RNC-OB Exam

If shoulder dystocia occurs during delivery, the maternal positioning that may elevate the pubic bone is to a. lift and hyperflex thighs b. turn to left lateral Sims position c. extend both legs

A (McRoberts maneuver). Shoulder dystocia occurs when the head is delivered but the shoulders are not because they are blocked by the symphysis pubis. Shoulder dystocia may be assoicated with post-term pregnancies, macrosomia, assisted vaginal delivery, maternal diabetes, and protracted labor. Suprapubic pressure may be applied externally to facilitate delivery while traction is applied to the neonate or the neonate is manually rotated. An episiotomy may be necessary.

Maternal gonorrhea (Neisseria gonorrhoeae) places the infant at risk of a. bilateral conjunctivitis b. encephalitis c. myocarditis

A (aka ophthalmia neonatorum). If not treated, the conjunctivitis usually occurs within about 5 days of birth with evidence of inflammation and purulent discharge. Prophylactic antibiotic ointment or drops (typically erythromycin ointment) are applied to the neonate's eyes after birth as a preventive measure. If infection occurs, treatment with IV antibiotics is indicated. Disseminated gonococcal infection (DGI) may occur in some infants.

The most common complication of vacuum-assisted delivery is a. scalp abrasions b. cephalohematoma c. retinal hemorrhage

A (bruises, small breaks in skin) resulting from suction applied to the infant's head. Swelling is less of a concern with the plastic or silastic cups used now than with earlier metal cups. Cephalohematoma, intracranial hemorrhage, and subgaleal (beneath scalp) hematoma are rare complications of vacuum-assisted delivery. Retinal hemorrhage occurs in over 25% of newborns but rates may be slightly increased in those undergoing vacuum-assisted delivery.

The purpose of the modified Ritgen maneuver during delivery is to a. prevent perineal lacerations b. speed delivery of the head c. rotate the fetus the correct position

A (hands on). as the head is delivered, the physician or midwife applies upward pressure from the coccygeal region, which causes the fetal head to extend during birth, protecting the perineal musculature. A different approach (hands off) is also sometimes used. With this approach, the physician or midwife does not touch the perineum or assist with delivery of shoulders or body but applies light pressure to the fetal head if necessary to prevent rapid expulsion.

An indication of placenta previa is a. painless bleeding after 20 weeks' gestation b. tender uterus with increased resting tone c. hypertonic uterine contractions

A (implantation of the placenta on or near the internal cervical os) is painless bleeding after 20 weeks gestation. The woman is also at risk for hemorrhage in the third trimester. Placenta previa is classified as complete (covering the internal cervical os), partial, or marginal (to the edge of the internal cervical os). When diagnosed, bedrest is usually required. As the uterus expands, the implantation site may move away from the cervical os, correcting the condition.

Risk factors for placenta previa include a. previous cesarean b. older than 30 years c. maternal hypertension

A , age older than 35 years, multipara (more than 5 pregnancies), prior uterine surgery (dilation and curettage, removal of fibroids), and previous history of placenta previa. Contributing factors that are within the patient's control include use of cocaine and smoking. Some patients have few symptoms that indicate placenta previa, but other may develop sudden vaginal bleeding but with no associated pain while others may develop early labor. Any unexplained bleeding during pregnancy may indicate placenta previa.

Which NICHD category predicts normal fetal acid-base status? a. I b. II c. III

A -Category I: Predicts normal fetal acid-base status with baseline fetal heart rate of 110-160, moderate baseline variability, and no late or variable decelerations although early decelerations may be evident. -Category II: Indeterminate classification with all tracings varying from both Category I and Category III findings. -Category III: Predicts abnormal fetal acid-base status with sinusoidal pattern and absent variability associated with recurrent late or variable decelerations or bradycardia.

The three most common factors associated with labor abnormalities are (1) the fetus, (2) the pelvic size and shape, and (3) the a. uterine contractility b. age of the mother c. weeks of gestation

A -Fetus: size (such as macrosomia), lie and presentation may slow labor or interfere with contractions and fetal descent - Pelvic size and shape: a small or narrow pelvis or abnormally shaped pelvis may prevent the fetus from engaging and descending -Uterine contractility: if the uterine contractions are missing or too weak, labor progression ceases or slows, but if they are too strong, precipitous labor may occur.

The birthing method that encourages women to use specific movements called the "birth dance" to relieve discomfort is a. Kitzinger method b. Bradley method c. Lamaze method

A -Kitzinger: Encourage alternatives to usual hospital procedures, development of a birth plan, and the use of chest breathing, abdominal relaxation, touch relaxation, visualization, and the "birth dance" to relieve discomfort. -Bradley: Focuses on natural childbirth and education about woman's health and needs of the newborn. Woman and partner participate. -Lamaze: Encourages the use of various methods to relieve discomfort and supports natural onset of labor and avoidance of supine delivery with only necessary medical interventions provided.

If meconium-stained amniotic fluid is observed during delivery of an infant, the initial response should be to a. suction the infant before his/her first breath b. evaluate the infant's respiratory status c. suction the infant after he/she begins breathing

A ..., before the shoulders and body are delivered if possible, to prevent aspiration of meconium and meconium aspiration syndrome (MAS). The severity of symptoms depends on the amount of meconium aspirated. Thick meconium poses more or a risk than think meconium. If the neonate aspirated meconium, the child may exhibit respiratory depression on delivery, requiring resuscitation.

Prior to induction, it is most essential to assess for a. cephalopelvic disproportion. b. psychological status. c. macrosomia.

A ....(CPD) and fetal malpresentation because vaginal birth may not be possible and Cesarean may be required rather than induction. CPD may result from increased size of the fetus or from abnormally shaped or small pelvis. Both (vaginal assessment of pelvic bones to determine pelvic size) and ultrasound may be used to assess for CPD, but examination is often inaccurate before labor because fetal molding may alter the proportions.

Following delivery, the mother should be encouraged to urinate a. within 1 hour b. within 3 hours c. within 4 hours

A ....and should empty the bladder at least every 4-6 hours. Because of periurethral edema post delivery, dysuria is common and bladder retention may occur; catheterization should be avoided and should not be done more than twice in 24 hours if possible. Warm water may be poured over the perineum to relax muscles and promote urination. Normal urinary volume per voiding is usually 300-400 mL.

A common problem in the mouth during pregnancy is a. gingivitis. b. tooth demineralization. c. decreased saliva.

A ....because of hyperemia of the mouth and gum tissues resulting from increased levels of estrogen. Some patients may develop red, swollen, bleeding gums because of vascular hypertrophy, but these conditions recede after delivery of the fetus. Excessive salivation (ptyalism) is also common, although the cause is unknown. Demineralization of the teeth is not associated pregnancy although it is a common belief.

A multiparous patient who is in active labor and dilating 0.8 cm per hour is likely experiencing a. prolonged labor. b. normal labor. c. precipitous labor.

A ....because the multiparous patient usually dilates approximately 1.5 cm per hour and the nulliparous patient 1.2 cm per hour. The patient should be assessed for hypertonic and hypotonic labor patterns as well as other complications, such as abnormalities in fetal presentation or size, to determine the cause of the prolonged labor.

Following birth of an infant, signs of placental separation usually begin within a. 5 minutes. b. 15 minutes. c. 30 minutes.

A ....but it may take up to 30 min to expel the placenta and membranes. Signs include globular shaped uterus, rise in fundus, sudden expelling of a gush of blood or a trickle of blood, and extended length of the umbilical cord as it is pushed exteriorly by the descending placenta. The placenta may separate from the middle to the edges and be expelled with the fetal side presenting (Schultze mechanism) or may separate from the outer edges, rolling and present with the maternal side (Duncan mechanism).

If the results of one study are replicated with additional studies, the initial study is said to have a. reliability b. validity c. usability

A ....especially using different methods or tools and different populations, the initial study is said to have reliability. Validity means that the study was successful in measuring that which was intended. External validity means that the study results are generalizable to other populations. Usability refers to the tools used in a study and the degree to which researchers are able to understand and use them properly.

Following an amniocentesis, the pregnant patient should be advised to avoid strenuous activities for at least how long? a. 24 hours b. 36 hours c. 48 hours

A ....in order to prevent bleeding. After the needle is removed, the insertion site should be reexamined with ultrasound to note movement of fluid that may indicate bleeding. Additionally, the patient should remain under observation for vital signs and fetal assessment for at least an hour after the procedure. Some mild cramping is normal, but dizziness, hypotension, severe cramping, and fever or chills may indicate complications.

If a patient's due date is April 3, the patient's pregnancy is considered postterm on a. April 10 b. April 17 c. April 24

A ....one week after the due date, assuming the due date was calculated correctly. Most designations of post-term pregnancies result from inaccurate due date. Post-term pregnancies are more common with primigravidas than multipara. Post-term pregnancies increase risk of stillbirth and neonatal mortality. About 1/4 of post-term pregnancies are assoicated with macrosomia, common in infants of mothers with diabetes.

A drug that may be administered to treat hypertonic contractions related to the use of prostaglandin gel for cervical ripening is a. terbutaline b. oxytocin c. misoprostol

A ....or magnesium sulfate. The patient should be placed in side-lying position and administrated oxygen by facemask at 8-10 L/min to improve oxygenation of the fetus because the hypertonic contractions interfere with blood flow to the placenta. Hypertonic contractions are most likely to occur about an hour after application of prostaglandin gel.

Prior to administration of a narcotic to relieve labor pain, a nullipara should generally be dilated to how many centimeters? a. 3 to 4 b. 4 to 5 c. 6 to 7

A ...and a multipara to 4-5 cm. However, the patient should have stable vital signs and be without drug allergy, drug dependency, or respiratory compromise; and the fetus should be at term and have FHR of 110-160 bpm with a reactive NST and no evidence of meconium staining. Additionally, the pattern of contractions should be well established and the presenting part engaged with progressive descent.

A mother's smoking during pregnancy places the fetus at increased risk of a. low birth weight. b. renal abnormalities. c. bradycardia.

A ...and preterm birth. In addition, miscarriages and stillbirths are more common, and the fetus may exhibit tachycardia, respiratory problems, and birth defects. After birth, the child of a smoker is at increased risk of sudden infant death syndrome. The more that a pregnant woman smokes, the greater the risk, so all pregnant women should be advised to stop smoking during pregnancy. Second-hand smoke after delivery continues to pose risks to the infant.

Which cardiac abnormality poses the least maternal risk during pregnancy? a. Atrial septal defect b. Moderate aortic stenosis c. Marfan syndrome with aortic root involvement

A ...are the most common cardiac abnormality in pregnant women. With previous surgical repair, there is little increased increased risk to the patient. Without previous surgical repair, the patient is at increased risk for deep vein thrombosis and may also be at risk for bacterial endocarditis. A pregnant patient >40 years has increased risk of developing atrial flutter or atrial fibrillation. Moderate aortic stenosis poses an intermediate risk to the patient, and Marfan syndrome with aortic root involvement poses a high risk.

During the fourth stage of labor, lochia should generally not exceed a. one saturated pad per hour. b. one saturated pad per 2 hours. c. two saturated pads per hour.

A ...as excessive drainage may indicate hemorrhage. Small clots are common in the lochia rubra, but large clots may indicate excessive bleeding. When changing the pad, it's important to examine the buttocks and back to determine if overflow drainage has pooled. If the uterus is firm but there is a continuous trickle of bright red blood, this may be an indication of laceration.

During the second stage of labor, the patient feels a strong urge to bear down because of a. pressure on the sacral and obturator nerves b. pressure on the femoral nerves c. pressure on the perineum, rectum, and anus

A ...as the fetus descends the birth canal. The second stage usually lasts for about 2 hours for the nullipara and 15 minutes for the multipara with contractions occurring every 1.5-2 minutes and persisting for 60-90 seconds. As the fetus descends and the head crowns, the patient feels increasingly intense pain and pressure on the perineum.

