NURS 326 Exam #2

Which test can the nurse anticipate will be ordered for the patient? Select all that apply. A. Contraction stress test. B. Amniocentesis for genetic testing C. Non stress test D. Ultrasound

B and D

A client has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse s plan of care after the procedure? (Select all that apply.) a. Observe the client for possible uterine contractions. b. Perform a minicatheterization to obtain a urine specimen to assess for bleeding. c. Perform ultrasound to determine fetal positioning. d. Administer RhoGAM to the client if she is Rh negative.

a and d

A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? Select all that apply. a. Decreased fetal movement b. Intrauterine growth restriction (IUGR) c. Postmaturity d. Placenta previa e. Amniotic fluid emboli

a, b, and c

A nurse is caring for a client in a active labor. The cervix is dilated 5 cm & membranes are intact. Based on external fetal monitoring, the FHR is 115 to 125/min with occasional increased up to 150 - 155/min that lasts 25 seconds with moderate variability. There is no slowing of the FHR from baseline. The client is exhibiting manifestations of which of the following? Select all that apply. a. Moderate variability b. FHR accelerations c. FHR decelerations d. Normal baseline FHR e. Fetal tachycardia

a, b, and d

A nurse is monitoring an obstetric client who is in early labor. Which of the following findings would be a cause for concern if observed by the nurse? (Select all that apply.) a. Android pelvis b. Biparietal diameter of less than 9.25 cm c. Vertex presenting part d. General flexion attitude e. Transverse lie

a, b, and e

A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? Select all that apply. a. Lengthening of the umbilical cord b. Swift gush of clear amniotic fluid c. Softening of the lower uterine segment d. Appearance of dark blood from the vagina e. Fundus firm upon palpation

a, d, and e

A patient is 27 weeks pregnant and is experiencing some mild uterine contractions. What actions should they take? Select all that apply. a. Void immediately b. Call their provider immediately c. Relax in a chair d. Drink 2 to 3 glasses of water or juice e. Palpate their uterus for 1 hour f. Resume the activity they were doing if the cramping subsides

a, d, and e

A nurse is reviewing the onset of labor. Which sign should the nurse identfy as not preceding the onset of labor? a. A decline in energy, as the body stores up for labor b. Stronger and more frequent uterine (Braxton Hicks) contractions c. A return of urinary frequency as a result of increased bladder pressure d. Persistent low backache from relaxed pelvic joints

a. A decline in energy, as the body stores up for labor

A nurse is working with a client in labor. Which of the following should the nurse not include in the plan of care? a. Administer antibiotics b. Observe for bloody, or pink, show c. To monitor the onset of progressive, regular contractions d. Assess for spontaneous rupture of membranes

a. Administer antibiotics

A nurse is reviewing the characteristics of uterine contractions. Which option should the nurse indicate as not being a characteristic? a. Appearance (shape and height) b. Frequency (how often contractions occur) c. Intensity (the strength of the contraction at its peak) d. Resting tone (the tension in the uterine muscle)

a. Appearance (shape and height)

The nurse is monitoring a client in labor who is experiencing back labor and complains of intense pain in her lower back. Which relief measure should the nurse implement? a. Apply counterpressure against the sacrum. b. Effleurage. c. Biofeedback. d. Encourage pant-blow (breaths and puffs) breathing techniques.

a. Apply counterpressure against the sacrum. Rationale: Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory.Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain but it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain.

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? a. Assist the client into the left-lateral position b. Apply a fetal scalp electrode c. Insert an IV catheter d. Perform a vaginal exam

a. Assist the client into the left-lateral position Rationale: The first action should be to increase circulation to the fetus

A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes the client is actively bleeding. Which of the following medications should the nurse expect the provider will describe? a. Betamethasone b. Indomethacin c. Nifedipine d. Methylergonovine

a. Betamethasone Rationale: To promote lung disease since delivery may be anticipated.

