a BP of 180/112 mm Hg. What BP is the treatment goal? A. Systolic BP 160 to 170 mm Hg; diastolic BP 100 to 110 mm Hg B. Systolic BP 150 to 160 mm Hg; diastolic BP 95 to 105 mm Hg C. Systolic BP 140 to 150 mm Hg; diastolic BP 90 to 100 mm Hg D. Systolic BP 130 to 140 mm Hg; diastolic BP 85 to 95 mm Hg

C. Systolic BP 140 to 150 mm Hg; diastolic BP 90 to 100 mm Hg Rationale: The patient's systolic BP should be lowered to between 140 and 150 mm Hg and the diastolic BP between 90 and 100 mm Hg. Attempting to lower the BP to normal may decrease uteroplacental perfusion and cause fetal harm. Decreased uteroplacental perfusion may lead to decreased fetal oxygenation, producing a change in FHR variability and the onset of late decelerations.

8. A primigravida receiving hydralazine for hypertension is concerned about the drug's effects on the baby. The patient asks the nurse, "Will this medicine harm my baby?" How should the nurse respond? A. State that the doctor will speak with the patient about it. B. Tell the patient that a risk of harm to the baby exists but that the benefits outweigh the risk. C. Tell the patient that the amount of drug that crosses the placenta is very small. D. State that everything should be fine and that the patient should not worry.

C. Tell the patient that the amount of drug that crosses the placenta is very small. Rationale: The nurse should answer the patient's question. Stating that the doctor will speak to the patient about the medication may cause more concern if the patient's question is not answered in a timely manner. Hydralazine crosses the placenta in a clinically insignificant degree and has not been found to directly harm babies. Stating that the benefits outweigh the risks, that everything should be fine, and the patient should not worry are inappropriate responses that do not answer the patient's question.

7. A patient at 40 weeks' gestation experiences SROM, and the umbilical cord prolapses. Why must excessive handling of the umbilical cord be avoided? A. To prevent drying of the umbilical cord B. To prevent further prolapse of the umbilical cord C. To prevent cord vessel vasospasm and trauma D. To prevent fetal tachycardia

C. To prevent cord vessel vasospasm and trauma Rationale: Excessive handling of the umbilical cord may cause cord vessel vasospasm and trauma. Drying out of the umbilical cord is caused by exposure to air. Further prolapse is not normally a factor with excessive handling of the umbilical cord. Bradycardia, not tachycardia, could result from umbilical cord vasospasm and trauma in association with excessive umbilical cord handling.

5. The patient with a cord prolapse is repositioned. Which position is the most appropriate? A. High Fowler B. Semi-Fowler C. Trendelenburg D. Hands and knees

C. Trendelenburg Rationale: Trendelenburg, modified Sims, and knee-chest positions may be used to relieve umbilical cord pressure. These positions raise the patient's hips above the head, thereby shifting the presenting part toward the diaphragm and off of the prolapsed cord. The high Fowler and semi-Fowler positions and hands-and-knees position should not be used because they may increase pressure on the umbilical cord.

4. When should a prophylactic antibiotic be given to a patient having a cesarean delivery? A. Within 30 minutes after the infant's birth B. Within 60 minutes before the infant's birth C. Within 60 minutes before the incision D. After the umbilical cord is clamped

C. Within 60 minutes before the incision Rationale: Prophylactic antibiotics should be given within 60 minutes before the surgical incision. Antibiotic administration within 30 minutes before the birth, within 60 minutes after the birth, and after the umbilical cord is clamped are not evidence-based practices.

4. The nurse offers the patient and family the opportunity to hold their newborn, whom they named Jonathan, following an expected death. They refuse, stating, "It's too hard to see him now." Which response by the nurse would be the most appropriate? A. "I'm sure you'll feel like holding him later." B. "You should hold him because it will help with the grieving process." C. "That's okay, you shouldn't hold him if you don't want to." D. "I'll take Jonathan to the nursery, and I'll check back with you in an hour."