What antimicrobial agent is contraindicated for treatment of bacterial infections during pregnancy? a. Fluoroquinolones b. Macrolides c. Penicillins

A ...as they may affect the musculoskeletal system of the fetus. Nitrofurantoin should be avoided in late stages of pregnancy as it may cause hemolytic anemia in the newborn. Tetracycline impairs development of fetal bones and teeth so it should only be used during the first trimester. Macrolides and penicillins are generally considered safe for pregnant women.

A pregnant patient with asymptomatic bacteriuria should a. receive antibiotics. b. have repeated monitoring. c. be advised to increase fluid intake.

A ...as though the patient has acute urinary tract infection because asymptomatic bacteriuria poses a risk to the pregnancy and may evolve to active cystitis or pyelonephritis, further increasing the risk of premature rupture of membranes and preterm birth. Following treatment, a culture should be done to ensure that the bacteria have cleared. If not, prophylactic suppressive treatment is indicated for the duration of the pregnancy.

Poor control of blood glucose levels during the third trimester in a patient with gestational diabetes increases the risk of a. preeclampsia. b. spontaneous abortion. c. congenital malformations.

A ...as well as fetal macrosomia, which may occur even with normal levels. Poor control of blood glucose levels in the first 10 weeks of pregnancy, when organs are being formed, may result in congenital malformations and spontaneous abortion. Gestational diabetes type A1 is usually controlled with diet while type A2 requires oral medications or insulin

If an initial biophysical profile (BPP) score is 6/10 and a repeat is 4/10, the next appropriate action is to a. deliver the fetus b. repeat the BPP in 2 hours c. wait and observe for 24 hours

A ...because a score of 4/10 indicates probable fetal asphyxia. A score of 6/10 indicates possible fetal asphyxia. If an initial score is 6/10 and the repeat score is 6/10, birth should be induced. A normal BPP is a score of 2 for each of 5 parameters (fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate with NST, and amniotic fluid volume), for a total of 10/10.

A pregnant woman who is addicted to heroin and beginning treatment with buprenorphine should first be stabilized with a. morphine b. naloxone c. methadone

A ...because addicts rarely have a steady supply of heroin, so blood levels of the drug vacillate. Once the blood level is stabilized, then buprenorphine can be initiated under close supervision. Because buprenorphine crosses the placental barrier, the fetus develops opioid dependence and will undergo withdrawal after delivery, requiring treatment of the neonate with decreasing doses of morphine.

Post-term pregnancies increase the risk of a. oligohydramnios b. hydramnios c. precipitous birth

A ...because amniotic fluid volume, which averages about 800 mL at week 40 of gestation, declines to about 400 mL by week 42. This decreased volume increases the risk to the fetus because hypoxia may develop due to compression of the umbilical cord. The fetus is also at increased risk of meconium aspiration syndrome, respiratory distress, polycythemia, and asphyxia. Because of the high risk factors associated with post-term pregnancies, some patients are induced at 41-42 weeks, although some may wait until 43 weeks if the fetus is unaffected.

A patient who survived the acute stages of amniotic fluid embolism (anaphylactoid syndrome of pregnancy) with disseminated intravascular coagulation (DIC) is at increased risk for a. left heart failure and neurological impairment b. right heart failure and liver failure c. left heart failure and renal insufficiency

A ...because left heart failure often occurs after other symptoms, and almost all patients who survive have some degree of neurological damage. Amniotic fluid embolism is characterized by sudden acute hypotension and/or cardiac arrest, hypoxia, and coagulopathy/hemorrhage (DIC) without other cause occurring during labor, assisted delivery, or cesarean, and up to a half hour postpartum.

What is an indication for vacuum-assisted delivery of a fetus? a. Extended second stage of labor b. Advanced cranial molding c. Uncertain fetal station

A ...because longer duration correlates with increased maternal risk from trauma (hemorrhage, lacerations, and chorioamnionitis). Vacuum-assisted delivery may also be utilized if the mother's health or state of exhaustion precludes normal delivery and if there is suspected fetal compromise. Contraindications include advanced cranial molding, uncertain fetal station or position, and malpresentation. Relative contraindications include preterm fetus, overlapping cranial bones, cephalopelvic disproportion, and probable macrosomia.

An indication of placental insufficiency is a. IUGR b. macrosomia c. placental rupture

A ...because the developing fetus is not able to receive the oxygen and nutrients necessary for adequate development. It may result from a failure to develop properly, such as with diabetes or hypertension, or from damage, which may occur with the use of methamphetamines or cocaine. It is associated with increased risk for pre-E, abruptio placentae, stillbirths, and preterm labor and delivery

A woman may be considered for vaginal delivery after cesarean if the prior cesarean incision was a. low transverse b. vertical c. T-incision

A ...because the pressure against this type of incision is less than with vertical or T incisions. Low transverse incision requires less dissection of the bladder, and there is less chance of bleeding because the uterus is thinnest at this point; however, they require a longer delivery time as there are major vessels on each side and the incision is smaller than other types.

A pudendal nerve block a. relieves pain in the lower vagina and perineum b. relieves the pain of uterine contractions c. relieves pain in the lower back

A ...but it must be administered 10-20 minutes prior to the need for perineal anesthesia. The nerve block provides effective relief of pain in the second stage of labor, episiotomy, and birth. It does not relieve pain associated with uterine contractions or back pain, and it has no effect on the thermodynamics of the mother or fetus and does not affect the FHR. The pudendal nerve block does result in lessened or absent bearing down reflex.

When using the vocalization technique during contractions to relax muscles, the patient is encouraged to a. make low-pitched moans b. make high-pitched moans c. describe relaxation verbally

A ...by dropping her jaw and mimicking "masculine" sounds because this method of vocalization causes the glottis to open and makes it easier to breathe, relieving tension. The patient is advised to avoid making any high-pitched moans or cries as these may increase tension and result in more discomfort. In a variation, some women may choose to grunt or sing softly

A risk factor most commonly associated with artificial rupture of the membranes (amniotomy) after the head is engaged is a. infection b. hemorrhage c. breech delivery

A ...especially if labor is prolonged. If the amniotomy is done before the head is engaged to 0 station or more, then there is some risk that the fetus will turn to breech position. Another risk factor is prolapse of the umbilical cord. Some physicians provide antibiotic prophylaxis prior to amniotomy, but this practice has neither been supported nor refuted by research.

Cervical effacement often begins a. before the onset of true labor. b. at the onset of true labor. c. after the onset of true labor.

A ...especially in the multiparous patient. As the cervix begins to efface, bloody show (blood-tinged mucous plug), which has served as a barrier to the cervical canal, is passed, sometimes all at once but at other times over a number of days. This usually occurs late in pregnancy and indicates cervical effacement is occurring. Effacement usually increases as lightening occurs with resultant increased pressure on the cervix and as Braxton Hicks contractions occur more frequently.

On day one of birth for a term infant, what is a normal blood glucose level? a. 40 to 60 mg/dL (2.2 to 3.3 mmol/L) b. 50 to 80 mg/dL (2.8 to 4.4 mmol/L) c. 60 to 100 mg/dL (3.3 to 5.6 mmol/L)

A ...increasing to 50-80 by day 2. Because capillary screening is less accurate than blood glucose, a low value should be verified by laboratory analysis. Typically, an infant is fed if values are 40-45 or less, especially with signs of hypoglycemia, and then the value rechecked 30-60 min after feedings until it remains above 50 twice.

If a patient is to receive general anesthesia for emergency cesarean, the patient should first be administered a. liquid antacid b. an opioid c. a barbiturate

A ...often a nonparticulate (clear) antacid, such as sodium citrate, to neutralize stomach acid. Additionally, some patients may also receive medication, such as an H2-receptor blocker, in order to decrease production of stomach acid and/or metoclopramide to increase the emptying rate of gastric contents. Cricoid pressure may be applied prior to incubation to reduce the risk of vomiting and aspiration.

If a mother is Rh- and the father Rh+, the mother should receive Rho(D) immune globulin (RhoGAM) a. at 26 to 28 weeks' gestation and 72 hours after delivery b. 72 hours after delivery only c. at 32 weeks' gestation and 24 hours after delivery

A ...to prevent erythroblastosis fetalis. RhoGAM contains Rh+ antibodies, which agglutinate any fetal blood cells that pass into the maternal circulatory system, preventing the mother from developing antibodies tot he fetal cells. If antibodies form, they attack the fetus and sensitize the mother for future pregnancies.

If fetal scalp blood sampling is done because of an unusual fetal heart rate pattern, a pH of 7.2 indicates a. the need for immediate delivery b. a normal value c. the need for repeat sampling in 20 minutes

A ...usually either with forceps delivery if criteria are met or with cesarean. A normal fetal pH is 7.25 or greater. If the level is 7.21-7.24, repeat fetal scalp blood sampling may be done every 20 minutes until there is a changes in the FHR pattern for better or worse, indicating the need for delivery

The maneuver that is used to avoid laceration or episiotomy during delivery is a. modified Ritgen. b. Leopold. c. Valsalva.

A ...which involves applying upward pressure from the coccygeal region beneath the fetal head to apply pressure on the fetal chin with one hand while the other hand is on the vertex. This maneuver helps to extend the fetal head, ensuring that the chin delivers slowly and the head follows the curve of the birth canal so that the musculature of the perineum does not tear during delivery.

If a primigravida has experienced frequent erratic painful contractions but has remained at 2 to 3 cm dilation for a prolonged period, this suggests a. hypertonic labor pattern b. hypotonic labor pattern c. maternal anxiety

A ...which is characterized by ineffectual contractions in the latent phase of labor with increased myometrial tone. The contractions are painful because of anoxia of myometrium but inadequate to produce effective effacement and dilation. The patient may become very fatigued and anxious, and fetal distress may occur as well as excessive molding and cephalohematoma.

The most common complication that occurs because of excessive force on the fetal neck during delivery is a. brachial plexus injury b. spinal cord injury c. respiratory distress

A ...which is often associated with shoulder dystocia. Five degrees of injury include: -First: Stretching of nerve fibers with recovery within a few days -Second: Compression and swelling of the nerve with recovery usually complete but takes longer -Third: Damage to the nerve sheath with full recovery not possible -Fourth: Formation of a neuroma that interferes with never regeneration -Fifth: Complete loss of nerve function because of injury of the nerve at the spinal cord

If massaging the uterus is ineffective for uterine atony, the next treatment is usually a. oxytocin infusion. b. hysterectomy. c. uterine artery embolization.

A ...which is often given routinely after delivery of the infant and after delivery of the placenta as a preventive measure. If the oxytocin is ineffective, bimanual massage may be tried and/or other medications, such as Methergine (methylergonovine maleate) or Hemabate (prostaglandin F-@-alpha). If the atony persists and bleeding cannot be controlled, then surgical intervention is indicated with hysterectomy a last resort.

When being assessed for the biophysical profile, what is the normal fetal breathing movement (FBM)? a. 1 FBM lasting ³30 seconds in 30 minutes b. 2 FBM lasting ³30 seconds in 30 minutes c. 3 FBM lasting ³30 seconds in 30 minutes

A ...which is scored as a 2. If there is no FBM of at least 30 seconds in a 30 minute period, it is a score of 0. FBMs are often irregular with periods of apnea and can be detected on ultrasound by about 10-11 weeks of gestation. Although FBM does not actually exchange air, the thorax rises and falls, and this helps prepare the fetus for breathing after birth.

Supporting a patient's request that she receive an opioid and an epidural during labor is an example of the ethical principle of a. autonomy. b. beneficence. c. justice.

