NR 327 Exam 2
The nurse is providing teaching to a client who has experienced placenta accreta. The nurse will use which statement to explain this diagnosis to the client? "The placenta detached early because it was attached in the incorrect location." "There is nothing to be concerned about because the placenta was perfect." "Because the placenta was attached deeply, it was difficult for it to detach." "The placenta was attached in an unsafe location in the uterus."
"Because the placenta was attached deeply, it was difficult for it to detach."
Which statements will the nurse make when reinforcing postpartum education regarding breastfeeding? Select all that apply. "Expressed milk can be frozen for up to 2 weeks." "Avoid wearing a bra to minimize engorgement." "Ensure your baby is latched correctly to avoid nipple irritation and pain." "Mastitis may develop as a result of frequent breastfeeding." "To cleanse your breasts, use soap and allow your breasts to air dry." "You will not need to use a contraceptive while breastfeeding."
"Ensure your baby is latched correctly to avoid nipple irritation and pain."
Which statements made by Rachel at her first postpartum visit are consistent with postpartum depression? "My emotions fluctuate. One minute I am happy and the next, I am sad." "I asked my partner for help and was able to get some sleep. Then I felt normal again." "I am hungry all the time." "I cry all the time no matter what I do." "I am having trouble sleeping." "I don't care about anything anymore."
"I cry all the time no matter what I do." "I am having trouble sleeping." "I don't care about anything anymore."
The nurse is caring for a client with an epidural infusion in active labor. Which statement indicates that the client needs more education about this treatment? "I will feel numbness in my legs while receiving this medication." "I'll be sleepy during the delivery after receiving this medication." "I may still feel pressure and some pain after receiving this medication." "I'll be able to stay alert during the delivery with this medication."
"I'll be sleepy during the delivery after receiving this medication."
What should the nurse tell the client to expect after a cesarean birth? Select all that apply. "Your only activity should be walking to the bathroom until your incision heals." "If you have a temperature over 100.4°F (38°C), let your healthcare provider know right away." "If you notice redness, drainage, or separation of the incision, let your healthcare provider know right away." "You will have your first postpartum visit in 6 weeks." "Do not lift anything heavier than 25 pounds to prevent incisional separation."
"If you have a temperature over 100.4°F (38°C), let your healthcare provider know right away." "If you notice redness, drainage, or separation of the incision, let your healthcare provider know right away."
The nurse is assessing a breastfeeding client who states that her breasts feel tight two days after birth. Which responses by the nurse are appropriate? Select all that apply. "If your breasts haven't emptied when the baby is done, use a breast pump after the feeding." "This can be normal but be sure that your breasts empty with each feeding." "Apply ice packs to your breasts before feeding for 20 minutes." "This is normal and a good sign that you have enough milk to feed your baby." "I see you are not wearing a supportive bra, which would help to minimize engorgement."
"If your breasts haven't emptied when the baby is done, use a breast pump after the feeding." "This can be normal but be sure that your breasts empty with each feeding." "I see you are not wearing a supportive bra, which would help to minimize engorgement."
Which statements should the nurse include in postpartum education regarding abnormal uterine characteristics? Select all that apply. "Make sure your uterus stays firm like a softball." "Your uterus should go down the width of your finger every week." "Since you are breastfeeding, you will continue to feel cramping in your uterus." "By 2 months postpartum, you should no longer be able to feel your uterus through your abdomen." "Make sure your uterus stays in line with your belly button."
"Make sure your uterus stays firm like a softball." "Since you are breastfeeding, you will continue to feel cramping in your uterus." "Make sure your uterus stays in line with your belly button."
The nurse is caring for a client who recently gave birth and is breastfeeding. The client asks, "Can I start taking my birth control pills once I am released to resume sexual intercourse?" What is the best response by the nurse? "Oral contraceptives that contain estrogen should be avoided during lactation. Would you like to discuss other options?" "You do not need to use any form of birth control as long as you are breastfeeding." "You cannot take birth control pills, but you can use the vaginal ring or transdermal patch." "Yes, once approved by your healthcare provider, you may begin taking birth control pills.
"Oral contraceptives that contain estrogen should be avoided during lactation. Would you like to discuss other options?"
A nurse is providing postpartum education regarding the perineum post vaginal delivery. Which statements by the nurse are correct? Select all that apply. "The sutures used to repair your episiotomy (or laceration) will dissolve on their own." "Do not submerge in a bathtub until your healthcare provider clears you to do so after your first postpartum visit in 6 weeks." "Your episiotomy (or laceration) should begin to heal in about 2-3 weeks." "Once the sutures dissolve, you may resume sexual intercourse." "You can use a sitz bath 2-4 times a day or take a bath in about a week." "Do not use any tampons, douche, or have sexual intercourse until your healthcare provider clears you to do so." "Continue to practice peri-care as we taught you for about a week."
