NUR 318 Day 2 Practice Questions
When determining the frequency of contractions, the nurse would measure which of the following? A. Start of one contraction to the start of the next contraction B. Beginning of one contraction to the end of the same contraction C. Peak of one contraction to the peak of the next contraction D. End of one contraction to the beginning of the next contraction
A
On the fetal heart monitor, the nurse notices an elevation of the fetal baseline with the onset of contractions. This elevation would describe _____________.
Acceleration—elevation of FHR above the baseline; a category I pattern, which is normal.
The cardinal movements of labor include which of the following? Select all that apply. A. Extension and rotation B. Descent and engagement C. Presentation and position D. Attitude and lie E. Flexion and expulsion
Answers A, B, and E are correct. The cardinal movements of labor by the fetus include engagement, descent, flexion, international rotation, extension, external rotation, and expulsion only. The other choices describe the various fetal positions.
1. Cindy, a 20-year-old primipara, calls the birthing center where you work as a nurse and reports that she thinks she is in labor because she feels labor pains. Her due date is this week. The midwives have been giving her prenatal care throughout this pregnancy. a. What additional information do you need to respond appropriately?
Ask about the frequency and duration of her contractions. Ask about how long she has experienced "labor pains." Ask about any other signs she may have experienced such as bloody show, lightening, backache, ruptured membranes, and so forth. Ask if walking tends to increase or decrease the intensity of contractions. Ask her when she last felt fetal movement. Ask her how far away (distance) she is from the birthing center. Ask her if she has a support person in the home with her.
b. What additional newborn instruction might be appropriate at this time?
At this time, it might be appropriate for the nurse to unwrap the newborn and complete a thorough bedside assessment, pointing out any minor deviations to the mother and explaining their significance. This will allay any future anxiety about her newborn and will afford the opportunity to instruct Ms. Scott on various physiologic and behavioral adaptations present in her daughter.
2. The woman activates her call light and states, "I feel increased wetness down below." a. What might be occurring?
Based on Marsha's description, the nurse might suspect spontaneous rupture of membranes.
The nurse performs a physical examination on a newborn 2 hours after birth. Which of the following findings indicate a need for a pediatric consultation? Select all that apply: A. Respiratory rate of 50 breaths per minute B. Intermittent episodes of apnea, lasting <10 seconds each C. Absent Moro reflex when startled D. Preauricular skin tag noted on left ear E. White raised bumps noted on nose and face F. Yellow blanching of the skin when pressure applied to the nose
C and F
A nursing student questions the nursery nurse why they don't bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of: A. Jaundice B. Infection C. Hypothermia D. Anemia
C.
b. What explanation can you offer Carrie's partner regarding her change in behavior?
Explain to her partner that she is in the transition phase of the first stage of labor and that her behavior is typical, since she is having hard contractions frequently. Reassure him not to take Carrie's comments personally, but to stay and be supportive to her.
b. How can the nurse address client's anxiety?
Give her, in an easily understood manner, facts about dysfunctional labor. Outline expected treatment and outcome. Encourage questions and expression of feelings. Identify how this dysfunctional labor pattern may alter her labor plan. Reassure Marsha about the status of her fetus. Maintain a positive attitude about her ability to cope with this situation.
d. What other premonitory signs of labor might the nurse ask about?
Has she experienced the feeling of the fetus dropping (lightening) lower down? Has her energy level changed (increased) in the last day or so? Has she noticed any reddish discharge (bloody show) from her vagina? Has she had any episodes of diarrhea within the last 48 hours? Has her "bag of waters" broken or does she feel any leakage?
An African-American mother who delivered her first baby and is on the mother-baby unit, calls the nursery nurse into her room and expresses concern about how her daughter looks. The mother tells the nurse that her baby's head looks like a "banana" and is mushy to the touch, and she has "white spots" all over her nose. In addition, there appear to be "big bluish bruises" all over her baby's buttocks. She wants to know what is wrong with her baby and whether these problems will go away. a. How should the nurse respond to this mother's questions?
In a calm manner, explain to Ms. Scott that all her observations are normal variations and address each one separately: • "Banana-shaped head"—is molding where the newborn had a slight overriding of the skull bones to navigate the bony pelvis and birth canal during the birth process • "Mushy" feel to head—caput succedaneum, which is an edematous area of the scalp as a result of sustained pressure of the occiput against the cervix during labor and birth process • "White spots on nose"—milia, which are plugged, distended, small, white sebaceous glands that are present in most newborns and should not be squeezed by the mother • "Blue bruises on buttocks"—Mongolian spots, which are bluish-black areas of pigmentation that are common in African Americans and have no clinical significance, but can be mistaken for bruises
c. What instructions need to be given to guide her decision making?