D. "I'll take Jonathan to the nursery, and I'll check back with you in an hour." Rationale: Presenting the option of holding the newborn and then giving the patient and family some time to make that decision is a good idea. Telling them that the nurse will check back with them also is important. The patient and family should not feel pressured to make the decision immediately, and they should understand that they will have the opportunity to hold the newborn if they change their minds. They should not be forced to hold a newborn who has died. Telling the family they should or should not hold the newborn may make them feel guilty or feel that the nurse expects them to do otherwise; the decision should be their own. The nurse should never assume how the patient and family will feel regarding the desire to hold their newborn.

6. A patient at 39 weeks' gestation has just delivered vaginally. The nurse is weighing the patient's perineal pads to determine the amount of blood loss in the first hour of recovery. What amount of blood loss is defined as a postpartum hemorrhage in the absence of signs and symptoms of hypovolemia? A. 500 ml or greater B. 1500 ml or greater C. 800 ml or greater D. 1000 ml or greater

D. 1000 ml or greater Rationale: Postpartum hemorrhage is defined as a cumulative blood loss of 1000 ml or more, or blood loss that occurs along with signs and symptoms of hypovolemia. In the absence of signs and symptoms of hypovolemia, 500 ml and 800 ml would trigger heightened surveillance and interventions as indicated but would not be considered a postpartum hemorrhage. A blood loss of 1500 ml or greater with or without signs and symptoms of hypovolemia would be considered a postpartum hemorrhage, but the definition of postpartum hemorrhage is 1000 ml or greater.

8. The nurse is preparing to administer a dose of labetalol IV push to a patient at 36 weeks' gestation who presented in the triage area 30 minutes ago. The patient had BP measured two times 15 minutes apart, and both readings were more than 160/110 mm Hg. Over which period of time should the nurse administer the IV push dose of labetalol? A. 1 minute B. 5 minutes C. 10 minutes D. 2 minutes

D. 2 minutes Rationale: The nurse should administer the labetalol IV push over 2 minutes. If the nurse administers the labetalol in less than 2 minutes, the risk of adverse effects, such as dizziness and orthostatic hypotension, increases. Administration of a medication over 10 minutes would be considered a slow infusion.

3. Hospitals with labor and delivery services should have the capacity of beginning a cesarean delivery within what length of time? A. The time required for the support person's arrival B. Less than 60 minutes of the decision to operate C. A reasonable amount of time D. An appropriate time period for the clinical situation

D. An appropriate time period for the clinical situation Rationale: Any hospital providing obstetric service should have the capacity to respond to an obstetric emergency. Although a previous consensus held that a cesarean delivery should begin within 30 minutes of the decision to operate, current thinking holds that an organization should be able to begin a cesarean delivery within an appropriate time period for the mother's and newborn's clinical situation. "A reasonable amount of time" is too vague and could be interpreted without consideration of an individual patient's clinical presentation. Although having the mother's chosen support person present is optimal, clinical factors may preclude waiting for his or her arrival before beginning the surgical procedure.

9. The preceptor asks a new labor and delivery nurse to name the three types of uterine cesarean incisions. Which response by the new nurse is correct? A. Upper vertical, low transverse, and low vertical B. Low vertical, classic, and upper vertical C. Upper vertical, low transverse, and classic D. Classic, low transverse, and low vertical

D. Classic, low transverse, and low vertical Rationale: The three types of uterine cesarean incisions are classic (associated with a higher incidence of blood loss, infection, and uterine rupture in subsequent pregnancies), low transverse (more popular because it is easier to repair with less blood loss, fewer infections, and fewer adhesions), and low vertical incision (places the patient at risk for uterine rupture in a subsequent birth).