A nurse caring for a pregnant patient suspected of being in preterm labor recognizes which sign as diagnostic of preterm labor? a. Cervical dilation of at least 2 cm b. Uterine contractions occurring every 15 minutes. c. Spontaneous rupture of membranes d. Presence of fetal fibronectin in cervical secretions.

a. Cervical dilation of at least 2 cm

A nurse is preparing to perform a vaginal exam on a client in labor. Which principle should guide the nurse's action? a. Cleanse the vulva and perineum before and after the examination as needed. b. Perform the examination every hour during the active phase of the first stage of labor. c. Perform an examination immediately if active bleeding is present. d. Wear a clean glove lubricated with tap water to reduce discomfort.

a. Cleanse the vulva and perineum before and after the examination as needed. Rationale: Cleansing will reduce the possibility that secretions and microorganisms will ascend into the vagina to the cervix. Maternal comfort will also be enhanced. Sterile gloves and lubricant must be used to prevent infection. Vaginal examinations should be performed only as indicated to limit maternal discomfort and reduce the risk for transmission of infection, especially when rupture of membranes occurs. Examinations are never done by the nurse if vaginal bleeding is present, because the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

Upon examination, it is noted that a full term primapara in active labor is ROA, 7cm dilated, and +3 station. Which of the following should the nurse report to the provider? a. Descent is progressing well. b. Fetal head is not yet engaged. c. Vaginal delivery is imminent. d. External rotation is complete.

a. Descent is progressing well.

A group of nurses are reviewing Category Characteristics of Fetal Monitoring. Which finding should the nurses identify as being representative of Category I ? a. Early decelerations, either present or absent. b. Bradycardia not accompanied by baseline variability. c. Tachycardia. d. Sinusoidal pattern.

a. Early decelerations, either present or absent.

A nurse is reviewing concepts relative to fetal circulation. Which factor should the nurse identify as not affecting fetal circulation during labor? a. Fetal position b. Uterine contractions c. Blood pressure d. Umbilical cord blood flow

a. Fetal position Rationale: Maternal position may affect fetal circulation; however, fetal position is unlikely to disturb umbilical blood flow.

A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station with a FHR around 140/min. Which of the following phases of labor is the client experiencing? a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage of labor

a. First stage, latent phase

A pregnant patient's labor is being induced. The nurse assesses the patient's status and that of the fetus and the labor process just before an increase in the Pitocin (Oxytocin) infusion of 2 milliunits/minute. The nurse discontinues the infusion and notifies the primary health care provider if during this assessment the nurse notes: a. Frequency of uterine contractions: every 1 1/2 minutes b. Variability of the fetal heart rate (FHR): present c. Deceleration pattern: early decelerations noted with several contractions. d. Intensity of uterine contractions at their peaks: 80 to 85 mmHg

a. Frequency of uterine contractions: every 1 1/2 minutes

Which of the following choices includes the correct order of the cardinal movements of labor? a. Internal rotation, extension, external rotation b. External rotation ,descent, extension c. Extension, flexion, internal rotation d. External rotation, internal rotation, expulsion

a. Internal rotation, extension, external rotation

A patient's labor is being suppressed using IV magnesium sulfate. Which measure should be implemented during the infusion? a. Limit IV fluid intake to 125ml/hour b. Discontinue infusion if maternal respirations are less than 14 breaths/minute c. Ensure that Indomethacin is available should toxcity occur. d. Assist the patient to maintain a comfortable semi fowler's position.

a. Limit IV fluid intake to 125ml/hour

The nurse should tell a primigravida that the definitive sign indicating labor has begun would be: a. Progressive uterine contractions. b. Lightening. c. Rupture of membranes. d. Passage of the mucus plug

a. Progressive uterine contractions.

A nurse is caring for a patient in the second stage of labor. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? a. Pudendal b. Epidural c. Spinal d. Paracervical

a. Pudendal

A group of nurses are discussing the concept of pain experience during labor. Which statement should the nurses identify as correct? a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding would indicate to the nurse that preterm labor is occurring? a. The cervix is effacing and dilated to 2 cm. b. Fetal fibronectin is present in vaginal secretions. c. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. d. Estriol is not found in maternal saliva.

a. The cervix is effacing and dilated to 2 cm.