"The sutures used to repair your episiotomy (or laceration) will dissolve on their own." "Do not submerge in a bathtub until your healthcare provider clears you to do so after your first postpartum visit in 6 weeks." "Your episiotomy (or laceration) should begin to heal in about 2-3 weeks." "Do not use any tampons, douche, or have sexual intercourse until your healthcare provider clears you to do so."
A woman asks the nurse, "What should I know about the birth control implant in the arm and how it prevents pregnancy?" What should the nurse explain about the impact of birth control implants? Select all that apply. "There may be some temporary tenderness or swelling around the implant after insertion." "It provides continuous contraception for 3 years." "A possible side effect is irregular bleeding (spotting), especially in the first 6-12 months." "It is implanted in the forearm." "The implant is 95% effective."
"There may be some temporary tenderness or swelling around the implant after insertion." "It provides continuous contraception for 3 years." "A possible side effect is irregular bleeding (spotting), especially in the first 6-12 months."
A woman in preterm labor is receiving magnesium sulfate intravenously and asks the nurse why she needs this medication. Which of the following is the nurse's best response? "This medication is used to relax the muscle of your uterus to prevent or reduce contractions." "This medication is used to treat the infection that is causing your preterm labor." "This medication will help mature your baby's lungs in case of delivery." "The medication is used to treat the low blood pressure that is causing your preterm labor."
"This medication is used to relax the muscle of your uterus to prevent or reduce contractions."
The nurse is caring for a laboring client and evaluates the characteristics of contractions. Which questions should the nurse ask? Select that all apply. "When did your contractions start?" "How long are your contractions lasting?" "What is the resting tone of your uterus?" "How often do you have contractions right now?" "What is the intensity of your contractions?"
"When did your contractions start?" "How long are your contractions lasting?" "How often do you have contractions right now?"
The nurse is assisting a client and a newborn with breastfeeding two days postpartum. The newborn is crying and is having difficulty latching. The client verbalizes concern that she is not producing enough milk and that's why her child is fussy. Which responses by the nurse are the most appropriate? Select all that apply. "When he does latch, we can hear him swallowing and see that he has a good suck." "The baby has lost 7% of his birthweight, so we will provide him with formula until your milk comes in." "The baby has had one wet diaper and two stools since birth, so we know that he is getting enough milk." "I will assist you in calming him and trying a new approach to get him to latch." "This is normal behavior and doesn't necessarily mean he isn't getting enough milk.
"When he does latch, we can hear him swallowing and see that he has a good suck." "I will assist you in calming him and trying a new approach to get him to latch." "This is normal behavior and doesn't necessarily mean he isn't getting enough milk.
At her first postpartum visit, Rachel is showing signs of postpartum depression and incisional infection. In addition, she reports that her baby is very fussy despite breastfeeding frequently, and her breasts are engorged and her nipples have become irritated. Which statements from the nurse are indicated at this time? Select all that apply. "You can take a warm shower and manually express milk to help with engorgement." "You can use lanolin cream between feedings to soothe sore nipples and it does not need to be wiped off before breastfeeding." "It is important that your baby is latched appropriately to avoid nipple tenderness." "To avoid nipple irritation, allow your breasts to air dry following a shower and use only warm water or mild soap." "Do not use a breast pump to express excess milk because this will cause further milk production."
"You can take a warm shower and manually express milk to help with engorgement." "You can use lanolin cream between feedings to soothe sore nipples and it does not need to be wiped off before breastfeeding." "It is important that your baby is latched appropriately to avoid nipple tenderness."
What is a normal range for the fetal heart rate? 120-140 bpm 110-160 bpm 110-130 bpm 90-110 bpm
110-160 bpm
The nurse providing postpartum teaching ensures the woman knows that her healthcare provider will usually schedule a postpartum follow-up visit at________________weeks postpartum after a normal, vaginal delivery and at _________weeks postpartum after a cesarean delivery.
4-6, 2
How long does it typically take for a woman who has delivered a baby to return to a pre-pregnant physical state? 2 weeks 6 months 1 year 6 weeks
6 weeks
The nurse is caring for a client who states that she breastfed her other children for the first 3 months and then switched to formula. The nurse advises her that exclusive breastfeeding is recommended for at least the first _____ months of life, but ideally the first _____ months of life.