3. A multipara with severe preeclampsia has an elevated BP of 198/112 mm Hg. The patient is receiving magnesium sulfate and oxytocin IV. The practitioner orders 10 mg of IV hydralazine. Fifteen minutes after the hydralazine is administered, the nurse observes a maternal BP of 120/72 mm Hg and minimal FHR variability with a new onset of late decelerations. Based on the diagnosis of severe preeclampsia and the current medications being administered, what is the most likely cause of the change in the FHR pattern? A. An adverse reaction to the hydralazine B. Imminent delivery C. Severe preeclampsia D. Decreased uteroplacental perfusion

D. Decreased uteroplacental perfusion Rationale: If antihypertensive therapy decreases the arterial pressure too significantly or too rapidly, uteroplacental perfusion may become compromised, which may result in an interruption of fetal oxygenation with category II (indeterminate) or category III (abnormal) FHR characteristics. The risk of hypotension increases when antihypertensive therapy is combined with magnesium sulfate. Imminent delivery does not cause loss of variability and late decelerations. Although minimal variability may be noted in patients with severe preeclampsia, the new onset of late decelerations indicates that the patient's BP is now too low. Late decelerations result from impaired uteroplacental perfusion. The most common adverse reactions to hydralazine are headache, palpitations, tachycardia, and drug-induced lupus syndrome. Other adverse reactions include dizziness, diarrhea, nausea, vomiting, edema, and peripheral neuropathy.

5. A postpartum patient is being discharged home with a prescription for labetalol, 300 mg by mouth twice daily. The patient will be taking the medication until the 4-week postpartum checkup. During discharge teaching, the nurse reminds the patient about the common adverse effects of labetalol. What are these effects? A. Constipation, insomnia, and leg cramps B. Visual disturbances, excessive thirst, and drowsiness C. Stomach cramps and diarrhea D. Dizziness, nausea or vomiting, and fatigue

D. Dizziness, nausea or vomiting, and fatigue Rationale: Dizziness, nausea or vomiting, and fatigue are adverse effects typically associated with labetalol that should be included in the patient's discharge teaching. The other adverse effects can be common to many medications. Excessive thirst, drowsiness, stomach cramps, constipation, insomnia, and leg cramps are not common adverse effects of labetalol.

1. A 37-year-old multipara at 38 weeks' gestation is admitted to the labor unit for induction of labor because of preeclampsia. The practitioner orders a 4 gm loading dose of magnesium sulfate and then 2 gm/hr. Before implementing this order, the nurse also must obtain an order for what? A. Indwelling urinary catheter B. Pain medication C. Antiemetic medication D. Mainline IV fluid and infusion rate

D. Mainline IV fluid and infusion rate Rationale: The nurse must obtain an order for mainline fluids and a rate of infusion because magnesium sulfate should never be infused via a primary line. The nurse may simultaneously obtain orders for pain medication, antiemetics, or an indwelling urinary catheter, but they are not required to implement the magnesium sulfate order.

2. As a patient is arriving in the recovery area following a cesarean delivery, the health care team member receives a hand-off report from the anesthesia provider. Which details of the hand-off report are needed for immediate nursing interventions or assessment? A. Urine output, IV intake, medications, and patient's weight B. Patient's diagnosis, allergies, urine output, and the procedure performed C. Most recent set of vital signs, patient's age, IV intake, and patient's weight D. Drains, patient's diagnosis, medications, and allergies

D. Drains, patient's diagnosis, medications, and allergies Rationale: The health care team member needs to know the name and age of the patient; name of the surgeon and procedure performed; patient's diagnosis and any pertinent patient medical history, allergies, type and tolerance of intraoperative anesthesia; presence of any external or implanted devices and settings; recently administered medications, including pain and comfort medications; current and applicable laboratory tests; estimated fluid deficit and replacement; estimated blood loss; complications, treatment, and response (as applicable); status of the operative site, dressings, and drainage tubes; and emotional status upon arrival to the OR. All of these factors must be reported and assessed because immediate nursing intervention may be required for safe patient care. The patient's age and weight, urine output, and IV intake should also be confirmed during a thorough report and are important for the plan of care, but none of these factors are applicable for immediate nursing interventions or assessment considerations.

9. A patient's fetus has died at 34 weeks' gestation, and the patient is fearful about how the newborn will look after delivery. What is the best response by the nurse? A. The nurse should explain how the newborn will look to prepare the patient. B. The nurse should tell the patient it is all right if the patient doesn't want to see the newborn. C. The nurse should tell the patient that it is better to see how the newborn looks at birth. D. The nurse should express uncertainty about how the newborn will look.