A nurse is taking care of a client in the third stage of labor. Which statement should the nurse identify as correct? a. The duration of the third stage may be as short as 3 to 5 minutes. b. The major risk for women during the third stage is a rapid heart rate. c. The placenta eventually detaches itself from a flaccid uterus. d. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface.

a. The duration of the third stage may be as short as 3 to 5 minutes. Rationale: The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage

On completion of a vaginal examination of a laboring patient, the nurse records the following: 50% effacement, 6 cm dilation, -1 station. What is a correct interpretation of this data? a. The fetal presenting part is 1 cm above the ischial spines. b. Effacement is 4 cm from completion. c. Dilation is 50% completed. d. The fetus has achieved passage through the ischial spines

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

A nurse is working on the labor and delivery unit. Under which circumstance would a nurse not perform a vaginal examination on a client in labor? a. When accelerations of the fetal heart rate (FHR) are noted b. An admission to the hospital at the start of labor c. When membranes rupture d. On maternal perception of perineal pressure or the urge to bear down

a. When accelerations of the fetal heart rate (FHR) are noted Rationale: An accelerated FHR is a positive sign not requiring vaginal examination; variable decelerations, however, merit a vaginal examination.

A pregnant patient, 37 years old presents to the perinatal testing unit. The OB history is as follows: gravida 3 Para 2, LMP March 17th. Their first prenatal visit was on July 3 at which time the fundal height was at the umbilicus. Fetal heart tones were audible by doppler ultrasound. The patient denies feeling any fetal movement.Which of the following high-risk factors apply to the patient's pregnancy and care?Select all that apply. a. Fetal cardiac anomaly b. Advanced maternal age c. Fundal height greater than dates d. Intrauterine growth restriction e. Decreased fetal movement

b and c

A nurse is providing instruction for an obstetrical client to perform a daily fetal movement count (DFMC). Which instructions should the nurse include in the plan of care? (Select all that apply.) a. The fetal alarm signal is reached when there are no fetal movements noted for 5 hours. b. Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted. c. Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted. d. The client can monitor fetal activity once daily for a 60-minute period and note activity.

b, c, and d Rationale: The primary focus is to establish a pattern of at least 10 movements. Fewer than 3 movements in an hour would warrant further investigation.

A nurse is providing care for a client who has abruptio placentae. Which of the following findings are risk factors for developing the condition? Select all that apply. a. Fetal position b. Blunt abdominal trauma c. Cocaine use d. Maternal age e. Cigarette smoking

b, c, and e

A nurse is reviewing findings of a client's Biophysical Profile. The nurse should expect which of the following variables to be included in this test? Select all that apply a. Fetal weight b. Fetal breathing movements c. Fetal tone d. Fetal position e. Amniotic fluid volume

b, c, and e

The patient's fundal height measures at the umbilicus despite being 15 weeks pregnant. Which of the following conditions could be associated with a fundal height greater than expected for 15 weeks? a. Oligohydramnious b. Polyhydramnious c. Twins d. Uterine fibroids e. Inaccurate date of LMP f. Hypertension

b, c, d, and e

When assessing a pregnant patient, the nurse is alert for factors associated with preterm labor. Which factor, if exhibited by this patient, increases their risk for spontaneous preterm labor and birth? (Circle all that apply). a. Caucasian race b. Obstetric history of gravida 3, Para -0-2-0-1 c. History of bleeding at 20 weeks d. Currently being treated for second bladder infection in 2 months. e. Employed as a nurse in a trauma intensive care unit. f. Body mass index of (BMI) of 22

b, c, d, and e (why b??)

A nurse is caring for a client who had a previous cesarian section and now presents with a transverse presentation in labor. Which information should the nurse provide to the client? a. "Because this is a repeat procedure, you are at the lowest risk for complications." b. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." c. "You will not need preoperative teaching because this is your second cesarean birth." d. "Because this is your second cesarean birth, you will recover faster."

b. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures."