6, 12
While reviewing the electronic health records of pregnant women coming to the clinic for antepartum care, the nurse identifies which women as candidates for planned (scheduled) cesarean deliveries? Select all that apply. A gravida 3, para 1 (G3P1) with a diagnosed partial placenta previa A gravida 1, para 0 (G1P0) whose pelvis is flat A healthy gravida 4, para 5 (G4P5) in her 41st week of gestation A small stature gravida 1, para 0 (G1P0), carrying twins A gravida 1, para 0 (G1P0) who fears the pain of labor A gravida 2, para 1 (G2P1) whose first child was an unscheduled cesarean delivery
A gravida 3, para 1 (G3P1) with a diagnosed partial placenta previa A gravida 1, para 0 (G1P0) whose pelvis is flat A small stature gravida 1, para 0 (G1P0), carrying twins A gravida 2, para 1 (G2P1) whose first child was an unscheduled cesarean delivery
Which statements are true of the cardinal movements of labor? Select all that apply. Induce uterine contractions Accommodate the fetal head Allow the largest diameter of the fetal head to align with the largest diameter of the pelvis Decrease labor pains
Accommodate the fetal head Allow the largest diameter of the fetal head to align with the largest diameter of the pelvis
The nurse is caring for a client with uterine atony. Which interventions will the nurse expect to complete to address uterine atony? Select all that apply. Administer antibiotics to treat the infection Administer oxytocin Perform fundal massage Increase intravenous (IV) fluids to promote additional hydration Encourage the client to empty her bladder
Administer oxytocin Perform fundal massage Encourage the client to empty her bladder
A client who is 10 hours post vaginal delivery is saturating two peri pads in an hour. Which intervention does the nurse know is contraindicated? Frequent vital signs monitoring Continue fundal massage Ambulation to stimulate uterine contractions Administer methylergonovine maleate intramuscular (IM)
Ambulation to stimulate uterine contractions
Which statements describe the actions of analgesics given in labor? Select all that apply. Analgesics may depress newborn respiratory efforts. Analgesics cross the placenta barrier. Analgesics slow labor. Analgesics are contraindicated.
Analgesics may depress newborn respiratory efforts. Analgesics cross the placenta barrier.
The nurse is caring for a client after vaginal delivery with a second-degree laceration. Which comfort measures can the nurse take immediately following the repair to reduce pain and edema? Increase the epidural rate Apply ice-pack Administer local anesthetics Administer ibuprofen Administer morphine
Apply ice-pack
The nurse is assessing a woman who gave birth vaginally 12 hours ago. The woman had a second-degree perineal laceration that was repaired and she had an epidural for anesthesia. Which actions by the nurse would be appropriate? Select all that apply. Ask about her pain level Explain that vital signs will be assessed every 12 hours Advise that she is no longer at risk for perineal infection Assess the perineum by asking if it feels less swollen Palpate the tone and level of the uterus in relation to the umbilicus Assess the characteristics of the lochia on the peri-pad
Ask about her pain level Palpate the tone and level of the uterus in relation to the umbilicus Assess the characteristics of the lochia on the peri-pad
A healthcare provider performs an amniotomy on a woman in labor. The amniotic fluid is thick and has an odor. The fetal heart tones immediately decrease. Which interventions should the nurse take immediately? Select all that apply. Ambulate the woman to increase fetal heart rate Assess for cord prolapse Assess the woman for a uterine infection Assist the client to a lateral position Administer pain medication to improve the fetal heart tones
Assess for cord prolapse Assess the woman for a uterine infection Assist the client to a lateral position
The nurse caring for a client in labor notices that the fetal heart rate has suddenly decreased. What can the nurse do initially to help the fetal heart rate to recover? Assist the woman to a high Fowlers position to improve her respiratory intake. Assist the woman to a lateral position to promote circulation. Assist the woman to a standing position to reduce head compression. Assist the woman to a supine position to best assess fetal heart tones
Assist the woman to a lateral position to promote circulation.