A ...which recognizes that people have the right to make their own decisions about care. Beneficence is taking action that benefits another, such as providing pain relief immediately when needed. Justice requires fair and equal treatment of all, making sure that resources and health care are distributed in a fair manner.

Compound presentation of the fetus increases the risk of a. umbilical cord prolapse b. uterine rupture c. hemorrhage

A ...with about 15-20% of compound presentations requiring Cesarean delivery because of prolapsed cord. With compound presentation (a rare event), one ore more limbs, usually a hand or arm) prolapses along with the presenting part (usually the cephalic vertex). If the extremity does not retract spontaneously or cannot be retracted manually, Cesarean is usually required. Compound presentation is more likely to occur with assisted obstetrics (amniotomy) and preterm labor.

Normal uterine activity is defined as a. no more than 5 uterine contractions in a 10 minute period of time averaged over a 30 minute period b. at least 5 uterine contractions in a 10 minute period of time averaged over a 30 minute period c. at least 8 uterine contractions in a 10 minute period of time averaged over a 30 minute period

A ...with at least 3 uterine contractions usually needed for effective labor. Tachysystole is defined as at least 5 uterine contractions in a 10 minute period of time averaged over a 30 minute period. While tachysystole may occur spontaneously, it may also result from assisted obstetrics procedures, such as amniotomy and use of oxytocin or misoprostol. Maternal hypertension and epidural anesthetics also increase risk of tachysystole.

Bloody show is an indication of a. extrusion of mucus from endocervical glands b. placental separation c. maternal bleeding because of alterations in coagulation

A ...with blood loss from cervical capillaries, often referred to as a mucus plug. Bloody show often occurs late in pregnancy after effacement has begun and may occur prior to the onset of true labor; bloody show is usually followed by labor within 24-48 hours. Blood-tinged discharge, usually brownish in color, noted on vaginal exam should not be confused with bloody show.

During the fourth stage of labor immediately after birth, the diameter of the contracted uterus for a singleton birth on palpation should be approximately a. 10 to 15 cm b. 15 to 20 cm c. 20 to 25 cm

A ...with the fundus palpated at or below the umbilicus. With multiple gestations, large infants, or multiparous women, the contracted uterus may be somewhat larger. The uterus should be assessed for firmness and massaged if soft to prevent bleeding and to help expel clots.

With a first episode of mild bleeding before 36 weeks associated with placenta previa, what is the usual treatment? a. Hospitalization until bleeding stops and modified bedrest b. Hospitalization on bedrest until delivery of the child c. Caesarean section

A ...with the patient spending most of the time in bed and avoiding strain and sexual intercourse, which may trigger contractions and bleeding. With a second episode of bleeding, the patient is usually hospitalized until delivery of the child. Corticosteroids may be administered to help mature fetal lungs if delivery is necessary prior to 34 weeks. If severe bleeding occurs, Cesarean is indicated.

After delivery, patients are most at risk of development of deep vein thrombosis a. for the first 3 days b. 1 week after delivery c. for the first 2 weeks

A ...with thrombophlebitis evident at days 3-7. During pregnancy, fibrinolytic activity decreases, which also decreases the risk for hemorrhage, but coagulation does not return to normal for about 3 days after delivery, a time in which the mother may be relatively inactive or on bedrest, resulting in clot formation in vessel walls and resultant inflammation and occlusion.

About a week after delivery of an infant, the mother's pulse often a. decreases b. increases c. remains the same

A 6-10 days. This is known as puerperal bradycardia and results from a combination of of decreased blood volume and strain on the heart and increased stroke volume. Pulse rates may range from 60-70 bpm. When tachycardia occurs, it is often an indication of excessive blood loss, but tachycardia may also result from the stress of prolonged labor. BP rates usually remain within normal limits but orthostatic hypotension may occur for the first few hours after delivery.

At 26 weeks' gestation, the fundal height is 31 cm, which may indicate a. macrosomia b. polyhydramnios c. uterine abnormality

A A fundal height more than 4 cm greater than the number of weeks of gestation is an indication of macrosomia, which is most common in women who are diabetic or severely obese, or who have gained an excessive amount of weight during pregnancy. Macrosomia is diagnosed with estimated fetal weight more than the 90th percentile for expected weight or more than 4500g. Because the fetus stretches the myometrium, the second stage of labor is often prolonged, and the mother is at risk for ruptured uterus. With vaginal delivery, the mother may have extensive lacerations or postpartum hemorrhage.

If the biophysical profile shows a score of 8 with normal amniotic fluid volume, what is the required intervention? a. No intervention needed b. Induction of labor c. Repeat test the same day

A A normal BPP is 10 (score of 2 on 5 different measures). A score of 8 with normal AFI suggests very little risk to the fetus and no intervention is required. If however, the amniotic fluid volume were abnormal, this would suggest chronic asphyxia and increased rate of perinatal mortality within a week, so birth should be induced. A score of 6 indicated possible asphyxia, 4 probably asphyxia, 2 almost certain asphyxia, and 0 certain asphyxia

A maternal indication of amniotic fluid embolism is a. respiratory distress. b. hypertension. c. hypertonic uterus.

A Amniotic fluid embolism occurs when a bolus of amniotic fluid with particles of debris, such as hair or meconium, enters the maternal blood and travels to the lungs, most commonly after rupture of the membranes. Thick meconium, which can clog the pulmonary vein, poses the most risk. Patients may develop coagulopathy with DIC. The amniotic fluid may also cause maternal venospasm and pulmonary hypertension, leading to left ventricular failure.

A patient receiving an amniotomy to induce labor is also usually given a. oxytocin b. intravenous fluids c. steroids

A An amniotomy may be done when the cervix is ripe and the presenting part of the fetus is engaged or to speed labor if progress is slow. If used to induce labor, labor usually begins within 12 hours; however, if labor does not begin, the mother is at increased risk of infection and fetal malposition, so oxytocin is often given along with the amniotomy to ensure that labor commences.

When using the deep tendon reflex rating scale to assess CNS irritability secondary to preeclampsia, a low normal but diminished response is rated as what? a. 1+ b. 2+ c. 3+

A Assessment for hyperreflexia is done in the brachial, wrist, patellar, or Achilles tendons. Deep tendon reflex rating scale: 4+: Abnormal hyperactive, jerky, or clonic response 3+: More brisk than usual response but may be normal 2+: Normal 1+: Low normal response, diminished 0: Abnormal finding, no response

When cervical laceration occur during delivery, they are most common at what position? a. 3 and 9 o'clock b. 12 and 6 o'clock c. 10 and 4 o'clock

A Cervical lacerations are most often identified with vaginal retractors when bleeding is persistent after delivery. The lacerations are sutured with absorbable sutures, so no further treatment is usually indicated. Minor lacerations often occur during delivery, but they usually require no treatment. Tears are more common after forceps assisted and vacuum assisted deliveries than normal vaginal births

The type of breast milk that provides passive immunity to the neonate is a. colostrum b. transitional c. mature foremilk

A Colostrum, which is produced by the breast for the first 2-4 days, serves to provide passive immunity to the neonate through high levels of immunoglobulins (antibodies). Although colostrum, which is thick and buttery in appearance, is produced in low volume (teaspoons), it is three times higher in protein, because of antibodies, than mature milk and lower in fats and carbohydrates and is adequate for the small stomach of the neonate. Colostrum also has laxative action and promotes passage of meconium.

The trimester in which the ultrasound can first be used to examine the fetus for birth defects of the brain and spine is the a. first b. second c. third

A First: estimate gestational age (accuracy +/- 1 to 2 weeks), assess vaginal bleeding, assess for multiple fetuses, and assess for birth defects of brain/spine Second: estimate gestational age (accuracy +/- 2 weeks), assess size and position of placenta, fetus, and umbilical cord, assess for major birth defects (cardiovascular/neural tube) Third: estimate gestational age (accuracy +/- 2 to 3 weeks), assess fetal viability, assess size and position of placenta, fetus, and umbilical cord, and estimate AFI

When using the Silverman-Anderson index to score respiratory difficulty in a neonate, a score of 10 indicates a. severe respiratory distress b. mild to moderate respiratory distress c. normal respirations

A Five criteria, scored from 0 (normal) to 2 (severe) include chest/abdominal movement, intercostal spaces, xiphoid, nares, and expiratory sound.

If 10% to 20% of the placental surface is detached but the mother and fetus are not in distress, the placental abruption is classified as a. grade 1, mild. b. grade 2, moderate. c. grade 3, severe.

A Grade 1: 10-20% of the placental surface is detached o the mother and fetus are not in distress. Uterus may be tender and mild tetany evident Grade 2: 20-50% is detached with or without external bleeding. Uterine tenderness and tetany are evident. While the mother is not in shock, the fetus shows distress. Grade 3: over 50% detached with severe uterine tetany, maternal shock, and frequently coagulopathy. The fetus is dead.

When a transabdominal ultrasound is used to localize the placenta for an amniocentesis in gestation week 32, the woman should generally be advised to a. empty the bladder before the procedure b. drink 1.5 to 2 quarts of water 2 hours prior to the procedure c. drink 3 to 4 glasses of water immediately prior to the procedure

A If the amniocentesis is done early in pregnancy, then it is often done with a full bladder. A full bladder helps the examiner to assess other structures, such as the cervix and vagina, and is important if the patient is being assessed for vaginal bleeding or placenta previa.

In a multiparous woman, what is the lowest Bishop score that predicts labor induction will be successful? a. 5 b. 7 c. 9

A In a multiparous woman, the Bishop score that predicts that labor induction will be successful is 5 or more while it is a 9 or more for a nulliparous woman. The Bishop score is a rating system to determine readiness for induction based on scores of 0-3 in four different measures: dilation (cm), effacement (percentage), station (cm), and cervical consistency (firm, medium, soft), and cervical position (posterior, mid position, anterior). The fifth measure, cervical position, is scored only 0-2.

If a precipitous birth occurs and a nuchal cord is evident after delivery of the fetal head, the initial response should be to a. grasp the cord with curved fingers and pull it over fetal head b. double clamp and cut the cord c. keep fingers under the cord to pull it away from the neck

A In most cases, this maneuver is successful, but if it is not, then the cord should be double clamped and cut before delivery of the rest of the body to prevent asphyxia. The mother should be advised to pant and stop pushing until the cord is dealt with.

Upon initial assessment, a newborn is found to have a portion of the spinal cord protruding from his lower back. This is indicative of a. spina bifida b. hypospadias c. tetralogy of Fallot

A Is a severe neural tube defect and congenital anomaly in which the backbone and membranes around the spinal cord protrude through an incomplete closing in the lower back of the newborn. Upon birth, this sac should be closely protected from rupture or injury prior to surgery.

The primary purpose of percutaneous umbilical blood sampling (cordocentesis) is to a. diagnose and treat abnormal fetal blood conditions b. diagnose fetal chromosomal disorders c. diagnose fetal infections

A It is an ultrasound-guided procedure in which fetal blood is obtained from the umbilical cord with a needle inserted through the abdomen and placenta while the fetus is in utero. The blood sample is usually taken from a site near the placenta but this increases the risk that the blood may contain maternal cells. Samples may also contain amniotic fluid.

Anemia of pregnancy is defined as hemoglobin of a. 11 g/dL (110 mmol/L) or less b. 12 g/dL (120 mmol/L) or less c. 14 g/dL (140 mmol/L) or less

A Less than 11 g/dL (first and third trimesters) or less than 10.5 g/dL in the second trimester, while anemia in a non-pregnant woman would be less than 12 g/dL. During pregnancy, the RBC mass increases, resulting in lower relative hemoglobin. Anemia of pregnancy increases the risk of maternal infection, pre-E, and hemorrhage after delivery, as well as increases rates of miscarriage, low birth weight, and stillbirth.