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: a. Rupture of the client's amniotic membranes. b. A fetal heart rate (FHR) of 180 with absence of variability. c. Uterine contractions occurring every 8 to 10 minutes. d. The client needing to void.

b. A fetal heart rate (FHR) of 180 with absence of variability. Rationale: A fetal heart rate (FHR) of 180 with absence of variability is nonreassuring; the oxytocin should be immediately discontinued and the physician should be notified. The oxytocin should also be discontinued if uterine hyperstimulation occurs.

A nurse is reviewing the clinical diagnosis of ectopic pregnancy. Which location should the nurse identify as being the most common location for this occurrence? a. Fimbriae. b. Ampulla. c. Uterine fundus. d. Cervical os.

b. Ampulla.

A nurse is caring for a client who is 40 weeks gestation and reports a large gush of fluid from the vagina while walking to the bathroom. Which of the following actions should the nurse take first? a. Examine the amniotic fluid for meconium b. Check the FHR c. Dry the client & make them comfortable d. Apply a tocotransducer

b. Check the FHR

Which characteristic is associated with false contractions? a. Painful. b. Decrease intensity with ambulation. c. Regular pattern of frequency established. d. Progressive in terms of intensity and duration.

b. Decrease intensity with ambulation.

A nurse is reviewing the use of systemic analgesics administered during labor. Which statement should the nurse indicate as correct? a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. IV client-controlled analgesia (PCA) results in increased use of an analgesic. d. I'm administration is preferred over IV administration.

b. Effects on the fetus and newborn can include decreased alertness and delayed sucking.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. Which measure should the nurse include? a. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction. b. Encouraging the woman to try various upright positions, including squatting and standing. c. Telling the woman to start pushing as soon as her cervix is fully dilated. d. Continuing an epidural anesthetic so that pain is reduced and the woman can relax.

b. Encouraging the woman to try various upright positions, including squatting and standing.

A multiparous client, Gravida 3 Para 2002 was examined 5 minutes ago. Her cervix was 8cm, 90% effaced. She now states that she has to move her bowels. Which of the following should the nurse do first? a. Offer the client the bedpan. b. Evaluate the progress of labor. c. Notify the provider. d. Encourage the client to push.

b. Evaluate the progress of labor.

A nurse is providing information to a client in labor with regard to tactile approaches to comfort management. Which option should the nurse include in the plan of care? a. Acupuncture can be performed by a skilled nurse with just a little training. b. Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. c. Therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations. d. Either hot or cold applications may provide relief, but they should never be used together in the same treatment.

b. Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited.

A nurse is completing an admission assessment for a client who is 39 weeks of gestation & reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? a. Cord prolapse b. Infection c. Postpartum hemorrhage d. Hydramnios

b. Infection

A nurse providing care for an antepartum woman receiving a contraction stress test (CST). Which statement should the nurse identify as being accurate? a. Sometimes uses vibroacoustic stimulation. b. Is considered to have a negative result if no late decelerations are observed with the contractions. c. Is more effective than nonstress test (NST) if the membranes have already been ruptured. d. Is an invasive test; however, contractions are stimulated.

b. Is considered to have a negative result if no late decelerations are observed with the contractions.

A nurse is reviewing the concept of normal labor. Which statement should the nurse indicate as being incorrect? a. A regular progression of contractions, effacement, dilation, and descent occurs. b. It is completed within 8 hours. c. A single fetus presents by vertex. d. No complications are involved.

b. It is completed within 8 hours. Rationale: Although the amount of time varies with each woman, a normal uncomplicated labor is usually completed within 18 hours. In normal labor, a single fetus presents by vertex. A regular progression of contractions, effacement, dilation, and descent is the trajectory that the nurse expects for a woman experiencing a normal labor, which usually occurs with no complications.

A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? a. Alpha-fetalprotein (AFP) b. Lecithin/sphingomyelin (L/S) ratio c. Indirect Coombs test e. Kleihaur-betke test

b. Lecithin/sphingomyelin (L/S) ratio

The nurse is evaluating the fetal monitor tracing of a client, who is in active labor. Suddenly the fetal heart rate (FHR) drop from its baseline of 125 down to 80. The nurse repositions the mother, provides oxygen, increases IV fluid, and performs a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional measures should the nurse take? a. Insert a Foley catheter. b. Notify the primary health care provider immediately. c. Start oxytocin (Pitocin). d. Call for help.

b. Notify the primary health care provider immediately.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency to every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. What complication should the nurse suspect? a. Eclamptic seizure. b. Placental abruption. c. Placenta previa. d. Rupture of the uterus.

b. Placental abruption.