A client experienced a vaginal delivery involving the use of multiple positions for pushing due to malpresentation, vacuum assistance, and epidural anesthesia. Based on her delivery situation, which factors reflect why the client is at risk for thrombosis? Select all that apply. Blood vessel injury Likely urinary tract infection Hypercoagulable blood Venous stasis Low platelet count
Blood vessel injury Hypercoagulable blood Venous stasis
Which appearance in amniotic fluid requires follow up by the nurse? Select all that apply. Watery Bloody Yellow color Clear Greenish color Strong odor
Bloody Yellow color Greenish color Strong odor
The nurse should include which interventions to promote involution of the uterus into postpartum care of the mother? Select all that apply. Breastfeeding Administration of oxytocin Uterine massage Herbal tea Ambulation
Breastfeeding Administration of oxytocin Uterine massage
Which client history would prohibit the use of combined oral contraceptives? Select all that apply. Fetal demise Chronic uncontrolled hypertension Blood clots Migraines Multigravida Breast cancer
Chronic uncontrolled hypertension Blood clots Migraines Breast cancer
What common postpartum bodily alterations might cause a woman to experience abnormal vital signs? Select all that apply. Complications from epidural or spinal anesthesia Presence of pain Presence of infection after 24 hours Fluctuating hormone levels Hypovolemia due to blood loss
Complications from epidural or spinal anesthesia Presence of pain Presence of infection after 24 hours Hypovolemia due to blood loss
How can the nurse help prevent newborn abduction in the hospital? Select all that apply. Continually ensure that the newborn's identification bracelet is securely in place Continually ensure that the newborn's tracking bracelet is securely in place Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery Ensure that only the mother has a bracelet that matches the newborn's bracelet
Continually ensure that the newborn's identification bracelet is securely in place Continually ensure that the newborn's tracking bracelet is securely in place Educate the mother to verify the identity of a staff member who is taking the newborn to the nursery
When admitting a client to the labor and delivery unit, which is the priority assessment? Gravida and para status Time of last meal Presence of a labor partner Contraction frequency and duration
Contraction frequency and duration
What is the legal responsibility of the nurse in assessment of fetal heart rate (FHR) patterns? Provide technical assessment for the monitor technicians. The nurse is not legally responsible for fetal monitoring. Correctly identify abnormal FHR patterns and prescribe medication. Correctly identify abnormal FHR patterns and notify the healthcare provider.
Correctly identify abnormal FHR patterns and notify the healthcare provider.
Which statements describe the doula's role in labor? Select all that apply. Doulas are trained to provide basic unlicensed nursing skills in labor. Doulas are trained to assist nurses in the labor and delivery process. Doulas are trained and experienced childbirth support providers. Doulas provide reassurance, touch, companionship, and comfort during labor.
Doulas are trained and experienced childbirth support providers. Doulas provide reassurance, touch, companionship, and comfort during labor.
Brenda recently gave birth to a son and has indicated that she would like to use the diaphragm for birth control. Which information should the nurse include in teaching? Select all that apply. Empty bladder before inserting the diaphragm. It is acceptable to use the diaphragm during menstrual periods. Begin using the diaphragm as soon as cleared for sexual activity. Insert the diaphragm up to six hours before intercourse to enhance spontaneity. Wash the diaphragm with warm water and mild soap after use. Always void after intercourse when using a diaphragm. Remove the diaphragm one hour after intercourse. Apply spermicide only to the rim of the diaphragm just before insertion.
Empty bladder before inserting the diaphragm. Insert the diaphragm up to six hours before intercourse to enhance spontaneity. Wash the diaphragm with warm water and mild soap after use. Always void after intercourse when using a diaphragm.
Which actions should the nurse take to help a first-time mother bond with her infant? Select all that apply. Encourage the mother to hold the newborn from birth Postpone all nursing actions that require the newborn to be removed from the mother's arms Encourage the mother to allow you to take the newborn to the nursery every 2 hours to allow her to rest Compliment her on her child Assess for signs which indicate that normal attachment is taking place
Encourage the mother to hold the newborn from birth Compliment her on her child Assess for signs which indicate that normal attachment is taking place
The nurse caring for a client is providing education regarding breastfeeding. Which are appropriate guidelines for the nurse to provide? Select all that apply. If difficulty with breastfeeding persists, supplement with formula to avoid postpartum depression. If breasts become full and milk leaks between feedings, notify the healthcare provider. Each feeding should last a minimum of 30 minutes to ensure adequate intake. Ensure a proper latch to avoid nipple soreness and injury. Teach maternal and infant benefits of breastfeeding.
Ensure a proper latch to avoid nipple soreness and injury. Teach maternal and infant benefits of breastfeeding.