Instruct her on how to time the frequency and duration of contractions. Wait until contractions are 5 minutes apart or her membranes rupture to come to the birthing center. Tell her to come to the birthing center when she cannot talk during a contraction. Reinforce all instructions with her support partner.
As the nurse manager, you have been orienting a new nurse in the nursery for the past few weeks. Although she has been demonstrating adequacy with most procedures, today you observe her bathing several newborns without covering them, weighing them on the scale without a cover, leaving the storage door open with the transporter nearby, and leaving the newborns' head covers and blankets off after showing them to family members through the nursery observation window. a. What is your impression of this behavior?
It is evident the new nurse's behaviors demonstrate a lack of awareness or knowledge about thermoregulation in newborns. Reinforcement of these principles is needed. Perhaps she needs to be reminded of newborns' inability to keep themselves warm as a result of a variety of factors, or perhaps she may feel overwhelmed with caring for more than one newborn at a time. An in-service for all nursery personnel might be a good reinforcement of this concept.
c. What can hospitals do to prevent infant abduction?
Keys to infant security are awareness and education. The hospital staff should attend annual in-services on these measures and participate in a mock infant abduction drill to heighten awareness of infant security. Specially color-coded staff badges should be worn by all obstetrics staff, and parents should be instructed not to give their newborn to anyone without that specific color badge. Parents' wristbands should match the infant's ankle and wristbands. Everyone must work together to keep all infants safe.
Outline the fetal and maternal risks associated with a prolonged pregnancy.
Maternal/fetal risks associated with a prolonged pregnancy include maternal exhaustion, psychological depression, macrosomia, dysmaturity syndrome, fetal hypoxia, meconium aspiration syndrome, hypoglycemia, and stillbirth.
c. What reassurance can be given to this new mother regarding her daughter's appearance?
One can assume that this mother's concern is that these various normal deviations might be permanent. The nurse can identify each and provide reassurance about their approximate time of disappearance: • Molding—transient in nature and should disappear within 72 hours • Caput succedaneum—disappears spontaneously within 3 to 4 days • Milia—will clear up spontaneously within the first month • Mongolian spots—will gradually fade during the first or second year
A 20-year-old primigravida at term, comes to the birthing center in active labor (dilation 5 cm and 80% effaced, -1 station) with ruptured membranes. She states she wants an "all-natural" birth without medication. Her partner is with her and appears anxious but supportive. On the admission assessment, this client's prenatal history is unremarkable; vital signs are within normal limits; FHR via Doppler ranges between 140 and 144 bpm and is regular. a. Based on your assessment data and the woman's request not to have medication, what nonpharmacologic interventions could you offer her?
Progressive relaxation techniques of locating, then releasing tension from one muscle group at a time until the entire body is relaxed • Visual imagery such as taking a journey in the woman's mind to a relaxing place that is far away from the discomfort of labor • Music to bring about a calming effect as well as a distraction or attention focusing to divert attention away from the laboring process; focusing on sound or rhythm helps release tension and promote relaxation • Massage/acupressure to enhance relaxation, improve circulation, and reduce pain in labor; counterpressure on the lower back to help relieve back pain • Breathing techniques for effective attention-focusing strategies to enhance coping mechanisms during labor
A 26-year-old multipara, is admitted to the labor and birth suite in active labor. After a few hours, the nurse notices a change in her contraction pattern—poor contraction intensity and no progression of cervical dilatation beyond 5 cm. The client keeps asking about her labor progress and appears anxious about "how long this labor is taking." a. Based on the nurse's findings, what might you suspect is going on?
Since Marsha is multiparous and is in the active phase of labor without progression and the contraction pattern has become less intense, a hypotonic uterine dysfunction should be suspected.
b. What suggestions/recommendations would you make to her?
Stay in the comfort of her home environment as long as possible. Advise her to walk as much as possible to see what effect it has on the contractions. Also, tell her to drink fluids to hydrate herself. Review nonpharmacologic comfort measures she can try at home. Tell her to keep in contact with the birthing center staff regarding her experience.
At approximately 12:30 AM on a Friday, a woman enters a hospital through a busy emergency department. She is wearing a white uniform and a lab coat with a stethoscope around her neck. She identifies herself as a new nurse coming back to check on something she had left on the unit on an earlier shift. She enters a postpartum client's room containing the mother's newborn, pushes the open crib down a hallway, and escapes through an exit. The security cameras aren't working. The infant isn't discovered missing until the 2 AM check by the nurse. a. What impact does an infant abduction have on the family and the hospital?