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? a. Assist the client to the bathroom b. Prepare for an impending delivery c. Prepare to remove a fecal impaction d. Encourage the client to take deep,, cleansing breaths

b. Prepare for an impending delivery

A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool should the nurse identify as being appropriate to assess the pregnancy? a. Biophysical profile b. Transvaginal ultrasound c. Amniocentesis d. Maternal serum alpha-fetoprotein (MSAFP)

b. Transvaginal ultrasound Rationale: An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women, whose thick abdominal layers cannot be penetrated adequately with the abdominal approach.

A nurse is caring for a client who is 40 weeks gestation and experiencing contractions every 3 to 5 minutes and increasing. A vaginal exam reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? Select all that apply. a. Encourage use of patterned breathing b. Insert urinary catheter c. Administer opioid analgesics d. Suggest application of cold e. Provide ice chips

c and d

A nurse is caring for a client following the administration of an epidural block and is preparing to administer IV fluid bolus. The client asks about the purpose of IV fluids. Which of the following statements should the nurse make? a. "It is needed to promote increased urine output" b. "It is needed to counteract respiratory depression" c. "It is needed to counteract hypotension" d. "It is needed to prevent oligohydramnios"

c. "It is needed to counteract hypotension"

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the best nursing response? a. "You may have an epidural. You won't feel anything." b. "Don't worry about it. You'll do fine." c. "It's normal to be anxious about labor. Let's discuss what makes you afraid." d. "Labor is scary to think about, but the actual experience isn't."

c. "It's normal to be anxious about labor. Let's discuss what makes you afraid."

A nurse is providing instructions for a nonstress test (NST) to a woman who is at 36 weeks of gestation. Which statement by the client indicates a correct understanding of the nurse's instructions? a. "This test will help to determine whether the baby has Down syndrome or a neural tube defect." b. "I will need to have a full bladder for the test to be done accurately." c. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." d. "I should have my husband drive me home after the test because I may be nauseated."

c. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

A nurse teaches a pregnant woman about the characteristics of true labor contractions. Which of the following statements indicates that the client correctly undersands the nurse's instruction? a. "True labor contractions will cause discomfort over the top of my uterus." b. "True labor contractions will subside when I walk around." c. "True labor contractions will continue and get stronger even if I relax and take a shower." d. "True labor contractions will remain irregular but become stronger."

c. "True labor contractions will continue and get stronger even if I relax and take a shower."

A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? a. "You will lay on your right side during the procedure" b. "You should not eat anything for 24 hours prior to the procedure" c. "You should empty your bladder prior to the procedure" d. "The test is done to determine gestational age"

c. "You should empty your bladder prior to the procedure"

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description should a nurse indicate as being accurate with regard to the phases of the first stage of labor? a. Lull: no contractions; dilation stable; duration of 20 to 60 minutes b. Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours c. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours d. Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

c. Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? a. Administration of steroids b. Preparation of the woman for invasive hemodynamic monitoring c. Administration of blood d. Restriction of intravascular fluids

c. Administration of blood

A nurse is reviewing assessments used to determine gestational age. When timeframe should the nurse identify as being the best to establish gestational age based on ultrasound? a. At term b. 36 weeks c. Between 14 and 22 weeks d. 8 weeks

c. Between 14 and 22 weeks

A nurse is taking care of a client in labor who is exhibiting signs and symptoms of maternal hypotension syndrome. Which action should the nurse implement? a. Regional anesthesia. b. Oxytocin administration. c. Change in position. d. Intravenous analgesic.

c. Change in position.