What is the highest priority after birth of the fetus? Establishing the newborn's airway Medicating the mother for pain Assisting with the quick delivery of the placenta Promoting bonding and breastfeeding
Establishing the newborn's airway
What are possible complications associated with oxytocin for induction of labor? Select all that apply. Fetal distress Maternal bradycardia Hypertension Uterine hyperstimulation Decreased urine output
Fetal distress Hypertension Uterine hyperstimulation Decreased urine output
A pregnant woman comes to the emergency department in precipitous labor that started 30 minutes ago. She says that she feels like she needs to have a bowel movement. The nurse observes on the electronic fetal monitor that the fetal heart rate decreases gradually when a contraction starts and returns to baseline when the contraction ends. What does the nurse suspect is causing this? Fetal head compression Umbilical cord compression Uteroplacental insufficiency Severe fetal distress
Fetal head compression
When fetal heart rate decreases at the beginning of a contraction and returns to baseline at the end of the contraction, which condition is occurring? Umbilical cord compression causing variable decelerations Fetal head compression causing an early deceleration Fetal distress Uteroplacental insufficiency causing a late deceleration
Fetal head compression causing an early deceleration
What are the warning signs of infection following a cesarean section that the nurse should include in the teaching for the postpartum mother? Select all that apply. Constipation Foul-smelling vaginal discharge Chills Temperature greater than 100.4°F (38°C) Lochia becomes lighter and decreases in amount Hemorrhoids Redness, drainage, separation of cesarean incision
Foul-smelling vaginal discharge Chills Temperature greater than 100.4°F (38°C) Redness, drainage, separation of cesarean incision
Which statement reflects the newborn's visual abilities at birth? Once the prophylactic antibiotic eye drops are administered, newborns can see 8-10 inches away. From birth, newborns can best see objects held a few inches away. From birth, newborns can best see objects held 8-10 inches away. Newborns typically do not open their eyes for at least 12-18 hours.
From birth, newborns can best see objects held 8-10 inches away.
A woman who has been in labor for an extended time is getting very tired. Which of the following intrapartum complications is concerning the nurse, that may result from maternal fatigue? Her labor will go too fast. Her labor may slow down. Her milk production will decrease. She will fall asleep.
Her labor may slow down.
In what situation might a pregnant woman remain in the same hospital room from labor/induction admission through postpartum discharge? When the woman has a cesarean delivery planned In a larger hospital with larger rooms available When the pregnancy is high risk In a maternity unit set up with labor, delivery, recovery, and postpartum (LDRP) rooms
In a maternity unit set up with labor, delivery, recovery, and postpartum (LDRP) rooms
At her first postpartum visit, Rachel's lochia is dark brown. Her uterus cannot be palpated in the abdomen. Her vital signs are stable. She states that the baby is breastfeeding every 2-3 hours and her breast milk is thick and white. Rachel's incision is found to be reddened and draining. There is slight separation of the incision. Which, if any, complication has Rachel likely developed? Mastitis Incisional infection Uterine infection Rachel does not show any signs of complications
Incisional infection
Which device can assess the intensity of contractions? Doppler Internal fetal monitor Fetoscope External fetal monitor
Internal fetal monitor
How can the nurse provide comfort to the client's partner during childbirth? Keep the partner informed to a level appropriate to the client's wishes. Keep the partner informed of every detail of childbirth care. Ensure that the partner is not informed of complications in order to keep them calm. Advise the partner to leave the room if childbirth complications occur.
Keep the partner informed to a level appropriate to the client's wishes.
A woman in labor is experiencing complications that require augmentation of labor. Which of the following represents how the nurse would characterize her labor? Labor with issues Intrapartum hypertonia Labor dystocia Intervened labor
Labor dystocia
Which statement is accurate regarding the pain associated with childbirth? Labor pain is predictable and easily treated. Those with family present can cope with labor pain much easier. Labor pain has a foreseeable end, which can help some to cope. Labor pain is harder for women to cope with, knowing that it will result in the birth of a child.
Labor pain has a foreseeable end, which can help some to cope.
A pregnant client who is 39 weeks gestation reports that she is urinating a lot more lately and does not feel the baby up as high in her abdomen. What is the likely reason? Internal rotation Lightening Braxton Hicks contractions Urinary tract infection
Lightening
Which normal characteristics of lochia should the nurse include in postpartum teaching? Select all that apply. Lochia with some small clots Saturating a peripad in an hour for 10-14 days Lochia that will gradually become lighter in amount and color A soft uterus with heavy lochia Large clots or saturating more than 4 peripads per day
Lochia with some small clots Lochia that will gradually become lighter in amount and color
Which of the following variability classifications is generally indicative of fetal well-being? Moderate Absent Minimum Marked
Moderate
The nurse is caring for a woman in labor with ruptured membranes. The nurse is assessing her labor progress. Which of the following actions is most appropriate for the nurse at this time? Apply a fetal scalp electrode to determine fetal response to contractions. Perform a sterile vaginal exam to check cervical dilation and effacement. Monitor the client's behavior to help determine if labor is progressing. Ask the healthcare provider for permission to place an intrauterine pressure catheter
Monitor the client's behavior to help determine if labor is progressing.