The abduction of an infant is a devastating event that poses significant emotional, legal, and financial risks to both the family and the hospital. The sudden, unexpected loss of an infant followed by an indefinite period of uncertainty concerning the child's well-being places the traumatized family in crisis. The hospital typically will change its security systems, policies, and procedures; heighten supervision; and increase accountability for all staff.
c. How will you evaluate whether your instructions have been effective?
The effectiveness of the in-service can be evaluated by observing the behavior of the staff while caring for the newborns. Hopefully, the principles reinforced during the discussion will be applied in the handling of the newborns. For the new nurse, it would be important to observe the nurse covering the newborn when bathing, placing a warmed blanket on the scale prior to weighing, closing hallway doors to prevent drafts, and keeping a cap on the newborn's head when showing him or her to the parents. In addition, the nurse should verbalize why she is performing all these actions.
b. What principles concerning thermoregulation need to be reinforced?
The nurse is subjecting the newborn to heat loss by all four methods—evaporation (bathing), radiation (leaving door open), convection (cap off), and conduction (weighing). Newborns are unable to conserve body heat and experience heat loss through four mechanisms: conduction, convection, evaporation, and radiation. Placing newborns on cold surfaces without any protection (such as a blanket or cover) will cause them to lose body heat via conduction. By exposing them while wet, such as during bathing, heat is lost through evaporation. Leaving the storage room open permits cool air flow over the newborn, allowing heat loss by convection. Placing the infant transporter near cold rooms allows for transfer of neonatal body heat via radiation.
During clinical post-conference, share with the other nursing students how the critical forces of labor influenced the length of labor and the birthing process for a laboring woman assigned to you.
This discussion should involve the passenger, powers, passageway, position, and psychological response of the student's assigned women going through labor and how each affected the length and stages of labor.
c. What are the appropriate interventions to change this labor pattern?
Typically some form of labor augmentation is initiated to produce more effective contractions to facilitate cervical dilatation—rupture of membranes or use of IV oxytocin to stimulate the intensity of contractions. If neither one of these interventions changes the hypotonic pattern, a surgical birth is in order.
What positions might be suggested to facilitate fetal descent?
Upright positions such as walking, swaying, slow-dancing with her partner, or leaning over a birthing ball will all enhance comfort and use the force of gravity to facilitate fetal descent. • Kneeling and leaning forward will help relieve back pain. • Pelvic rocking on hands and knees and lunging with one foot elevated on a chair may help with internal fetal rotation and speed a slow labor.
An abnormal or difficult labor describes
dystocia
The most common mechanism of heat loss in the newborn is ___________________.
evaporation
c. What interventions are appropriate for this finding?
• Obtain a baseline set of vital signs to assess FHR patterns for changes possibly indicating a prolapsed umbilical cord. • Use Nitrazine paper to test for the presence of amniotic fluid: it will turn blue in the presence of amniotic fluid because it is alkaline. • Examine a sample of fluid from the vagina under the microscope for a fern pattern once it dries.
The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? A. Increase surfactant levels B. Stabilize the newborn's temperature C. Destroy Rh-negative antibodies D. Oxidize bilirubin on the skin
D.
The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: A. Stimulate uterine contractions B. Numb cervical pain receptors C. Prevent cervical lacerations D. Soften and efface the cervix
D.
A laboring woman is admitted to the labor and birth suite at 6 cm dilation. She would be in which phase of the first stage of labor? A. Latent B. Active C. Transition D. Early
B.
Interventions that are underutilized in promoting a normal birth. Select all that apply. A. Oral nutrition and fluids in labor B. Open glottis pushing in the second stage of labor C. Skin-to-skin contact after birth for infant bonding D. Routine artificial rupture of membranes (amniotomy) E. Labor induction with Pitocin given intravenously F. Routine episiotomy to shorten labor length
A, B, C
A nurse observes a 3-day-old term newborn that is starting to appear mildly jaundiced. What might explain this condition? A. Physiologic jaundice secondary to breast-feeding B. Hemolytic disease of the newborn due to blood incompatibility C. Exposing the newborn to high levels of oxygen D. Overfeeding the newborn with too much glucose water
A.
A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? A. Gonorrhea and chlamydia B. Thrush and enterobacter C. Staphylococcus and syphilis D. Hepatitis B and herpes
A.