Which action would be correct when palpation is being used to assess the characteristics and pattern of uterine contractions? a. Place the hand on the abdomen below the umbilicus and palpate uterine tone with the fingertips. b. Determine the frequency by timing from the end of one contraction to the end of the next contraction. c. Evaluate the intensity of the contraction by pressing the fingertips into the uterine fundus. d. Assess uterine contractions every 30 minutes throughout the first stage of labor.

c. Evaluate the intensity of the contraction by pressing the fingertips into the uterine fundus.

A nurse is reviewing factors leading to decreased variabilty. Which cause should the nurse determine as being the most common for decreased variability in the fetal heart rate that lasts 30 minutes or less? a. Altered cerebral blood flow. b. Umbilical cord compression. c. Fetal sleep cycles. d. Fetal hypoxemia.

c. Fetal sleep cycles.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. What action should the nurse implement? a. Tell the woman to slow the pace of her breathing. b. Administer oxygen via a mask or nasal cannula. c. Help her breathe into a paper bag. d. Notify the woman's physician.

c. Help her breathe into a paper bag.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. Which complication should the nurse anticipate as the being the greatest risk for thie client? a.Thrombophlebitis. b. Infection. c. Hemorrhage. d. Urinary retention.

c. Hemorrhage.

A group of nurses are discussing the strengths and limitations of various biochemical assessments during pregnancy. Which statement should the nurses indicate as correct? a. Chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis. b. Percutaneous umbilical blood sampling (PUBS) is one of the quad-screen tests for Down syndrome. c. MSAFP is a screening tool only; it identifies candidates for more definitive procedures. d. Screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects.

c. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

A nurse is caring for a client who is 42 weeks of gestation and is in active labor. Which of the following findings is the fetus at risk for developing? a. Intrauterine growth restriction b. Hyperglycemia c. Meconium aspiration d. Polyhydramnios

c. Meconium aspiration

A patient is in active labor. On spontaneous rupture of membranes, the nurse caring for the patient notices variable decelerations ration during evaluation of the monitoring tracing. When preparing to perform a vaginal examination, the nurse observes a small section of the umbilical cord protruding from the vaginal. What should the nurse do next? a. Increase the IV drip rate. b. Administer oxygen to the patient via face mask at 8 to 10 L/minute. c. Place a sterile gloved hand into the vagina and hold the presenting part off the cord while calling for assistance. d. Wrap the cord loosly with a sterile towel saturated with warm normal saline.

c. Place a sterile gloved hand into the vagina and hold the presenting part off the cord while calling for assistance.

A client has just delivered a healthy newborn. Which action should the nurse peform based on evidence-based care practice in the immediate newborn period? a. After drying, the infant should be given to the mother wrapped in a receiving blanket. b. The healthy newborn should be taken to the nursery for a complete assessment. c. Skin-to-skin contact of mother and baby should be encouraged. d. The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.

c. Skin-to-skin contact of mother and baby should be encouraged. Rationale: The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding.

The nurse is using intermittent auscultation (IA) to assess uterine activity. Which statement should the nurse identify as correct? a. The resting tone between contractions is described as either placid or turbulent. b. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. c. The examiner's hand should be placed over the fundus before, during, and after contractions. d. The frequency and duration of contractions are measured in seconds for consistency.

c. The examiner's hand should be placed over the fundus before, during, and after contractions. Rationale: The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits & states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? a. Second stage b. Fourth stage c. Transition stage d. Latent phase

c. Transition stage

A reactive non-stress test is a determined by the following criteria? a. Three FHR accelerations lasting 15 minutes and 15 beats above baseline in a 30 minute period. b. Three FHR accelerations of any duration in a 30 minute period. c. Two FHR accelerations lasting 15 seconds and 15 beats above baseline in a 20 minute period. d. Two FHR accelerations of any duration in a 20 minute period.

c. Two FHR accelerations lasting 15 seconds and 15 beats above baseline in a 20 minute period.