D. Ensure that the newborn is bathed and dressed. Rationale: Before taking photographs, the nurse should offer the patient and family the opportunity to bathe and dress the newborn, and if they do not wish to do so, the nurse should bathe and dress the newborn just as would be done for a live newborn. Although the nurse may wrap the newborn in plastic to protect the skin in between offering the patient and family the chance to hold the bathed, dressed, and swaddled newborn, taking photographs of the newborn wrapped in plastic wrap would be completely inappropriate. Footprints or handprints of the newborn do not need to be obtained before taking pictures. Required documentation for fetal or newborn death should not be completed until after most other procedure steps have been completed, including taking photographs.

8. When massaging the fundus of a patient after delivery, what step should the nurse take to avoid a uterine inversion? A. Apply firm pressure on the fundus only if excessive bleeding is observed. B. Apply firm pressure on the fundus toward the vagina. C. Ensure that the uterus is boggy before attempting to express clots. D. Ensure that the uterus is firm before attempting to express clots.

D. Ensure that the uterus is firm before attempting to express clots. Rationale: To avoid a uterine inversion, the nurse should ensure that massaging the fundus has resulted in a firm uterus before applying firm but gentle pressure toward the vagina to attempt to express clots. If the uterus is boggy, then applying firm pressure on the fundus to express clots, regardless of whether excessive bleeding is observed or whether the direction of pressure is toward the vagina, could lead to uterine inversion.

7. A patient on the postpartum unit was diagnosed with hypertension at 35 weeks' gestation and delivered a healthy newborn 2 days ago. The patient never had hypertension before the pregnancy. There was no proteinuria or severe features of preeclampsia since being diagnosed with hypertension, and since delivery, the BP has returned to normal. What does this patient's history indicate? A. Preeclampsia B. HELLP syndrome C. Chronic hypertension D. Gestational hypertension

D. Gestational hypertension Rationale: This patient had gestational hypertension. Features of this disorder include a systolic BP of 140 mm Hg or more or diastolic BP of 90 mm Hg, or both, measured on two occasions at least 4 hours apart without proteinuria or severe features occurring after 20 weeks' gestation in a patient with previously normal BP. The BP returns to normal during the postpartum period. Chronic hypertension is first diagnosed before 20 weeks' gestation and does not return to normal in the postpartum period. Preeclampsia may have severe features and usually has proteinuria associated with it. HELLP syndrome is usually a third trimester diagnosis, but may be first expressed or progressive in the postpartum period; its main presenting symptoms are right upper quadrant pain, general malaise, and nausea and vomiting.

10. A primigravida at 39 weeks' gestation is in the recovery room after a cesarean delivery for a breech presentation. A multimodal approach to pain management is being used. What does this include? A. IV or intrathecal opioids in addition to steroidal antiinflammatory medications B. Intramuscular opioid injection in addition to nonsteroidal antiinflammatory medications C. Intramuscular opioid injection in addition to steroidal antiinflammatory medications D. IV or intrathecal opioids in addition to nonsteroidal antiinflammatory medications

D. IV or intrathecal opioids in addition to nonsteroidal antiinflammatory medications Rationale: A multimodal approach, including the use of IV or intrathecal opioids in addition to nonsteroidal antiinflammatory medications, has been shown to be a highly effective approach to pain management after cesarean birth. Steroidal antiinflammatory medications are not necessary to use in a multimodal approach because the nonsteroidal multimodal approach is highly effective in pain management after a cesarean birth. Intramuscular opioid injections are not superior to the IV route because this requires multiple intramuscular injections to control the patient's pain. The IV route of opioid pain administration can also give the patient more control over pain management because a PCA pump can be used.