After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have: A. Intense back pain B. Frequent leg cramps C. Nausea and vomiting D. A precipitous birth
A.
After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? A. Foramen ovale B. Ductus arteriosus C. Ductus venosus D. Umbilical vein
A.
When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: A. 15 to 30 minutes B. 5 to 10 minutes C. 45 to 60 minutes D. 60 to 75 minutes
A.
Which of the following findings in a newborn would be considered normal? A. Passage of meconium within the first 24 hours B. Respiratory rate of 80 breaths per minute C. Yellow skin tones at 10 hours after birth D. Bleeding from the umbilicus area
A.
Which of the following practices would not be included in a physiologic birth? A. Early induction of labor <39 weeks' gestation B. Freedom of movement for the laboring woman C. Continuous presence and support throughout labor D. Encouraging spontaneous pushing when urge felt
A.
As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: A. Discomfort level is greater with false labor. B. Progressive cervical changes occur in true labor. C. There is a feeling of nausea with false labor. D. There is more fetal movement with true labor.
B.
During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? A. Moderate amount of dark red lochia drainage on peripad B. Uterine fundus palpated to the right of the umbilicus C. An oral temperature reading of 100.6°F D. Perineal area bruised and edematous beneath her ice pack
B.
The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to promote: A. Conjugation of bilirubin B. Blood clotting C. Foreman ovale closure D. Digestion of complex proteins
B.
The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: A. Encourage ambulation every 30 minutes B. Provide pain relief measures C. Monitor the Pitocin infusion rate closely D. Prepare the woman for an amniotomy
B.
The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor? A. Hepatitis B. Herpes simplex virus C. Toxoplasmosis D. Human papillomavirus
B.
When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: A. Initial period of reactivity B. Second period of reactivity C. Decreased responsiveness period D. Sleep period for newborns
B.
Which fetal lie is most conducive to a spontaneous vaginal birth? A. Transverse B. Longitudinal C. Perpendicular D. Oblique
B.
A client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: A. Hypertonic labor B. Precipitate labor C. Hypotonic labor D. Dysfunctional labor
C.
By the end of the second stage of labor, the nurse would expect which of the following events? The A. cervix is fully dilated and effaced B. placenta is detached and expelled C. fetus is born and on mother's chest D. woman to request pain medication
C.
Physiologic preparation for labor would be demonstrated by: A. Decrease in Braxton Hicks contractions felt by mother B. Weight gain and increase in appetite by mother C. Lightening, whereby the fetus drops into true pelvis D. Fetal heart rate accelerations and increased movements
C.
The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of: A. Respiratory distress syndrome B. Bottle mouth syndrome C. Sudden infant death syndrome D. GI regurgitation syndrome
C.
The nurse is developing a plan of care for a woman experiencing dystocia. Which of the following nursing interventions would be the nurse's high priority? A. Changing the woman's position frequently B. Providing comfort measures to the woman C. Monitoring the fetal heart rate patterns D. Keeping the couple informed of the labor progress
C.
The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? A. Reposition the client on the left side. B. Begin 100% oxygen via face mask. C. Document this as indicating a normal pattern. D. Call the health care provider immediately.
C.
The shortest but most intense phase of labor is the: A. Latent phase B. Active phase C. Transition phase D. Placental expulsion phase
C.
When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate: A. Abnormal gastrointestinal newborn transition and needs to be reported B. An intestinal anomaly that needs immediate surgery C. A patent anus with no bowel obstruction and normal peristalsis D. A malabsorption syndrome resulting in fatty stools
C.
When managing a client's pain during labor, nurses should: A. Make sure the agents given do not prolong labor B. Know that all pain relief measures are similar C. Support the client's decisions and requests D. Not recommend nonpharmacologic methods
C.
Which assessment would indicate that a woman is in true labor? A. Membranes are ruptured and fluid is clear. B. Presenting part is engaged and not floating. C. Cervix is 4 cm dilated, 90% effaced. D. Contractions last 30 seconds, every 5 to 10 minutes.
C.
Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? A. Hypothyroidism B. Cystic fibrosis C. Phenylketonuria D. Sickle cell disease
C.
Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? A. Two soft spots palpated between the cranial bones B. A spongy area of edema outlined on the head C. Head circumference 32 cm, chest 34 cm D. Asymmetry of the head with overriding bones
C.
Which of the following observations would suggest that placental separation is occurring? A. Uterus stops contracting altogether. B. Umbilical cord pulsations stop. C. Uterine shape changes to globular. D. Maternal blood pressure drops.