In the immediate postpartal period, a patient's white blood count increases from 15,000 mm3 to 28,000 mm3, probably indicating a. normal physiological response b. puerperal infection c. coagulation disorder

A Leukocytosis (up to 30,000 mm3) is common during labor and the early postpartal period with most of the increase attributed to neutrophils, which increase in response to inflammation and pain. The leukocytosis recedes and levels usually return to baseline normal by about 6 days after delivery.

The nonstress test (NST) measures the a. fetal heart rate. b. fetal movement. c. fetal breathing movement.

A NST measures the feta heart rate in relation to fetal movement. Normally, the heart rate should increase during activity and decrease at rest. A reactive (normal) NST shows that, for a fetus at 32 or more weeks gestation, the fetal heart rate increases by at least 15 bpm for at least 15 seconds after a fetal movement. A reactive NST on a fetus under 32 weeks should show increase of at least 10 bpm for at least 10 seconds.

An amniotic fluid index (AFI) of 28 cm a. indicates hydramnios (polyhydramnios). b. indicates oligohydramnios. c. is a normal AFI.

A Normal AFI ranges from 5-25 cm. Oligohydramnios is < 5 cm. While some pregnant patients with hydramnios may complain of difficulty breathing, most are asymptomatic and the condition is identified on ultrasound. It may occur with multiple gestations, maternal diabetes, and fetal abnormalities. It increases the risk of preterm labor and birth, premature rupture of membranes, uterine atony, abruptio placentae, prolapse of umbilical cord, and death of the fetus.

A patient is more likely to require an episiotomy if a. asked to stop pushing during the second stage of labor b. asked to push harder during the second stage of labor c. laboring in the lateral side-lying position

A Other factors that predispose to an episiotomy are use of lithotomy or other recumbent position and setting arbitrary time limits on what is a normal duration for the second stage of labor. Incidence of episiotomies has decreased markedly in the US, and there is little evidence that it reduces risk to the fetus, speeds the second stage of labor, or reduces lacerations. Incidence of third and fourth degree lacerations is higher with episiotomies.

During the second stage of labor, the patient's vital signs should be monitored every a. 5 to 15 minutes b. 15 to 30 minutes c. 30 to 60 minutes

A Patient vital signs should be monitored every 5-15 minutes and fetal heart rate (FHR) every 5-15 minutes, depending on risk factors. If the FHR is unstable, it should be monitored continuously. The fetal descent should also be monitored, as well as the mother's response to analgesia and/or anesthesia and her coping mechanisms. The bladder should be palpated for distention. If the bladder is distended and the patient unable to urinate, a straight catheterization may be indicated to prevent bladder rupture during delivery.

During labor, if the presenting part has reached the level of the ischial spines, the station is a. 0 b. -1 c. +1

A Station refers to the position of the presenting part in relation to the ischial spines, which are usually the narrowest area through which the fetus must pass during delivery. If the presenting part is higher than the level of the ischial spines, the station is designated with negative numbers (-1 to -5) with each number representing a centimeter. If the presenting part is below the level of the ischial spines, the station is designated with positive numbers (+1 to +5).

Fetal heart rate patterns are categorized as baseline, a. periodic, and episodic b. normal, and abnormal c. accelerated, and decelerated

A The baseline pattern must persist over at least 2 minutes in a 10 minute period and must exclude accelerations and decelerations or other types of variability. The baseline heart rate pattern is utilized when assessing changes, such as accelerations. Periodic heart rate patterns are those that occur during uterine contractions while episodic heart rate patterns are those that occur when the uterus is resting.

If a neonate does not blink when a light is flashed in his or her eyes, this may indicate a. cerebral palsy b. a normal finding c. sedation

A The blinking reflex should be present at birth and remain throughout life. The assessment consists of flashing a light or aiming a puff of air at the neonate's eyes. The normal response is for the child to immediately blink, as this is a protective mechanism. If the blink reflex is absent or delayed, this may be an indication of brain damage, such as may occur with cerebral palsy, hydrocephalus, or some form of developmental delay. Further testing is indicated to determine the cause of the abnormal response.

A fetal murmur auscultated immediately after birth would be considered a. common, but abnormal if it persists after 48 hours b. an expected finding in the newborn's cardiovascular adaptation process c. an indication of cardiac disease that must be addressed immediately

A The cardiovascular system undergoes changes in the newborn's adaptation to extrauterine life. The late term fetus's right ventricle accounts for 2/3 of cardiac output and the left ventricle, 1/3; but after birth the output equalizes between the ventricles, and cardiac output doubles because of the extra demand for oxygen. The right ventricle predominates in the fetus and the left in the neonate. After birth, blood flow to the lungs increases, and the patent ductus arteriosus closes by about 15 hours.

The transcervical Foley catheter balloon is used to a. increase cervical ripening b. stimulate uterine contractions c. slow precipitous labor

A The catheter is inserted aseptically into the undilated cervix and the balloon inflated just inside the internal ox, usually to 30-80 mL. Then, the distal end of the catheter is taped to the inner thigh under slight tension. As the cervix ripens, the distal end of the catheter may need to be repositioned in order to maintain a degree of tension. Eventually, the balloon should be spontaneously expelled.

Which anesthetic technique provides the best relief of pain during labor and delivery? a. Epidural b. Spinal c. Pudendal block

A The epidural can provide continuous relief during both labor and delivery and does not pose the risk of spinal headache and provides less motor blockade. Additionally, there is a deceased risk of hypotension because of reduced risk of sympathetic blockade. Spinal is now usually reserved for Cesareans. The pudendal block provides relief primarily during delivery.

A common cause of symmetric intrauterine growth restriction (IUGR) is a. chromosomal abnormalities b. placental insufficiency c. preeclampsia

A The head and the body are both growth-restricted proportionately. This condition usually arises early in pregnancy because of chromosomal abnormalities or infections that affect fetal growth. With asymmetric IUGR, the head is large and appropriate for gestational age, but the body is growth restricted. This condition usually arises because of placental insufficiency or pre-E that occurs late in pregnancy. IUGR is diagnosed prenatally with ultrasound. IUGR is often associated with oligohydramnios.

An infant born to a mother who is positive for hepatitis B surface antigen should receive a. hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth b. hepatitis B immune globulin within 12 hours of birth only c. hepatitis B vaccine within 12 hours of birth only

A The hepatitis B immune globulin will provide protection against the infection while the vaccine takes effect. All infants should receive 3 doses of hepatitis B vaccine. If the mother's status is unknown, the initial vaccine should be given within 12 hours of birth, but if the mother's status is negative, the initial vaccine may be given withing the first 2 months.

A maternal serum screen that shows increased levels of human chorionic gonadotropin (hCG) and inhibin A and decreased levels of unconjugated estriol (uE3) and alpha-fetoprotein (AFP) is an indication of a. Down syndrome b. spina bifida c. Turner syndrome

A The maternal screening test is done to screen for chromosomal abnormalities, and screens for three or four substances: AFP, hCG, uE3, and sometimes inhibin A. A positive finding should be followed by further testing, such as high-resolution ultrasound and/or amniocentesis, as well as analysis of chromosomes, so that the parents are able to make informed decisions about the pregnancy.

The maternal serum screen should be done at a. 15 to 20 weeks b. 18 to 22 weeks c. 20 to 26 weeks

A The maternal serum test is a second trimester screening that is done between 15-20 weeks of gestation. Screening tests include: -First trimester: ultrasound at 8-12 weeks and noninvasive prenatal testing (NIPT) from 10 weeks, nuchal translucency at 11.5-13.5 weeks, and chorionic villus sampling at 11-13 weeks. -Second trimester: maternal screening test at 15-18 weeks, amniocentesis at 15-19 weeks, and ultrasound at 18-20 weeks.

The best method for a patient to suppress lactation is to a. wear a support bra and apply cold packs b. avoid wearing a bra and apply warm packs c. take estrogen for suppression

A The patient should also avoid anything that may stimulate production of milk, such as a warm shower or nipple stimulation. While medications were once routinely given to suppress lactation, they are usually avoided because of potential adverse effects. Ice packs or other cold compresses may help to depress milk production and relieve discomfort.

With battledore placenta, the greatest maternal risks are for a. preterm labor and bleeding. b. postpartal hemorrhage. c. late abortion and pre-term labor.

A The umbilical cord inserts into the placenta at or near the placental margin. Maternal risks include preterm labor and bleeding. Risks to the fetus include prematurity and fetal stress. Succenturiate placenta is at least 1 accessory lobe of fetal villi develops on the placenta. Maternal risk includes postpartal hemorrhage although there are few fetal risks Circumvallate placenta is a ring of chorion and amnion that surround the umbilical cord on the fetal side of the placenta. Maternal risks include late abortion, antepartal hemorrhage, and pre-term labor. Fetal risks include IUGR, preterm birth and mortality.

Fetal tone evaluates a. extension and return to flexion. b. gross body movements. c. fetal resting position.

A To be scored as normal tone (2) in a BPP, the fetus should exhibit at least one episode of extension with return to flexion of limbs/trunk or lands. Fetal tone is scored as absent (0) if there is no movement or if there is slow extension with partial return flexion or movement of a limb in full extension.

In the postpartal period, marked edema and severe bruising on one side of the episiotomy with severe pain in the perineal area and severe rectal pressure probably indicates a. vulval hematoma b. episiotomy infection c. soft tissue trauma

A Typically, the risk of hematoma decreases with an episiotomy, but if a vessel is leaking, the hematoma may occur as blood pools in the tissue. Treatment includes incision and drainage and ligation of drainage. In some cases, a drainage tube may be left in place temporarily.

A pregnant patient who presents with sudden onset of severe uterine pain with slow increase in fundal height but no vaginal bleeding should be assessed for a. abruptio placentae. b. bladder retention. c. fecal impaction.

A Up to 80% of patients with abruptio placentae exhibit vaginal bleeding, but bleeding may be contained between the uterine wall and the placenta, resulting in maternal shock without obvious bleeding. If the fetus is at term, bleeding is severe, or the mother or fetus is in jeopardy, immediate delivery is indicated.

With the vibroacoustic stimulation test, stimulus with an artificial larynx or other device is applied to the maternal abdomen for a. 1 to 3 seconds. b. 5 to 10 seconds. c. 1 to 2 minutes.

A Usually, stimulus is applied for 1-2 seconds and repeated up to 3 times with time extending to 3 seconds in order to stimulate fetal movement. A positive or reactive finding is an increased fetal heart rate of 15 bpm or more for at least 15 seconds; however, a nonreactive result does not always indicate fetal abnormality but indicates the need for further testing.

If a woman develops vaginal candidiasis during pregnancy, the treatment recommendation is a. vaginal cream or suppository, such as Monistat (miconazole) b. oral Diflucan (fluconazole) c. delay treatment until after delivery of infant

A Vaginal candidiasis is especially common during the second trimester because of hormonal changes, and may result in itching and watery, yeast-smelling discharge. Oral Diflucan (fluconazole) is not advised during pregnancy or lactation because of safety concerns. Untreated, the mother may pass the infection to the infant during delivery, resulting in oral candidiasis (thrush).