1. A nurse receives an order for IV calcium gluconate for a patient experiencing magnesium toxicity from magnesium sulfate therapy. The nurse prepares the injection and enters the patient's room. What should the nurse's initial steps be? A. Check the patient's name and room number with the corresponding information on the MAR. B. Check the patency of the IV line and administer the medication slowly. C. Discontinue the magnesium sulfate infusion and notify the practitioner. D. Identify the patient using two identifiers and compare the patient record number on the identification band with the number on the MAR.

D. Identify the patient using two identifiers and compare the patient record number on the identification band with the number on the MAR. Rationale: The Joint Commission recommends that two patient identifiers be used to confirm the right patient with the right medication; comparing the patient record number on the patient's identification band to the record number on the MAR helps ensure that the right medication is being administered to the right patient. The patient's room number is not considered an identifier. The nurse has an order for calcium gluconate, so the practitioner has already been notified and the magnesium sulfate infusion should have been discontinued. Although the nurse should ensure that IV access is available and that a mainline fluid, such as a 0.9% sodium chloride solution, is infusing normally, identifying the patient is critical before administering the medication.

9. A nurse is preparing to administer a repeat dose of labetalol to an antepartum patient with preeclampsia and a BP of 170/110 mm Hg. If the BP does not drop below 160/110 mm Hg or increases, how soon can a repeat dose of labetalol IV be administered? A. In 20 minutes B. In 30 minutes C. In 5 minutes D. In 10 minutes

D. In 10 minutes Rationale: Additional doses of IV push labetalol can be given every 10 minutes up to 300 mg in 24 hours if the BP does not drop below 160/110 mm Hg or if it increases. Waiting 20 or 30 minutes is not necessary for a BP at this level. A 5-minute wait is not long enough and could result in hypotension.

3. The nurse is caring for a patient with a suspected postpartum hemorrhage. What is the nurse's next step? A. Administer IV fluids and oxygen. B. Obtain a CBC with platelet count. C. Massage the fundus and administer oxytocin. D. Initiate the postpartum hemorrhage protocol and call for help.

D. Initiate the postpartum hemorrhage protocol and call for help. Rationale: Initiating postpartum hemorrhage protocol and calling for help allows for the team approach to begin immediately. Interventions to manage postpartum hemorrhage may occur simultaneously with a multidisciplinary team approach. Massaging the fundus; obtaining blood specimens for a CBC with platelet count; and administering oxytocin, IV fluids, and oxygen are interventions that the team can do to help identify the source, assess blood loss, manage shock, and prevent further blood loss.

2. A primigravida presents to the labor and delivery unit with severe preeclampsia. The admission BP is 210/110 mm Hg. The practitioner orders hydralazine by IV push administration. Which is the primary advantage of administering hydralazine? A. It is available for oral administration. B. It causes hypotension, which is desirable in a patient with an elevated BP. C. It causes uteroplacental insufficiency. D. It increases cardiac output.

D. It increases cardiac output. Rationale: Hydralazine is one of three first-line medications for managing acute-onset hypertension in patients with severe preeclampsia. As a vasodilator, hydralazine increases heart rate, stroke volume, cardiac output, and left ventricular ejection fraction. Hypotension, an adverse effect of hydralazine, is not desirable because it may lead to uteroplacental insufficiency, which may result in an interruption of fetal oxygenation with category II (indeterminate) or category III (abnormal) FHR characteristics. Hydralazine is available for both oral and IV administration; however, IV administration is preferable to oral administration in a hypertensive crisis.

10. A patient at 30 weeks' gestation is receiving magnesium sulfate for fetal neuroprotection. The nurse notes that the patient has a history of renal failure. Why should magnesium sulfate be used with caution in this patient? A. Magnesium sulfate is excreted primarily by the liver. B. Magnesium sulfate can cause kidney damage. C. Magnesium sulfate causes uremia in a patient with renal failure. D. Magnesium sulfate is excreted primarily by the kidneys.

D. Magnesium sulfate is excreted primarily by the kidneys. Rationale: Magnesium sulfate has to be used with caution in patients with renal failure because it is excreted primarily by the kidneys and could lead to magnesium sulfate toxicity if it is not excreted adequately. Magnesium sulfate is not excreted primarily by the liver. Magnesium sulfate does not cause kidney damage or uremia.