A nurse is caring for a client in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? a. "A full bladder increase the risk of fetal trauma" b. "A full bladder increases the risk for bladder infections" c. "A distended bladder will be traumatized by frequent pelvic exams" d. "A distended bladder reduces pelvic space needed for birth"

d. "A distended bladder reduces pelvic space needed for birth"

A nurse is caring for a client who is pregnant and undergoing a non stress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? a. "It is used to stimulate uterine contractions" b. "It will decreased the incidence of uterine contractions" c. "It lulls the fetus to sleep" d. "It awakens a sleeping fetus"

d. "It awakens a sleeping fetus"

A nurse is reviewing spinal and epidural (block) anesthesia use during labor. Which statement should the nurse identify as being accurate? a. Epidural blocks allow the woman to move freely. b. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. c. Spinal and epidural blocks are never used together. d. A high incidence of postbirth headache is seen with spinal blocks.

d. A high incidence of postbirth headache is seen with spinal blocks.

The nurse observes accelerations on the fetal monitor in a laboring client. How should the nurse interpret this finding? a. As caused by umbilical cord compression. b. Warrants close observation. c. As caused by uteroplacental insufficiency. d. As reassuring.

d. As reassuring.

A primigravida asks the nurse about what signs they can look for that would indicate that the onset of labor is getting closer. They should describe: a. Weight gain of 1 to 3 pounds. b. Quickening. c. Fatigue and lethargy. d. Bloody show.

d. Bloody show.

A nurse is working with a client who is in labor and providing information relative to breathing techniques. Which option should the nurse include in the plan of care? a. Controlled breathing techniques are most difficult near the end of the second stage of labor. b. The patterned-paced breathing technique can help prevent hyperventilation. c. By the time labor has begun, it is too late for instruction in breathing and relaxation. d. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

d. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? a. Inspect the Introits for prolapsed cord b. Perform a test to identify the ferrying pattern c. Monitor station of the presenting part d. Defer vaginal examinations

d. Defer vaginal examinations

The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would the nurse identify as being another tool to help confirm the diagnosis? a. Daily fetal movement counts b. Amniocentesis c. Contraction stress test (CST) d. Doppler blood flow analysis

d. Doppler blood flow analysis Rationale: Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high risk pregnancy due to intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor.Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed in a woman whose fetus is preterm. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation.

A nurse suspects that the laboring client has ruptured membranes. Which test should the nurse perform? a. Leopold maneuvers b. AROM c. Urine analysis d. Fern test

d. Fern test

A nurse is reviewing clinical manifestations between abruptio placentae and placenta previa. Which finding should the nurse identifying as being the mostsignificant difference between the two? a. Cramping. b. Bleeding. c. Uterine activity. d. Intense abdominal pain.

d. Intense abdominal pain.

A nurse is taking care of a client in labor who is experiecing back pain. What action should the nurse implement? a. Lie on her back for a while with her knees bent. b. Take some deep, cleansing breaths. c. Do less walking around. d. Lean over a birth ball with her knees on the floor.

d. Lean over a birth ball with her knees on the floor.

A nurse is reviewing clinical indications for a contraction stress test(CST). What should the nurse identify as being an appropriate indicator for this test? a. History of preterm labor and intrauterine growth restriction b. Adolescent pregnancy and poor prenatal care c. Increased fetal movement and small for gestational age d. Maternal diabetes mellitus and postmaturity

d. Maternal diabetes mellitus and postmaturity Rationale: Decreased fetal movement is an indicator for performing a contraction stress test

Which of the following actions should the nurse implement for the patient following an amniocentesis? a. Place patient on the EFM (external fetal monitor) for 30 minutes. b. Monitor VS for one hour. c. Place patient on EFM for 60 minutes. d. Monitor for contractions and, vaginal bleeding,

d. Monitor for contractions and, vaginal bleeding,

A nurse is assessing a client at 42 weeks of gestation. Which finding, if noted by the nurse requires more assessment? a. Cervix dilated 2 cm and 50% effaced b. Score of 8 on the biophysical profile c. Fetal heart rate of 116 beats/min d. One fetal movement noted in 1 hour of assessment by the mother

d. One fetal movement noted in 1 hour of assessment by the mother

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness & tingling of the fingers. Which of the following actions should the nurse take? a. Administer oxygen via nasal cannula at 2 L/min b. Apply a warm blanket c. Assist the client to a side-lying position d. Place an oxygen mask over the client's nose and moth

d. Place an oxygen mask over the client's nose and moth Rationale: The client is experiencing hyperventilation caused by low CO2 levels. The mask will allow the client to reduce intake of oxygen & CO2 will rise.