If a patient has vasa previa, the most appropriate treatment is a. cesarean b. carefully monitored vaginal birth c. steriods

A Vasa previa is most often assoicated with velamentous cord insertion but also may be assoicated with in vitro fertilization pregnancies and multiple gestations. if identified early in pregnancy, the infant is usually delivered by cesarean at about 35 weeks. If vasa previa is suspected at the time of labor, then an emergency cesarean should be performed because the mother is at risk of hemorrhage and the fetus of stillbirth

A neonate who developed hyperbilirubinemia after delivery because of ABO incompatibility is at increased risk for development of a. anemia b. thrombocytopenia c. congestive heart failure

A While ABO incompatibility rarely results in serious fetal complications, the neonate may develop hyperbilirubinemia after delivery and should be monitored carefully; the infant may develop anemia in the weeks following delivery because of increased breakdown of red blood cells. ABO incompatibility occurs with the first pregnancy and does not worsen with subsequent pregnancies. Anti-A and anti-B antibodies, which occur as the mother is exposed to food or bacteria with A and B antigens, are relatively large and do not easily enter fetal circulation, but smaller antibodies form if fetal blood leaks into maternal blood.

A mother with active tuberculosis should a. avoid contact with her newborn until she is noninfectious b. use contact precautions when caring for her newborn c. use droplet precautions when caring for her newborn

A While rates of transmission to the fetus are low, most cases of transmission from mother to infant occur after birth from contact with the mother. TB usually does not worsen as a result of pregnancy; while isoniazid and ethambutol cross the placental barrier, they are not considered teratogenic, so a pregnant woman with TB should be started on treatment immediately.

If the partner of a woman in labor and delivery begins shouting at her and hitting her, the best response is to a. call security immediately. b. restrain the partner and call for help. c. stand between the patient and the partner.

A While the initial inclination may be to intervene and restrain the partner, this places the healthcare worker at risk of injury as well as the patient, so the best response is to immediately call security. Any interventions, such as calling out to the person to stop, should be done from a safe distance and preferable with additional staff members present. It's important to bear in mind that a person who is violent may carry a weapon, putting everyone in the vicinity at risk.

The primary advantage of a combined spinal epidural (CSE) over a regular epidural is a. ability to ambulate b. better pain control c. fewer fetal effects

A With a regular epidural, the mother is typically confined to bed but advised to turn from side to side at least every hour. With the CSE, an opioid and/or anesthetic is injected into the intrathecal area and then the needle is withdrawn into the epidural space and the catheter threaded into that area. Epidural anesthesia can be administered when the patient feels the initial injection is no longer adequate.

1. Late in pregnancy, a patient often develops supine hypotension because of a. partial occlusion of the vena cava and aorta. b. decreased peripheral collateral circulation. c. increased blood flow to the placenta.

A because of partial occlusion of the vena cava and aorta from the weight of the uterus. This impedes venous return from the lower extremities although increased collateral circulation during pregnancy helps to compensate. Remaining in the supine position for long periods of time could decrease fetal oxygenation as well. The lateral recumbent position relieves the pressure on the vena cava and aorta, allowing the blood pressure to increase and symptoms to decrease.

If using fetal pulse oximetry, what is normal oxygen saturation? a. 30% to 65% b. 65% to 90% c. 90% to 100%

A because of the fetus's high hemoglobin and hematocrit. A value below 30% may be associated with hypoxia and metabolic acidosis. For fetal pulse oximetry, which may be used to determine whether immediate intervention is needed for non-reassuring fetal heart rate, a special single-use sensor is placed internally along the fetal cheek, temple, or forehead. However, fetal pulse oximetry has not been found to reduce overall rates of Caesarean.

If vaginal fluid contains blood, the nitrazine test for the presence of amniotic fluid a. may show a false positive. b. may show a false negative. c. is unaffected by blood.

A because the pH of blood ranges from 7.35-7.45 and the pH of amniotic fluid ranges from 7.0-7.5, so they may react similarly. A pH in the range of 6.57.5 is considered positive for amniotic fluid in the absence of other factors (blood, semen, urine) that may affect results. The test sample should include vaginal secretions from the posterior vagina but not the mucous plug

The twin pregnancy in which the fetuses are most at risk is a. monozygotic, monochorionic/monoamniotic b. monozygotic, dichorionic/diamniotic c. dizygotic

A mono/mono twins which includes only 2% of twin monozygotic pregnancies. With this type of twin pregnancy, which carries a mortality rate of more than 50%, the zygote division occurs late, 9-13 days after fertilization. In di/di twins (30% of monozygotic twins) the division occurs at 72 hours after fertilization. With mono/di twins (68% of monozygotic twins), division occurs 4-8 days after fertilization. Dizygotic twins (67% of all twins) develop from two ova and are fraternal rather than identical.

During pregnancy, where are vascular spiders most common? a. Face, arms, and upper torso b. Abdomen, breasts, and thighs c. Palms of the hands

A spider like vessels from dilated arterioles and small veins surrounding the arteriole filled with blood. They are most common on the face, arms, and upper torso and may occur in pregnant women because of increased levels of estrogen, so they recede after delivery. Palmar erythema (redness of the palms) is also caused by increased estrogen levels. Striae gravidarum (stretch marks) occur on the abdomen, breasts, and thighs and are caused by stretching of the skin

Before flu season, a pregnant woman should a. receive injectable flu vaccine b. receive nasal spray flu vaccine c. avoid all forms of vaccine

A ...which helps protect both the mother and the fetus (and the infant after birth up to 6 months). However, the nasal spray vaccine should be avoided during pregnancy. Influenza may result in more severe forms of illness in a woman who is pregnant because of pregnancy-associated immune differences. Additionally, influenza poses risks to the fetus, sometime resulting in premature delivery. The pregnant woman should also avoid contact with those with influenza.

When eliciting the scarf sign in a neonate, the infant's elbow crosses the midline of the chest, probably indicating a a. preterm infant. b. term infant. c. postterm infant.

A At fullterm, the elbow should not cross the midline. For the scarf test, the neonate should be placed supine. One arm is grasped and the hand pulled toward the opposite shoulder and then the position of the elbow is assessed in relation to the midline of the chest.

An indication for an amniocentesis is a. maternal age at least 35 years b. maternal hypertension c. placenta previa

A...at this time of the mother's due date because of the increased risk of having an infant with a chromosomal defect, such as Down Syndrome. A mother who has previously given birth to another child with a birth defect or who has a history of birth defects in the family is also a candidate. Additionally, if genetic tests are abnormal, an amniocentesis may be recommended. Not to be confused with amnioreduction (removing amniotic fluid) due to polyhydramnios.

An indication of good health in a newborn is an Apgar score of a. at least 5 b. at least 7 c. at least 9

B

When the nadir of a deceleration corresponds to the peak of the contraction, it is classified as a. late deceleration b. early deceleration c. variable deceleration

B -Early decelerations: The nadir of the deceleration corresponds to the peak of a contraction with the duration from onset to nadir is at least 30 seconds. The decrease in fetal heart rate is symmetrical and gradual. -Late decelerations: Similar to an early deceleration in appearance and duration except that the nadir follows the contraction. -Variable decelerations: Abrupt fall in heart rate below baseline greater than 15 bpm for at least 15 seconds but less than 2 minutes, occurring irrespective of contractions

The purpose of the Leopold maneuvers is to determine fetal a. movement, size, and presentation. b. lie, presentation, and position. c. size, lie, and presentation.

B -Lie: long axis of fetus in relation to long axis of mother, typically longitudinal (99%), although may be transverse or on rare occasions oblique -Presentation: refers to the presenting part, usually cephalic or breech with longitudinal lie Position: refers to the relation of the presenting part to the maternal pelvis, typically left or right. If the presenting part faces anteriorly or posteriorly, this is referred as anterior or posterior asynclitism.

The latent phase of the first stage of labor for a nullipara usually lasts about a. 10 hours b. 8.5 hours c. 5.3 hours

B ...(5.3 hours for a multipara) and the cervix dilates up to 3 cm. The frequency of contractions varies from every 3 to every 30 minutes with contractions lasting 20-40 seconds. Contractions usually range from mild to moderate. Most patients can manage the discomfort during this phase but they may feel increasing anxiety, especially nulliparas.

A contraindication to induction of labor is a. postterm gestation b. multiple gestation c. oligohydramnios

B ..., abnormalities in fetal heart rate pattern, breech presentation, uncertain presentation, hydramnios, maternal hypertension, maternal heart disease, active maternal genital herpes infection, and history of myomectomy. Other contraindications include prolapse of umbilical cord and placenta previa. Prior to induction, the gestational age of the fetus should be at least 39 weeks. There should also be evidence that the fetal lungs are mature, or induction should be delayed for the administration of steroids.

A woman who has human papilloma virus (HPV) and genital warts should be advised that a. pregnancy should have be avoided as the infection may result in birth defects b. HPV is rarely transmitted to the infant during vaginal delivery c. cesarean will be required to prevent transmission to the infant

B ..., so infection is not a routine reason for a cesarean, but it may be advised if the genital warts are so large that they block the birth canal. In rare instances, the infant may develop HPV infection and warts in the mouth and throat (laryngeal papillomatosis).

The fetal head is considered engaged at which station? a. -1 b. 0 c. +1

B ..., the level of the ischial spines. Station refers to the position of the presenting part in relation to the ischial spines. If the presenting part is above station zero, then the station is expressed in negative numbers with each number referring to a centimeter (-1, -2, -3). If the presenting part is below the ischial spines, the station is expressed in positive numbers (+1, +2, +3).

The best solution for a severely heroin-addicted patient who is pregnant is likely a. continuation of heroin during pregnancy b. methadone maintenance program c. heroin withdrawal

B ....because methadone poses less danger to the fetus than heroin, which can result in iron-deficiency anemia, pre-E, eclampsia, preterm birth, early separation of the placenta, and breech presentation. Abruptly stopping heroin use cold turkey may result in onset of preterm labor, spontaneous abortion, or stillbirth, so transitioning to methadone under close supervision is the best option. Methadone may reduce cravings and delay withdrawal symptoms.

During labor, the fetal descent causes the bladder to a. descend. b. ascend. c. move laterally.

B ....relative tot he lower portion of the uterus and the cervix. Because of this and resultant pressure, the patient may experience difficulty urinating and may develop urinary retention. The patient should be assisted to urinate frequently, sitting upright in the bathroom if possible, because urinating on a bedpan is usually more difficult. In some cases, patients may require straight catheterization to reduce a distended bladder.

Premature rupture of the membranes (PROM) increases the risk of a. hemorrhage b. cord prolapse c. delayed labor

B ...and fetal hypoxia. PROM occurs when the membranes rupture prior to onset of labor. Labor usually begins shortly after membranes rupture. If the PROM is also preterm (PPROM), labor usually starts within a week. Maternal risks associated with PROM include chorioamnionitis because of invasion of bacteria before birth and endometritis from infection of the endometrium postpartally. Abruptio placentae is more common in women with PROM.

The labor management approach that is most successful in lowering rates of cesarean births is a. ambulation during labor b. one-on-one support c. frequent maternal position changes

B ...and this can take a variety of forms: nurse, husband/partner, midwife, or doula. Someone should stay with the pregnant woman during labor, providing support and encouragement and assisting with comfort measures. Other interventions include encouraging the patient to ambulate during labor, make frequent changes of position, practice methods of relaxation, take adequate fluid and nutrition, and use various methods of nonpharmacologic pain relief.

During contractions in the second stage of labor, the patient should be encouraged to a. relax muscles. b. push. c. avoid pushing.

B ...as the patient is fully dilated. Pushing at this stage aids the contractile force of the uterus in facilitating delivery. The mother should be instructed to carry out an extended Valsalva maneuver as each contraction starts, inhaling, holding her breath, and bearing down to help increase intra-abdominal pressure. The patient usually feels the urge to bear down and push.

When a woman is using paced breathing during labor, the rate of breathing should be no more than a. one and a half times normal rate. b. two times normal rate. c. three times normal rate.

B ...because a faster rate may result in hyperventilation. If using slow-placed breathing, the rate should be no slower than half the normal rate (usually 6-9 breaths per minute) to ensure that oxygenation remains adequate. Breathing during the first stage of labor may include cleansing breaths, slow-paced, modified paced, and pattern paced ("hee hoo") breathing. Breathing in short puffs may help control the urge to push.