C.
After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? A. Transporting the newborn in an isolette B. Maintaining a warm room temperature C. Placing the newborn on a warmed surface D. Drying the newborn immediately after birth
D.
At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as: A. 5 points B. 6 points C. 7 points D. 8 points
D.
Because the newborn's red blood cells break down much sooner than those of an adult, what might result? A. Anemia B. Bruising C. Apnea D. Jaundice
D.
When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? A. Hold your breath and push through entire contraction. B. Use chest-breathing with the contraction. C. Pant and blow during each contraction. D. Wait until you feel the urge to push.
D.
When assessing the following women, which would the nurse identify as being at the greatest risk for preterm labor? A. Woman who had twins in a previous pregnancy B. Client living in a large city close to the subway C. Woman working full time as a computer programmer D. Client with a history of a previous preterm birth
D.
When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as: A. Cervical insufficiency B. Contracted pelvis C. Maternal disproportion D. Fetopelvic disproportion
D.
Which of the following newborns could be described as breathing normally? A. Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm. B. Newborn B is breathing diaphragmatically with sternal retractions, at a rate of 70 bpm. C. Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis. D. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.
D.
Which one of the following immunizations is most commonly received by newborns before hospital discharge? A. Pneumococcus B. Varicella C. Hepatitis A D. Hepatitis B
D.
b. How will the nurse confirm the suspicions?
Depending on the agency protocol, the nurse may perform or assist with a sterile speculum examination to observe for evidence of fluid pooling in the posterior vagina, any discharge present, inflammation or lesions, or protrusion of the membranes through the cervix. The nurse should also document the amount, color, and consistency of any fluid found during the examination.
2. Several hours later, the client complains of nausea and turns to her partner and angrily tells him to not touch her and to go away. a. What assessment needs to be done to determine what is happening?
The nurse should perform a vaginal examination to validate that Carrie is in the transition phase (8 to 10 cm dilated).
b. What security measure was the weak link in the chain of security?
The woman was able to pass into the hospital via the emergency room posing as a "nurse" without anyone checking her name tag. The security cameras were not working at the time of the abduction. This allowed the abductor to pass down the hall with the infant unnoticed and unrecorded. The nurses on the unit were unaware of this woman on their unit, which should not happen. There should be an alarm on the doors leading into the unit and the doors should remain locked and only be opened electronically by a staff member on the unit after the person has been identified. There was truly a breakdown of several security measures in this scenario.
e. What manifestations would be found if Cindy is experiencing true labor?
There would be progressive dilation and effacement of her cervix if true labor is occurring. Contraction pain also would not be relieved with walking, and the pain would start in the back and radiate around toward the front of the abdomen. Contractions also would occur regularly, becoming closer together, usually 4 to 6 minutes apart, and last 30 to 60 seconds. If she is experiencing false labor, slight effacement might be present, but not dilation.
The newborn creates heat in three ways—shivering, muscle activity and through thermogenesis by the metabolism of brown adipose tissue. Which is the most effective?
Thermogenesis is the most effective way to produce warmth for the newborn by increasing cellular metabolic rate in skeletal muscle and brown fat, thereby increasing heat production. Brown fat, also called brown adipose tissue is a special kind of highly vascular fat in newborns with an ample supply of blood vessels that can generate heat. Shivering and muscle activity by moving are both ineffective methods to generate heat production.
The most important adaptations for the newborn to make after birth are to establish respirations, make cardiovascular adjustments, and establish thermoregulation. Nursing care focuses on monitoring and supporting adjustments to extrauterine adaptation. Write appropriate nursing interventions to help achieve the following newborn adaptations: a. Respiratory adaptation
a. Suction the mouth and then the nose to remove any mucus. Stimulate crying by drying the newborn immediately after birth. Assess respiratory effort to validate that it is within normal parameters. Observe for signs of respiratory distress. Auscultate chest for gas for normal gas exchange.
b. Safety, including prevention of infection
b. Safety measures include matching identification bracelets for mother and infant; footprinting the newborn and thumbprinting the mother for identification purposes as well as prevention of abduction; handling the newborn with both hands securely to prevent dropping; positioning the newborn on his or her back to sleep; frequent handwashing when handling all newborns.
c. Thermoregulation
c. Provide warmth by placing a hat on the newborn's head to prevent heat loss through the scalp. Take and record the newborn's axillary temperature frequently to monitor thermoregulation. Keep the newborn away from drafts and wrap in a blanket to keep warm or place under a radiant heater. After temperature stabilizes, bathe the newborn.