A pregnant woman's amniotic membrane has ruptured and a prolapsed cord is suspected. Which intervention is the nurse's highest priority? a. Cover the cord in a sterile towel saturated with warm normal saline. b. Prepare the woman for a cesarean birth. c. Start oxygen by face mask. d. Place the woman in the knee-chest position.

d. Place the woman in the knee-chest position. Rationale: This action will relieve pressure on the cord, which is the nursing priority. The nurse may also use her gloved hand or two fingers to lift the presenting part off the cord.

A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in breech presentation. For which of the following possible complications should the nurse observe? a. Precipitous labor b. Premature rupture of membranes c. Postmaturity syndrome d. Prolapsed umbilical cord

d. Prolapsed umbilical cord

A nurse is reviewing the electronic monitor tracing of a client in active labor. A fetus receives more oxygen when which of the following appears on the tracing? a. Peak of uterine contraction b. Moderate variability c. FHR acceleration d. Relaxation between uterine contractions

d. Relaxation between uterine contractions

A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? a. No alteration in menses b. Transvaginal ultrasound indicating a fetus in the uterus c. Blood progesterone greater than the expected reference range d. Report of severe shoulder pain

d. Report of severe shoulder pain

A nurse is caring for a pregnant patient at 30 weeks of gestation in preterm labor. The physician orders betamethasone 12 mg IM for two doses, with the first dose to begin at 11 am. In implementing this order the nurse should: a. Consult the physician, because the dose is too high. b. Explain to the patient this medication will reduce their heart and help them breathe easier c. Prepare to administer the medication IV between contractions. d. Schedule the second dose for 11am on the next day

d. Schedule the second dose for 11am on the next day

A nurse is working with a client in the second-stage of labor. Which position would the nurse suggest if the pelvic outlet needs to be increased? a. Semirecumbent b. Side-lying c. Sitting d. Squatting

d. Squatting

A nurse is caring for a patient in labor. Which observation by the nurse would indicate that the second stage of labor, the descent phase, has begun? a. The presenting part is below the ischial spines. b. The amniotic membranes rupture. c. The woman experiences a strong urge to bear down. d. The cervix cannot be felt during a vaginal examination.

d. The cervix cannot be felt during a vaginal examination. Rationale: The second stage of labor begins with full cervical dilation

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular. A gush of dark red blood comes from her vagina. How does the nurse interpret this finding? a. A cervical tear occurred during the birth. b. Clots have formed in the upper uterine segment. c. The woman is beginning to hemorrhage. d. The placenta has separated.

d. The placenta has separated.

The nurse is monitoring a client during labor. Which observation if noted by the nurse would indicate fetal well-being? a. Accelerations in the FHR. b. An FHR greater than 110 beats/min. c. Maternal pain is being controlled by using breathing techniques. d. The response of the fetal heart rate (FHR) to uterine contractions (UCs).

d. The response of the fetal heart rate (FHR) to uterine contractions (UCs).

A client calls a provider's office and reports having contractions for 2 hrs that increased w/ activity & did not decrease w/ rest. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following is the client experiencing? a. Braxton Hicks contractions b. Rupture of membranes c. Fetal descent d. True contractions

d. True contractions

A pregnant patient enters the labor and delivery unit they state " I think I am in labor." Which of the following assessments will provide the nurse with the most valuable information regarding the patient's labor status? a. Leopold maneuvers b. Fundal contractility c. Fetal heart rate assessment d. Vaginal examination

d. Vaginal examination

A nurse is reviewing the clinical manifestation of fetal bradycardia. What indication should the nurse identify as being the most common cause? a. Maternal hyperthyroidism. b. Fetal anemia. c. Tocolytic treatment using ritodrine. d. Viral infection.

d. Viral infection. Rationale: Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, viral infections such as cytomegalovirus (CMV), maternal hypothermia, and maternal hypothermia