A client with substance use disorder is admitted in active labor. She admits to using heroin. Which of the following medications should the nurse know is contraindicated for this client? Diphenhydramine Promethazine Nalbuphine Ibuprofen
Nalbuphine
The labor nurse is caring for Tiffany in the second stage of labor. The fetal heart rate pattern has shown a baseline of 120-130 beats per minute with recurrent variable decelerations ranging from 80-90 beats per minute and lasting 15-40 seconds. Based on these findings, what might the nurse anticipate when the fetus is delivered? Select all that apply. Discovery of a partial placental abruption Nuchal cord Low APGAR scores Normal APGAR scores Malfunctioning electronic fetal monitor
Nuchal cord Low APGAR scores
Which manifestations would the nurse anticipate if postpartum hemorrhage is occurring? Select all that apply. Oliguria Restlessness Hypertension Dizziness with standing Increased platelet count Decreased hemoglobin and hematocrit
Oliguria Restlessness Dizziness with standing Decreased hemoglobin and hematocrit
What is the cause of molding in the newborn skull? Presence of cerebral tumor Overlapping of the unfused bones compressed during vaginal delivery Abnormal accumulation of cerebral spinal fluid Use of forceps during vaginal delivery
Overlapping of the unfused bones compressed during vaginal delivery
The nurse is providing education at a nursing home. The nurse reminds the clients, who are in their 70s, that a man of any age can reproduce if he is able to perform which function? Maintain an erection Ejaculate Maintain a high sperm count Participate in intercourse
Participate in intercourse
A woman in labor whose uterine contractions have slowed and weakened, whose fetus is in an occiput posterior position, and who is crying is experiencing issues with which processes of labor and delivery? Select all that apply. Passenger Passageway Psyche Position Powers
Passenger Psyche Powers
Which nursing actions promote initial bonding immediately following birth? Select all that apply. Complete initial assessment in radiant warmer in client's room Place infant on mother's chest Involve partner in care Encourage breastfeeding within the first hour Delay full assessment for 1 hour
Place infant on mother's chest Involve partner in care Encourage breastfeeding within the first hour Delay full assessment for 1 hour
A newborn born one hour ago is wrapped in blankets and sleeping in the crib at the mother's bedside. The axillary temperature is 97.6ºF (36.4ºC). Which actions should the nurse initiate? Double wrap the newborn Take the newborn to the nursery for a full assessment Place the newborn in the radiant warmer Place newborn skin-to-skin on mother's chest
Place newborn skin-to-skin on mother's chest
Following a client's rupture of membranes, the nurse finds an umbilical cord in the vagina. What are the two priority actions for the nurse? Place the patient in a knee-chest position. Call a code blue. Relieve pressure on the cord by lifting the presenting part off the cord. Instruct the patient to bear down. Monitor the intensity of contractions. Obtain fetal heart tones.
Place the patient in a knee-chest position. Relieve pressure on the cord by lifting the presenting part off the cord.
When caring for a newborn, which action indicates the newborn is ready to breastfeed? Places hands in mouth Spits up clear mucus Sleeps quietly in a supine position Turns head toward sound
Places hands in mouth
The nurse should include which information regarding blood clots when providing postpartum teaching? Pregnancy makes the blood thicker and more likely to form clots. Clots are caused by a high fat diet during pregnancy. The symptoms are the same as those of an incisional infection in the leg. Having a cesarean delivery causes leg pain that will be resolved with extra activity.
Pregnancy makes the blood thicker and more likely to form clots.
What are indications for labor induction? Select all that apply. Placenta previa Prolonged rupture of membranes Client request to select the delivery date Post-term gestation History of precipitous labor
Prolonged rupture of membranes Post-term gestation History of precipitous labor
A client arrived at the labor and delivery unit having frequent and strong contractions. She is loud in expressing her pain and appears anxious. She has a language barrier but is able to communicate and understand limited English. No support persons are present. Which nursing actions will best support the client upon her arrival to the unit? Select all that apply. Discourage loud expressions of pain Remain with the client Provide emotional support Administer pain medication Arrange for an interpreter
Remain with the client Provide emotional support Arrange for an interpreter
A client who delivered a newborn 12 hours ago is concerned that the newborn is sleepy and doesn't want to breastfeed. Which newborn assessment item should the nurse collect first? Axillary body temperature Time of last feeding and the number of wet diapers since delivery Blood glucose level Response to being unwrapped and placed at the breast
Response to being unwrapped and placed at the breast
Rachel arrives for a follow-up postpartum appointment. Which findings indicate that she has followed her teaching instructions from the last appointment? Select all that apply. She tells the nurse that she has been able to begin running again. She has begun antidepressant therapy and is seeing a therapist. She has not resumed sexual activity but has plans to begin contraception when cleared by her healthcare provider. She lifts nothing heavier than her baby.
She has begun antidepressant therapy and is seeing a therapist. She has not resumed sexual activity but has plans to begin contraception when cleared by her healthcare provider. She lifts nothing heavier than her baby.