The most common complication after spinal blockade is a. hypertension b. hypotension c. confusion

B ...because of blockade of sympathetic fibers. maternal hypotension increases the risk of fetal hypoxia, so vital signs must be monitored frequently after spinal blockade. Preventive measures include prehydrating with IV fluids (500-1000 mL non-dextrose) and positioning so that the uterus is displaced to the left. If hypotension occurs, the patient should be placed in left lateral, head lowered position, and rapidly infusing with IV fluids.

An extra-long umbilical cord often results in a. fetal death. b. transient decelerations. c. umbilical cord rupture.

B ...because of knots that have formed. The average length of the umbilical cord is 55 cm. A longer cord rarely results in fetal death, but knots can form in the cord if the fetus is active and, although these are rarely pulled tight enough to completely restrict blood flow, they may tighten during contractions, resulting in decelerations. Knots are more likely to form in identical-twin pregnancies than singleton.

The most important considerations when a patient is using the birthing ball is that a. the patient have a bar to grasp b. the patient should not be left unattended c. the patient should practice before being left alone

B ...because of the danger that the patient may lose balance and fall. Ideally, the patient should also have practiced before labor and should have a bar to grasp for support. On the birthing ball, the patient should spread the legs apart and then gently rock to and fro as this helps to increase pelvic diameter and encourage fetal descent

Prior to delivery, a patient with immune thrombocytopenia (ITP) should have what minimum platelet count? a. 30,000 mm3 b. 50,000 mm3 c. 100,000 mm3

B ...because of the risk of bleeding if a Cesarean is required. With a platelet count of at least 30,000 mm3, treatment is usually withheld until 36 weeks gestation or earlier if birth is expected. The initial treatment is oral corticosteroids, usually started 10 days before anticipated due date or intravenous immunoglobulin. Transfusions are used only in emergent situations.

Following an amniotomy or spontaneous rupture of the membranes, the maternal temperature should be assessed at least every a. hour b. two hours c. four hours

B ...because ruptured membranes increase the risk of infection, usually from endogenous bacteria. One of the first signs of maternal fever may be an increase in the fetal heart rate of greater than 160 bpm. Any maternal temperature greater than 38C/100.4F is caused for concern and should be reported to the physician and trigger further evaluation.

The cephalic presentation that generally requires a cesarean for delivery is a. face b. brow c. occiput

B ...because the average anterior-posterior diameter of this presentation is 13.5 cm while the largest diameter that generally is able to pass through the pelvis is about 9.5 cm. The occiput presentation (most normal) and face presentation both have anterior-posterior diameters of about 9.5 cm, although face presentation presents some risk to the fetus because of hyper-extension of the neck and may require cesarean if the mentum (chin) is in posterior position.

In a very obese pregnant patient, auscultation of the fetal heart rate usually requires a. stethoscope b. Doppler ultrasound c. fetoscope

B ...because the extra layers of abdominal fat muffle the fetal heart sounds. Doppler is most commonly used for external auscultation of the fetal heart rate in all patients because it is easy to use and may have a digital display. If the patient is giving birth under water, some Doppler devices can be used under water effectively.

If a labor patient is standing during a contraction and having severe back pain, she should a. sit down b. lean forward c. lean backward

B ...because the fetus will then fall anteriorly, relieving pressure on the sacral promontory and reducing pain. Standing during contractions allows gravity to assist with fetal descent, and contractions are sometimes less painful. However, if the patient stands for long periods, she may become very tired, and standing and walking during contractions prevents electronic fetal monitoring unless telemetry is available.

If a nurse observes signs of fetal distress but fails to notify the physician and the fetus is born with cerebral palsy, this is an example of a. contributory negligence b. gross negligence c. comparative negligence

B ...because the nurse willfully disregarded the safety of another and provided inadequate care that resulted in harm. Contributory negligence occurs when the person does something to contribute to his/her own harm. Comparative negligence is the term used when attempts are made to determine what percentage of harm can be attributed to each individual involved.

When breastfeeding, a woman should increase caloric intake over pre-pregnant intake by about a. 200 to 300 calories b. 400 to 500 calories c. no increase is necessary

B ...but this will vary somewhat depending on how balanced the woman's diet was before pregnancy. There is little difference in the nutritional content of breast milk regardless of the mother's diet, so the mother will suffer from poor nutrition before the infant if the mother's diet is inadequate. A well-balanced diet with a good source of protein, fruits, vegetables, and whole grains is ideal.

The most common cause of uterine inversion is a. multiple gestations. b. excessive cord traction. c. abruptio placentae.

B ...during expulsion of the placenta. The inversion may be partial or complete. The inverted uterus may be obvious if it protrudes from the cervical os or vaginal orifice, but other indications may be inability to palpate the fundus, maternal hypotension, and excessive vaginal bleeding. Initial treatment includes stopping oxytocic medications and reinserting the uterus manually (Johnson maneuver) after administration of medications, such as magnesium sulfate, to relax the uterine muscle.

A comfort measure to reduce perineal edema in the immediate postpartal period is a. hot pack b. ice pack c. Sitz bath

B ...especially for the first 24 hours As the edema subsides, then a Sitz bath may provide comfort, especially if the patient has had an episiotomy. Swelling that is localized on one side may indicate that the patient has a hematoma and should prompt immediate evaluation to determine the cause of the bleeding.

Prior to the induction phase of Subutex® (buprenorphine) administration, the patient should abstain from drug use for how many hours? a. 6 to 12 b. 12 to 24 c. 24 to 48

B ...in order to avoid abrupt withdrawal symptoms when the drug is administered. Induction may be controlled through administration of morphine to stabilize blood levels in the pregnant woman. During the stabilization phase, the patient should discontinue use of other drugs, and the drug dosage may require adjustment. During the maintenance phase, the patient's dose is stable and the patient should be progressing well.

The first Leopold maneuver is to a. palpate the lateral sides of the uterus b. palpate the fundus of the uterus c. palpate the bottom of the uterus

B ...in order to differentiate between breech and cephalic presentation. The second maneuver is to palpate the lateral sides of the uterus, supporting one side while palpating with the other to feel the fetal limbs and back. The third maneuver is to palpate the bottom of the uterus at the suprapubic area to confirm the presentation. The fourth maneuver is to palpate both sides of the lower uterus to determine if the fetus's head is flexed or extended.

The placental and umbilical cord variation that is associated with increased incidence of late abortion, intrauterine growth restriction (IUGR), prematurity, and fetal death is a. succenturiate placenta b. circumvallate placenta c. battledore placenta

B ...in which a double fold of chorion and amnion form a ring that surrounds the umbilical cord on the fetal side of the placenta. The mother is also at increased risk of antepartal hemorrhage and preterm labor. With succenturiate placenta, one or more accessory lobes of villi implant and develop on the placenta. With battledore placenta, the umbilical cord is inserted at/near the placental margin.

A patient with lupus erythematosus places the fetus at risk if she takes which medication during pregnancy? a. Prednisone b. Methotrexate c. Plaquenil® (hydroxychloroquine)

B ...methotrexate or cyclophosphamide. Both of these medications should be discontinued at least 30 days prior to the patient becoming pregnant. Plaquenil and prednisone may be continued during pregnancy. A patient with lupus should be stabilized for at least 6 months before attempting to become pregnant because pregnancy may exacerbate symptoms, and the patient may have antibodies that increase risk of miscarriage or stillbirth in late pregnancy.

Edema of the fetal scalp resulting from pressure of the head against the cervix is called a. cephalohematoma. b. caput succedaneum. c. molding.

B ...or from suction of vacuum-assisted delivery. The swelling crosses suture lines and is usually soft and resolves within the first 12 hours after delivery. Cephalohematoma is bleeding between the periosteum and the skull. The welling is usually firm, most commonly over parietal areas and does not cross suture lines. Molding is an overlappling of cranial bones at suture lines. This condition usually resolves within a week.

Infants born to addicted mothers are likely to experience the least severe neonatal abstinence syndrome (NAS) if, during pregnancy, the mother received a. Suboxone (buprenorphine and naloxone) b. buprenorphine c. methadone

B ...rather than methadone. NAS symptoms tended to be milder, and infants required shorter hospitalizations to control withdrawal. Suboxone (buprenorphine and naloxone) is usually avoided during pregnancy because of the addition of naloxone.

A pregnant woman with pre-eclampsia who develops petechiae, hematuria, and oozing of blood at IV insertions site, likely has a. sepsis. b. coagulopathy. c. anemia.

B ...such as disseminated intravascular coagulation (DIC). DIC is an emergent condition that occurs secondary to another disorder, so immediate assessment should include coagulation studies. The patient should be tilted toward the left to increase blood flow to the uterus and should receive oxygen and blood products. Urinary output must be monitored carefully for signs of renal failure.

If a pregnant woman has chlamydia, vaginal delivery of the neonate may result in a. skin infection. b. eye and lung infections. c. genitourinary infection.

B ...such as pneumonia. The antibiotic prophylaxis used to prevent eye infections from gonorrhea is ineffective for chlamydia infections, which are usually treated with systemic erythromycin. If the pregnant woman is untreated, there is increased risk of premature rupture of membranes, preterm labor, and low birth weight.

On the New Ballard Score for assessment of gestational age, a score of zero (0) indicates how many weeks gestation? a. 20 b. 24 c. 40

B ...the gestational age at which a fetus is considered viable. Scores range from -10 (20 weeks) to 50 (44 weeks) with each increase of 5 points on a scale indicating 2 additional weeks of gestation, so a score of +5 is equal to 26 weeks. The New Ballard Score assesses 6 measures of neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, and heel to ear). and 6 measures of physical maturity (skin, lanugo, plantar surface, breast, eye/ear, genitals-male and female).

If it is unclear whether the membranes have ruptured when a patient is admitted in labor, the initial vaginal exam should be a. digital b. sterile speculum c. delayed

B ...to determine if spontaneous rupture has occurred. Additionally, if there is bleeding, a speculum allows visualization to help identify the source, while a digital exam may disrupt a placenta previa. If a digital exam is indicated, it should be done using aseptic technique after labor has ensued even if the membranes have ruptured.

For a fetal nonstress test (NST), the correct position for the mother is a. semi-Fowler with pillow under left hip b. semi-Fowler with pillow under right hip c. upright position with legs dependent

B ...to displace the uterus to the left. The mother should refrain from smoking before the rest but should be non-fasting. The test should be scheduled during the daytime hours when the fetus may be more active. An electronic fetal monitor is used to monitor the fetal heart rate and a tocodynamometer to detect uterine contractions or movement of the fetus.

If maternal hypotension occurs during labor, the initial response should be to a. administer a bolus of IV lactated Ringer's solution b. reposition the patient to lateral position c. administer ephedrine 5-10 mg intravenously

B ...toward the left is preferable, but either side is acceptable because lying flat during labor increases the risk of maternal hypotension and decreases uteroplacental blood flow. If the patient remains hypotensive, then a bolus of IV lactated Ringer's solution may be administered. If hypotension persists despite the other interventions, then ephedrine 5-10 mg IV may be administered.

Diabetes mellitus during pregnancy increases the risk of a. oligohydramnios b. hydramnios c. microsomia

B ...which is an increased volume of amniotic fluid (AFI >24 cm, volume more than 1700 mL). Hydramnios occurs in about 10% of diabetes associated pregnancies. Normal AFI varies according to weeks of gestation with the average amount at 34 weeks of 800 mL (peak volume) but falling to 600 mL at 40 weeks. Polyhydramnios may result in preterm birth, malpositioning of the fetus because the fetus is essentially floating, prolapse of the umbilical cord, and abruptio placentae.