10. The nurse has just been given an order for a uterotonic drug after delivery in a patient who was induced for preeclampsia at 36 weeks' gestation. The patient's most recent blood pressure is 158/100 mm Hg. Which medication should the nurse avoid in this situation? A. Oxytocin B. Misoprostol C. Tranexamic acid D. Methylergonovine

D. Methylergonovine Rationale: Methylergonovine should not be given to a patient with hypertension because this uterotonic medication will cause an increase in blood pressure. Giving the patient oxytocin or misoprostol would be appropriate because these uterotonic medications will not cause blood pressure to increase. Tranexamic acid is an antifibrinolytic medication recommended for administration to patients with postpartum hemorrhage in addition to standard care for postpartum hemorrhage. It does not cause an increase in blood pressure and may be safely used in the hypertensive patient.

9. A patient has just received an epidural anesthetic for a cesarean section at term because of labor dystocia. The patient is positioned on the OR table with a hip roll under the right hip to prevent supine hypotension and a safety strap is placed over the legs. The nurse determines that the FHR is 65 beats per minute. Which action should the nurse take next? A. Continue to assess the FHR. B. Place pneumatic or sequential compression devices on the patient. C. Place an indwelling catheter. D. Notify the practitioner of the FHR.

D. Notify the practitioner of the FHR. Rationale: Although continuing to assess the FHR is appropriate, the nurse's next action should be to notify the practitioner of the FHR because the cesarean delivery may become emergent. The indwelling catheter and pneumatic or sequential compression devices can be placed after the practitioner is notified.

1. A patient who is at 33 weeks' gestation presents to the labor and delivery unit with an elevated BP. The patient states, "I've had a headache for 3 days and a pain under my right breast, and I vomited twice today. I woke up this morning seeing white spots." What is the priority nursing intervention for this patient? A. Prepare for emergency delivery. B. Administer a calcium gluconate IV bolus immediately. C. Obtain informed consent and anticipate an order for a phenytoin infusion. D. Place the patient on seizure precautions and perform a neurologic assessment.

D. Place the patient on seizure precautions and perform a neurologic assessment. Rationale: The nurse should initiate seizure precautions and frequently monitor the patient for changes in CNS activity. In this case, neurologic assessment should include assessment of vital signs and DTRs and a check for visual disturbances. Headache, visual disturbances, hyperreflexia, and clonus are indications of increased cerebral irritability secondary to decreased cerebral circulation and cerebral edema. Magnesium sulfate, not phenytoin, is the drug of choice for the prevention and treatment of seizures by decreasing CNS irritability and cardiac conduction. Calcium gluconate should be readily available for magnesium toxicity, but this patient has not yet received any magnesium. An emergency delivery is not indicated because the patient is exhibiting initial signs of preeclampsia and has not experienced a seizure.

4. A prolapsed umbilical cord is suspected after the patient's membranes rupture. An SVE is immediately performed on the patient. What is the primary goal of performing the SVE? A. Pushing the cord back through the cervix B. Determining the fetal station C. Determining cord position D. Relieving pressure on the cord

D. Relieving pressure on the cord Rationale: Exerting upward pressure on the fetal presenting part via SVE and changing maternal position relieve cord compression. Reducing umbilical pressure increases the fetus' oxygenation and helps prevent or reduce fetal hypoxia, which may result in brain injury. Determining fetal station and assessing the cord's position are not the primary goals of the SVE. Pushing the cord back through the cervix is contraindicated.

8. The nurse is called to the room of a patient at 41 weeks' gestation who is in labor. The patient reports feeling something between the legs. Upon investigation, the nurse sees the umbilical cord prolapsing out of the vagina. What should the nurse do as part of an appropriate response? A. Attempt to push the cord back through the cervix if possible. B. Place a fetal scalp electrode to monitor the FHR. C. Be careful not to touch the prolapsed umbilical cord. D. Saturate a sterile towel with warm sterile 0.9% sodium chloride solution and loosely wrap the cord.