The nurse is caring for a client in labor who is receiving oxytocin. Which assessment finding requires immediate action? Urine output 75 mL in 2 hours Six contractions in 10 minutes Contraction duration 50-60 seconds Fetal heart rate 125 bpm with moderate variability
Six contractions in 10 minutes
Samantha is a primigravida (G1P0) seeking care at the area health clinic. She is scheduled for a cesarean section (C/S) for a transverse lie and expected cephalopelvic disproportion (CPD) due to her narrow pelvic outlet. The nurse would anticipate which of the following pain management options used for Samantha's cesarean section?
Spinal Anesthesia
The nurse is caring for a gravida 2, para 1 (G2P1) client, 41-weeks-pregnant, whose membranes ruptured prior to arrival at the hospital. The vaginal exam reveals no cord prolapse. Fetal heart rate is 120 bpm with moderate variability. Cervix is 8 cm dilated and 100% effaced. The current fetal station is +1. Which stage of labor should the nurse document? Stage 1, Transitional phase Stage 2 Stage 1, Active phase Stage 3
Stage 1, Transitional phase
The nurse is caring for a newborn one minute after delivery. Which is the best indication that the newborn is adjusting well to extrauterine life? Acrocyanosis Temperature 98.6ºF (37ºC) Minimal secretions Strong, vigorous cry
Strong, vigorous cry
Which nursing action is most critical when caring for the newborn immediately following birth? Assess axillary body temperature Suction the mouth and nares Assess for congenital anomalies
Suction the mouth and nares
Rachel reports pain and tenderness in her left calf. Her left foot is swollen and she says that the back of her left knee is warm and tender as well. What action should the nurse take at this time? Check her incision for infection Explain to Rachel that having a cesarean delivery has caused her leg pain and she will need to exercise more Assist Rachel to walk in the halls to help the leg pain Tell Rachel to sit down and alert the healthcare provider
Tell Rachel to sit down and alert the healthcare provider
What does the fetal heart rate and pattern indicate, particularly in response to uterine contractions? The fetus's position and presentation The fetus's condition Labor progression The mother's pain tolerance
The fetus's condition
What does uterine atony refer to? The complete loss of vascular perfusion to the uterus The loss of uterine muscle tone and strength The excessive shaking of the uterus following delivery The presence of excessive uterine muscle tone
The loss of uterine muscle tone and strength
Which of the following does the nurse need to consider when providing postpartum teaching to the mother? If the woman has already had a baby, she will not require as much postpartum teaching. The mother will be well rested and focused on the information after she's been able to nap. The mother may be discharged quickly, possibly as soon as 24 hours postpartum. If this is the woman's first baby, she will need to stay longer in the hospital and have more time for teaching.
The mother may be discharged quickly, possibly as soon as 24 hours postpartum.
What has likely occurred when a placenta is not delivered intact? The placenta has come apart in pieces and at least some of the pieces remain in the uterus. The placental tissue was weakened by disease. The placenta was accidentally cut during delivery. The placenta is much smaller than anticipated and pulled apart.
The placenta has come apart in pieces and at least some of the pieces remain in the uterus.
The nurse completing the BUBBLE-HEER postpartum assessment determines that the woman's patellar deep tendon reflexes are 1+. What does this finding indicate? May be a sign of preeclampsia The reflex assessment was inaccurate These are normal findings The reflexes are hyperactive
These are normal findings
The nurse is assessing the newborn's initial meconium stool. What characteristics should the nurse expect the stool to have? Select all that apply. Thick Malodorous Dark green Yellow Liquid Odorless
Thick Dark green Odorless
Why is it important for a client in labor to maintain an empty bladder? Select all that apply. To assess hydration status To ensure that fetal descent is not impaired To avoid delayed contraction frequency To protect the uterus from the pressure of the bladder To prevent damage to the bladder from uterine compression
To ensure that fetal descent is not impaired To prevent damage to the bladder from uterine compression
Which nursing actions encourage relaxation during the early stages of labor? Select all that apply. Turning on the television Dimming the lights Guided imagery Short puffing breaths Slow-paced breathing
Turning on the television Dimming the lights Guided imagery Slow-paced breathing
The nurse is caring for a gravida 4, para 3 (G4P3) client, 37-weeks-pregnant, who has come to the hospital because she believes her water has broken. How should the nurse verify if the wetness the client feels is urine or amniotic fluid? Use nitrazine paper to test the fluid at the bedside. Press downward on the fundus and observe for a fluid gush. Assess the color, consistency, and odor of the fluid. Complete a vaginal examination to assess for cervical dilation and effacement.
Use nitrazine paper to test the fluid at the bedside.