Following precipitous labor and birth, the mother is most as risk for a. hypertension. b. hemorrhage. c. retained placenta.

B ...which is defined as at least 500 mL of blood loss after vaginal delivery or more than 1000 mL of blood loss after Cesarean. The hematocrit may show greater than 10% change from admission values. With hemorrhage, the patient is at increased risk for hypovolemic shock. Immediate treatment includes providing increased intravenous fluids, elevated feet and legs, and exploring the cause of bleeding, such as vaginal lacerations or retained placental fragments.

Placing the newborn infant against the mother's bare skin helps to reduce a. evaporative heat loss b. conductive heat loss c. convective heat loss

B ...which occurs when the neonate contacts objects with lower temperature than the neonate's skin. Drying the neonate immediately helps prevent evaporative heat loss and providing a warm environment, free of drafts, helps prevent convective heat loss. Placing the child into a radiant warmer transfers heat from the warmer to the neonate through radiation.

The hormone that most affects glucose metabolism during pregnancy, making control of type 1 diabetes difficult, is a. estrogen b. human placental lactogen c. progesterone

B ...which the placenta produces in large amounts as it enlarges. This hormone affects both fatty acid and glucose metabolism by increasing lipolysis and decreasing glucose uptake. Increased production of estrogen and progesterone can also interfere with the insulin-glucose relationship, and increased production of insulinase degrades insulin. Insulin levels may need to be adjusted to compensate for hormonal changes.

When using ultrasound to determine the estimated date of birth (EDB) for a pregnant woman whose menstrual cycles are irregular, the crown-rump length is most accurate at a. 4 to 6 weeks b. 6 to 10 weeks c. 12 to 18 weeks

B ...with accuracy of plus or minus 3-5 days. However, after about the 12th week of gestation, the fetus begins to curve, making the crown-rump length less accurate. Thus, after the first trimester, the estimated date of birth is obtained using three measures: femur length, abdominal circumference, and biparietal diameter.

Preterm labor is defined as onset of labor before a. 35 weeks b. 37 weeks c. 39 weeks

B ...with cervical change and uterine contractions during weeks 20-36. Most infant deaths (more than 75%) associated with preterm labor and birth occur in infants who are fewer than 32 weeks gestation. Risk factors for preterm labor include maternal age younger than 17 or older than 35 years, non-white race, lower economic status, and lower educational status. Patients with previous preterm labor or birth or who have undergone second trimester abortions or had stillbirths are also at increased risk.

The initial postpartal intervention indicated for a soft boggy uterus is to a. apply an ice compress. b. massage the fundus until firm. c. apply a warm compress.

B ...with the dominant hand while supporting the inferior uterus with the non-dominant hand to prevent trauma. If the fundus does not contract with massage, then further evaluation is indicated to determine if placental fragments remain. After the fundus becomes contracted, the nurse should push firmly downward on the fundus to expel clots that may have pooled.

With precipitous labor, the entire process of labor and delivery occurs within a. 2 hours b. 3 hours c. 4 hours

B ...with the primigravida dilating 5 cm or more per hour and the multipara up to 10 cm per hour. Precipitous labor is most common in women older than 35 years. It is usually associated with low resistance in soft tissues so that the cervix dilates and effaces rapidly, and with unusually strong uterine contractions. Because the birth is so rapid, it may be unattended or occur on the way to the hospital.

The most frequent cause of postpartal hemorrhage is a. vaginal laceration. b. uterine atony. c. retained placental fragments.

B 90%. Following delivery, uterine contractions are needed to compress vessels and prevent bleeding from the placenta attachment site, but with uterine atony, the contractions are absent or ineffective. Predisposing factors induce distended uterus (multiple gestations and hydramnios), precipitous and prolonged labor, and administration of magnesium sulfate. The uterus may respond to massage, oxytocin, or Methergine (methylergonovine maleate), but surgical intervention (ligation of vessels, repair of lacerations, selective arterial embolization, or hysterectomy) may be required.

Most ectopic pregnancies implant in the a. cervix b. fallopian tubes c. abdominal cavity

B About 95%, with the remaining pregnancies occurring in the abdominal cavity, ovary, and cervix. Ectopic pregnancy may lead to maternal death (10% of total maternal deaths) and is associated with resultant infertility; only about 60% of women are able to conceive after having an ectopic pregnancy, and 40% of these pregnancies result in another ectopic pregnancy. Although it is possible to carry an ectopic pregnancy in the abdominal cavity to term with surgical delivery, these pregnancies carry a high risk of fetal deformity.

For a preterm fetus at 31 weeks' gestation, what is considered an acceleration? a. Increase of at least 5 bpm for at least 5 seconds b. Increase of at least 10 bpm for at least 10 seconds c. Increase of at least 15 bpm for at least 15 seconds

B Accelerations is a temporary increase in fetal heart rate. Less than 32 weeks, a preterm infants' heart rate increases at least 10 bpm for at least 10 seconds. If the fetus is under 28 weeks, there is usually very little variability because the autonomic nervous system is still immature. If accelerations persist for more than 2 minutes, they are classified as prolonged. If the accelerations persist for more than 10 minutes, they are considered a change in the baseline rate.

The minimum anesthesia usually needed for forceps-assisted delivery is a. spinal block. b. pudendal block. c. general anesthesia.

B Although forceps-assisted delivery is sometimes carried out with only local anesthetic, most patients cannot tolerate the use of forceps well without a minimum of a pudendal block. Regional anesthesia may be used in some circumstances and general anesthesia poses increased risk to the fetus. The criteria for forceps application, including the fetus's position, station, and presentation, should be reviewed to ensure that the patient is a candidate prior to forceps-assisted delivery.

At 4 weeks gestation, two beta hCG values taken 48 hours apart show decreasing values. This suggests a. normal pregnancy b. miscarriage/ectopic pregnancy c. inaccurate calculation of inception

B Beta hCG is produced by the trophoblast or placenta and accurately indicates the presence of pregnancy. For the first 10 days of pregnancy, the levels double every 2 days and then continue to increase until peaking at 60-90 days after conception, so a stable to falling level indicates that the pregnancy is not progressing.

The best method to determine if maternal-infant bonding is occurring is to a. ask the mother if she is bonding b. observe maternal-infant interactions c. ask the father/partner if he/she observes bonding

B Bonding is characterized by progression in the mother touching the infant and making face-to-face eye contact as well as verbally responding to and cuddling the infant. The mother should demonstrate pleasure in the infant through actions or words, such as referring to the infant by name and noting family characteristics. The mother should show sensitivity to the needs of the infant, such as hunger.

Idiopathic cardiomyopathy of pregnancy is a condition that a. precedes pregnancy and exacerbates due to the stress of pregnancy. b. develops in the last month of pregnancy or soon after birth without preexisting cardiac disease. c. develops in the first trimester of pregnancy and must be monitored throughout the pregnancy and delivery.

B Develops in the last month of pregnancy or the first 5-6 postpartal months and is not associated with pre-existing myocarditis, endocarditis, or cardiac disease. It is characterized by left ventricular systolic dysfunction. Typical symptoms are similar to heart failure and include dyspnea (the most common symptom), orthopnea, cough, palpitations, and chest pain. The heart is markedly enlarged, and the ejection fraction is less than 45%. It increases risk of thromboembolia, so the woman is often treated with heparin. Treatment is similar to that for heart failure although if it occurs prior to delivery, ACE inhibitors are withheld because of adverse effects to the fetus. Management includes bedrest, diuretics, and digoxin.

The three classic signs of placental separation after delivery are a. uterus falls, blood gushes, and cord lengthens b. uterus rises, blood gushes, and cord lengthens c. uterus rises, blood gushes, and cord shortens

B Extrusion of the placenta usually occurs within 30 minutes of delivery. Slight tension is usually placed on the cord during delivery of the placenta, but excessive tension may result in tearing of the cord or inversion of the uterus and must be avoided. The placenta should be carefully examined after delivery to determine if it is complete as placental fragments increase risk of maternal hemorrhage.

An obstetric laceration that extends through the rectal sphincter but not into the rectal mucosa would be classified as a. second degree b. third degree c. fourth degree

B First: involves vaginal mucosa or skin of perineum but not the underlying tissue Second: involves underlying tissue but the tear does not invade the rectal sphincter or rectal mucosa Third: extends through the rectal sphincter but not further into the rectal mucosa Fourth: extends through the rectal sphincter and into the rectal mucosa

Following birth, fetal characteristics during the first period of reactivity include a. sleepiness and/or prolonged sleeping. b. alert state and movement of limbs. c. periods of apnea and regurgitation.

B Following birth, fetal characteristics during the first period of reactivity, which begins at birth and lasts for 30 min to 2 hours, include an alert state and movement of limbs. The neonate appears wide-awake and may appear hungry and begin rooting. The neonate will begin nursing if offered a breast. Respirations may be quite rapid, up to 80 per minute, and the heart rate may be elevated to 180 bpm although the respiratory rate and heart rate gradually slow as the infant enters a period of sleep.

For a multipara, protracted labor is diagnosed when descent of the presenting part is less than a. 1 cm per hour b. 2 cm per hour c. 3 cm per hour

B For nullipara, protracted labor is less than 1 cm per hour. Other abnormal labor patterns include prolonged latent phase when there is no progress from the latent to the active phase after more than 20 hours for multiparas and more than 14 hours for nulliparas and arrest disorders, including secondary arrest of dilation and arrest of descent.

On the maternal serum screen, a high level of alpha-fetoprotein indicates a possibility of a. trisomy 21 (Down syndrome) b. neural tube defect c. trisomy 18 (Edwards syndrome)

B However, levels may also be high with multiple gestations, other fetal abnormalities (gastroschisis), and fetal death. Many false positives occur because of inaccuracy in gestation age because the test is most accurate if done between 16-18 weeks, although it can be done anytime between 14-22 weeks. The alpha-fetoprotein level identifies about 85% of fetuses with neural tube defects.

With acute respiratory distress syndrome (ARDS) in the neonate, the goal of therapy is to maintain oxygen saturation greater than a. >85%. b. >90%. c. >95%.

B If ARDS is mild, oxygen administration per nasal prongs or mask may be adequate, but if levels fall under 90% then endotracheal incubation with mechanical ventilation or high-frequency oscillatory ventilation may be indicated. ARDS is characterized by tachypnea, crackling rales, decreased lung volume, cyanosis, hypotension, and tachycardia. In the early stages, respiratory alkalosis is common but later develops into hypercarbia and respiratory acidosis.

The appropriate endotracheal tube size (internal diameter) for a neonate of 30 weeks' gestation and 1,500 g is probably a. 2.5 mm b. 3 mm c. 4 mm

B In a resuscitation kit for neonates, endotracheal tube sizes should include tubes ranging from 2.5-4 mm. -2.5 mm: neonates less than 28 wks/less than 1000g -3 mm: neonates 26-34 wks/1000-2000g -3.5 mm: neonates 34-38 wks/2000-3000g -3.5-4 mm: neonates 38+ wks/3000g+

If retained placental fragments are suspected, the best method of to confirm the diagnosis is a. manual exploration b. ultrasound c. hysteroscopy

B In some cases, manual exploration may identify fragments, which can be loosened manually and removed. After expulsion of the placenta, it should be carefully examined for missing cotyledons to ensure it is intact. Retained fragments may occur if the placenta is forcefully separated during fundal massage prior to spontaneous separation. Retained fragments can prevent the uterus from contracting and compressing vessels, resulting in hemorrhage.

Iron deficiency anemia during pregnancy is usually treated with a. blood transfusion. b. ferrous sulfate, 325 mg orally daily. c. iron dextran, intramuscular.