D. Saturate a sterile towel with warm sterile 0.9% sodium chloride solution and loosely wrap the cord. Rationale: Although touching the umbilical cord should be kept to a minimum, saturating a sterile towel with warm sterile 0.9% sodium chloride solution and loosely wrapping the cord is the appropriate intervention. Attempting to push the umbilical cord back through the cervix or placing an internal fetal scalp electrode to monitor FHR could cause excessive handling, trauma, and compression of the cord and should not be done.

8. A patient and family have been offered a memento box of their deceased newborn's handprints and footprints, hair, ID band, and photographs. The patient and family refuse to take the memento box. What is the next action by the nurse? A. Tell the patient and family to take the memento box because if they don't, they may later wish they had. B. Throw the memento box away after shredding any identifiable information. C. Save the memento box and call the patient and family 1 week after discharge to see if they are ready to take the memento box. D. Save the memento box because the patient and family may request it weeks or months later.

D. Save the memento box because the patient and family may request it weeks or months later. Rationale: The nurse should save the memento box because the patient and family may request it weeks or months later. Pressuring the patient and family to take the memento box by saying they may later regret not taking it is inappropriate. Throwing the memento box away and shredding identifiable information is also not appropriate because in many cases, the patient and family will later request the memento box after discharge. Calling the patient and family 1 week after discharge may be too soon, and they should not be pressured into taking the box.

3. The circulating nurse receives a hand-off report from the labor nurse and assists the patient, who needs regional anesthesia, to the OR table. What is the most appropriate action for the circulating nurse? A. Complete a preoperative checklist, apply the blood pressure cuff, and attach safety straps to the patient's lower extremities. B. Remove the labor bed from the room and call the neonatal team. C. Record the time, remove the labor bed from the room, and bring in the support person to comfort the patient. D. Stay by the patient's side, call for a time-out verification, and position the patient for anesthesia induction.

D. Stay by the patient's side, call for a time-out verification, and position the patient for anesthesia induction. Rationale: The circulating nurse should stay by the patient to prevent falls until the safety straps can be applied; a time-out verification should then be completed before anesthesia induction or further invasive procedures. Once the patient, procedure, and informed consent are appropriately confirmed, the circulating nurse should position the patient for the type of anesthesia to be used. The labor bed can be removed from the area near the surgical table during anesthesia administration and from the room after the patient is safely strapped. The circulating nurse should record the patient's arrival time in the OR and begin completing the preoperative checklist before the patient is moved to the OR table. Monitor pads and a blood pressure cuff are applied after the patient is secured, near the time of anesthesia induction.

6. Which element is necessary for discharge from the PACU? A. Fluid intake needs to be equal to the patient's blood loss and urine output. B. The patient can tolerate clear fluids by mouth. C. Pain medications have not been administered in the last 30 minutes. D. The patient meets the criteria of a discharge scoring system.

D. The patient meets the criteria of a discharge scoring system. Rationale: Discharge scoring systems are used to assess the patient's readiness to be transferred from one phase of perianesthesia care to another. In most cases, having a patient's intake equal the output is desirable, but this goal is unrealistic and may in some cases lead to adverse effects. Many patients have orders to receive nothing by mouth for a period of time after an operative abdominal procedure or may have nausea after the procedure. Patients may or may not require pain medication to be administered in the recovery room, or they may be receiving continuous analgesia.

9. A multigravida patient at 38 weeks' gestation who has a history of one vaginal delivery is completely dilated and at a +3 station. A prolapsed umbilical cord is noted. The nurse performs an SVE to relieve pressure on the cord. When may the nurse stop applying pressure to the fetal presenting part? A. When the FHR returns to normal B. When the patient is moved to the OR C. When the patient is prepped for surgery D. When the delivery takes place

D. When the delivery takes place Rationale: When a prolapsed cord is discovered, pressure is applied by means of an SVE until delivery takes place. The application of pressure must not be released when the patient is prepped for surgery or moved to the OR and must continue in the OR to help prevent compression of the umbilical cord. Pressure cannot be safely discontinued before delivery.