What does a decrease in the fetal heart rate after a contraction peaks indicate? Uteroplacental insufficiency causing a late deceleration A normal fetal heart rate pattern Fetal head compression causing an early deceleration Umbilical cord compression causing variable decelerations
Uteroplacental insufficiency causing a late deceleration
Which findings may indicate a deep vein thrombosis (DVT) in a lower extremity in a postpartum woman? Select all that apply. Bilateral redness Pedal edema Weak pedal pulse in the affected extremity Localized warmth Tenderness
Weak pedal pulse in the affected extremity Localized warmth Tenderness
The nurse is assisting a new mother to ambulate for the first time after delivery. Which questions should the nurse address to determine if the woman is ready to walk? Select all that apply. Is her blood pressure elevated? What was the estimated blood loss at delivery? Is her blood pressure low? Following an epidural, has the feeling returned to her lower extremities?
What was the estimated blood loss at delivery? Is her blood pressure low? Following an epidural, has the feeling returned to her lower extremities?
The nurse is caring for a client who is breastfeeding. Which assessment findings indicate to the nurse that the client is experiencing normal physiological responses related to breastfeeding? Select all that apply. The client has a slight fever and a headache. When the client takes a warm shower, milk leaks from the breasts. After breastfeeding, the client feels lightheaded. The client feels uterine cramping and experiences a flow of lochia. When the newborn cries, the client feels a warm sensation in the breasts.
When the client takes a warm shower, milk leaks from the breasts. The client feels uterine cramping and experiences a flow of lochia. When the newborn cries, the client feels a warm sensation in the breasts.
Which pre-operative teaching topics should be provided to Samantha prior to scheduling a cesarean section (C/S)? Select all that apply. When to stop eating or drinking before surgery Who can be with her in the operating room Importance of staying hydrated and fed immediately before arriving to the hospital for the surgery Situations in which she will need to have an intravenous line The use of a bed pan during surgery Medication verifications
When to stop eating or drinking before surgery Who can be with her in the operating room Medication verifications
The nurse weighs a newborn who is 40 weeks gestation and obtains a measurement of 8 pounds, 11 ounces. Which reflects how the nurse will describe this measurement? Lower than normal for a term neonate Higher than normal weight for a term neonate Lower than normal weight for a post-term neonate Within normal range for a term neonate
Within normal range for a term neonate
The indwelling urinary catheter is usually placed ______ spinal anesthesia, so that ________________
after, it is more comfortable for the client
The nurse notes that a woman who is 36 hours postpartum following a vaginal delivery has saturated a peri pad with lochia rubra 15 minutes after it was replaced. How will the nurse categorize this amount of lochia? heavy normal excessive moderate
excessive
A nurse is caring for a G6P5 woman in labor who is attempting a vaginal birth after cesarean. The nurse is assessing the woman's contraction pattern. Which of these contraction patterns is the most concerning to the nurse? in 30 minutes: 10 contractions, lasting 30-45 seconds each, 2 minutes between contractions in 30 minutes, 12 contractions, lasting 60 seconds each, 90 seconds between contractions in 30 minutes: 5 contractions, lasting 30 seconds each, 2 minutes in between contractions in 30 minutes: 16 contractions, lasting 2 minutes each, 45 seconds between contractions
in 30 minutes: 16 contractions, lasting 2 minutes each, 45 seconds between contractions
The _______ process of the fetal skull is the most rounded and smooth surface of the fetal head and is best for fitting through the pelvis and dilating the cervix.
occiput
The nurse is caring for a woman in labor who is complaining of low back pain and pressure despite having an epidural. Which of the following cephalic positions might the nurse anticipate the fetus is in, requiring a hands and knees position to rotate the fetus into the correct position? occiput anterior occiput interior occiput posterior occiput transverse
occiput posterior
A woman who is 35 weeks gestation says that she has a urinary tract infection and feels urine leaking. Which of the following does the nurse suspect is the most likely cause of this leak? preterm premature rupture of membranes prolonged premature rupture of membranes prolonged rupture of membranes premature rupture of membranes
preterm premature rupture of membranes
The _________and _______of the woman's pelvis determine the ease with which the fetal head can pass through for vaginal delivery to occur.
size, shape
The nurse is caring for a client who is 1 hour post vaginal delivery. Which findings would make the nurse consider postpartum hemorrhage as a potential complication? Select all that apply. uterine fundus difficult to locate fundus located 2 cm above the umbilicus fundus firm at the umbillicus moderate bleeding with small clots uterus is firm when massaged but quickly loses tone
uterine fundus difficult to locate fundus located 2 cm above the umbilicus uterus is firm when massaged but quickly loses tone