B Iron deficiency anemia during pregnancy, accounts for approximately 95% of cases of anemia, is usually treated with oral ferrous sulfate, 325 mg orally daily. Higher or more frequent doses may result in GI upset and constipation and decreased absorption. If patients are unable to adequately absorb oral iron, then iron dextran 100 mg every other day for about 3 weeks may be administered IM. Transfusions are only indicated if severe symptoms, such as dyspnea, tachycardia, dizziness, are present.

In a neonate, Klumpke paralysis is associated with injury to the a. median and ulnar nerves in the arm b. lower nerves of the brachial plexus c. upper roots of the brachial plexus

B It affects the hand while Erb (Erb-Duchenne) palsy, caused by injury to the upper roots of the brachial plexus, causes paralysis of the upper arm and forearm so that the arm hangs limply with the forearm extended and internally rotated. Finger function is usually not impaired. Injury to the brachial plexus is most common with macrosomia and breech or difficult deliveries.

A symmetrical deceleration with a gradually decreasing fetal heart rate and return to baseline over at least 30 seconds in response to uterine contractions with the deceleration nadir occurring at the peak of the contraction is a. a late deceleration b. an early deceleration c. a variable deceleration

B Late decelerations: similar parameters but the nadir of the deceleration occurs after the peak of the uterine contraction. Variable deceleration: sudden decrease in heart rate lasting less than 30 seconds that may or may not be associated with uterine contractions with the heart rate decreasing by at least 15 bpm for at least 15 seconds but less than 2 minutes. Prolonged decelerations: lasts at least 2 minutes but less than 10 minutes

A primigravida patient nearing term who complains of leg cramps, increased pelvic pressure, increased urinary frequency, and peripheral edema is probably experiencing. a. active labor b. lightening c. Braxton Hicks contractions

B Lightening often occurs in first-time pregnancies about 2 weeks prior to onset of labor as the fetal presenting begins to descend into the pelvis. This relieves pressure on the diaphragm, which decreases indigestion and shortness of breath but increases pressure on the bladder and lower circulation, resulting in leg cramps, increased pelvic pressure, increased urinary frequency, increased vaginal secretions, and peripheral edema. In multiparous women, lightening may be delayed until onset of active labor.

A patient at 24 weeks' gestation with blood pressure (BP) 150/94 mm Hg and 0.4 g of protein in 2-hour urine specimen would be classified as having a. hypertension b. mild preeclampsia c. severe preeclampsia

B Mild Pre-E: BP 140/90 or higher with BP previously normal and 0.3g or higher protein in a 2 hour urine specimen. Severe Pre-E (one or more of the following): BP 160/110 mm Hg or higher separated by 6 hours on bedrest. Proteinuria at least 5g per 24 hour urine specimen or at least 3+ in 2 random urine specimens at least 4 hours apart. Oliguria less than 500 mL per 24 hours, pulmonary edema/cyanosis, visual disturbances, thrombocytopenia, impaired liver function, or epigastric/RUQ pain.

According to NICHD terminology and definitions, a fetal baseline heart rate of 140 bpm would be considered a. bradycardia b. normal c. tachycardia

B Normal fetal baseline heart rate is 110-160 bpm. Bradycardia is heart rate below 110 bpm and tachycardia is above 160 bpm.

What is a contraindication of oxytocin infusion? a. Eclampsia b. Non-reassuring fetal heart rate c. Dystocia

B Other contraindications include cephalopelvic disproportion, transverse lie, placenta previa, vasa previa, previous classic uterine incision or uterine surgery, and invasive carcinoma of the cervix. Oxytocin is used to stimulate uterine contractions, thus inducing or augmenting labor, and may be indicated for suspected fetal jeopardy, dystocia, postterm pregnancy, eclampsia, fetal death, chorioamnionitis, and multiple maternal medical problems, such as renal disease or uncontrolled diabetes mellitus

Patients in labor are usually advised to come to the hospital when a. contractions occur every 10 minutes for at least an hour. b. the membranes rupture. c. bloody show occurs.

B Other indications include contractions that are occurring every 5 min for at least an hour, significant vaginal bleeding (always a warning sign), or decreased fetal movement. On admission, both a focused review of systems to determine if possible complications of pregnancy are present and a limited general physical examination are completed. Contractions should be assessed for intensity and duration and fetal heart tones auscultated immediately after a contraction.

The HELLP syndrome refers to hemolysis, elevated liver enzymes, and a. labor pain b. low platelet count c. large placenta

B Patients usually complain of pain in the epigastric or RUQ area of the abdomen. HELLP may occur in up to 20% of patients with pre-E or eclampsia. When diagnosed, the treatment of choice is to immediately deliver the infant (even if premature) as the condition may worsen rapidly and threaten both the mother and child.

The first stage of labor is the time period between onset of labor and a. cervical dilation of 8 cm. b. cervical dilation of 10 cm. c. delivery of infant

B Phases: -Latent: may vary widely in duration but is commonly 10-12 hours in multiparas and about 20 hours in primigravidas. The cervix begins effacement and contractions increase in frequency and intensity. -Active: The cervix dilation is 3-4 cm at onset and 8-9 cm at the end with this phase lasting about 5 hours for primigravidas and 2 hours for multiparas. -Deceleration phase: Dilation completes and delivery is imminent.

When administering magnesium sulfate to a patient in preterm labor, the patient's fluids should be a. restricted to 1,000 to 1,500 mL per 24 hours b. restricted to 1,500 to 2,400 mL per 24 hours c. forced to 2,400 to 3,000 mL per 24 hours

B Pulmonary status should be monitored closely as patients receiving some tocolytics, such as magnesium sulfate and some beta-2 agonists (terbutaline), may develop tocolytic-inducted pulmonary edema; however, this is a fairly rare condition.

If a neonate is bobbing his head and holding his hands in fists, this probably indicates a. neurological impairment b. hunger c. pain

B Signs of hunger may be subtle with crying (squawking) typically the last sign. Once an infant begins crying and acting frantic, the child may have difficulty latching on. Other signs of hunger include licking, sucking motions, rooting, bringing hands to mouth or face, and trying to suck a finger stroking the infant's cheek or lower lip. If the neonate is consistently underfed, the infant may become listless and show less interest in nursing.

While adapting to the maternal role, the puerperal phase in which the mother is most receptive to patient education is a. taking-in b. taking-hold c. letting go

B Taking in (1-2 days): The patient remains somewhat passive, tending to her own needs, taking in details about the neonate, and discussing labor and delivery. Taking hold (several days): The patient takes a more active role and questions her competence, seeking out information. This is the most teachable time. Letting go: The patient begins to let go of previous lifestyle and learns to accept the real infant as opposed to the one imagined.

A patient is in active labor and has contractions every 8 minutes lasting for 45 seconds and increasing in intensity by 25 mm Hg during contractions. This patient is likely experiencing a. hypertonic labor. b. hypotonic labor. c. normal labor.

B The average amplitude is 40-50 mmHG. Because the contractions are often irregular and have low amplitude, cervical dilation is usually slowed or may arrest so that labor becomes prolonged without interventions. Treatment may include ROM and/or oxytocin to strengthen the contractions

For forceps-assisted and vacuum-assisted delivery, if the leading edge of the fetal skull is at station +2 or lower, it is classified as a. outlet b. low c. midpelvis/midforceps

B The classification system for assisted delivery includes specific criteria: -Outlet: Scalp is visible as fetal head is on perineum. Positions are ROA, LOA, ROP, or LOP. -Low: Leading edge of fetal skull at +2 station or lower. -Midpelvis/midforceps: Fetal head engaged and above +2 station.

Repeated variable decelerations of fetal heart rate during labor suggest a. normal variations b. umbilical cord occlusion c. uteroplacental insufficiency

B The fetus may roll on the cord or the cord may be around the neck, resulting in occlusion during uterine contractions Repeated variable decelerations may also indicate a short cord or occult prolapse of the cord. If the variable decelerations occur occasionally without pattern, they are usually not of concern, but if they are repeated and worsen as labor progresses, the fetus is at risk. If the variable decelerations are in response to rupturing the membranes, changing the mother's position may alleviate the decelerations.

In a normal singleton pregnancy with cephalic presentation, if the fundal height is palpated at 28 cm, the gestational age is approximately a. 22 weeks b. 28 weeks c. 32 weeks

B The fundal height in centimeters approximately corresponds to the gestational age in weeks if gestation is between 1-36 weeks. After 36 weeks, the uterus begins to change shape as the body prepares for delivery and the fetal head becomes engaged. At this time, the fundal height may even decrease or grow more slowly.

Hypotension with a positive Cullen sign (ecchymosis about umbilicus) and shoulder pain may indicate a. ruptured uterus b. ruptured ectopic pregnancy c. spontaneous abortion

B The hypotension occurs because of blood loss, and blood in the perineal cavity causes irritation of the diaphragm and referred pain to the shoulder area as well as the ecchymosis about the umbilicus. While an unruptured ectopic pregnancy often causes pain, the pain increases with rupture and may vary in intensity and site, with some patients complaining of pain in the lower abdomen and some with unilateral or generalized abdominal pain

If a patient is to give birth in the left lateral Sims position, the best comfort measure is to a. reassure the patient b. support the upper leg with pillows c. encourage frequent change of position

B The left lateral Sims position helps to reduce the need for episiotomy by increasing perineal relaxation. The left lateral Sims position slows fetal descent and reduces the risk for aspiration, although it prevents the mother from observing the birth process. If the patient should require an episiotomy or the use of forceps, then repositioning is necessary.

If a fetal scalp sampling shows pH of 7.23 with non-reassuring fetal heart rate, the response should be to a. monitor and repeat sampling in 2-3 hours b. monitor and repeat sampling in 15-20 minutes c. immediately repeat sampling and, if no improvement, immediate delivery

B The normal fetal blood pH is 7.25-7.35. If the pH falls to a pH of 7.2 or less, then immediate delivery is indicated because acidosis is present and presenting a risk to the fetus. The sample is taken transvaginally with a special lancet that punctures the fetal scalp rather than cuts in order to prevent bleeding.

Complications associated with maternal obesity in the labor process include a. maternal hypotension, uterine rupture and lacerations b. prolonged second stage of labor, fetal macrosomia and maternal hypertension c. meconium aspiration and maternal hemorrhage

B The obese mother is at increased risk of developing gestational diabetes and hypertension. The second stage of labor is often prolonged because the myometrium is overstretched. Additionally, labor is difficult and associated with macrosomia and shoulder dystocia, which can cause permanent brachial plexus injury in the newborn. Because of excessive fatty tissue in the abdomen, monitoring of fetal heart rate and contractions may be difficult. During labor and delivery, the woman is at increased risk of uterine rupture and lacerations.

The most common visual complaint during pregnancy is a. myopia. b. blurred vision. c. hyperopia.

B The pregnancy woman tends to retain fluid, and this retention along with decreased intraocular pressure causes some thickening of the cornea and change of shape during the first trimester, resulting in blurring of vision. However, these changes usually resolve within the first 8 weeks of pregnancy, so the visual changes should not be causes for changing prescriptions for corrective lenses. Pregnant women also commonly complain of dry eyes, which may be relieved by the use of artificial tears.

A tocotransducer detects a. intensity of uterine contractions. b. frequency and duration of uterine contractions. c. resting tone of the uterus between contractions.

B The toco has a pressure sensitive area that detects changes in the contour of the abdomen that occur with contractions. The sensor may also detect other movements, such as those associated with maternal respirations and fetal movements. The toco cannot provide a reliable estimate of the intensity of uterine contractions or the resting tone, and different maternal positions may affect the pressure against the toco.

If a vanishing twin is noted in the first trimester, the pregnancy is considered a. high risk b. normal c. aborted

B The vanishing twin syndrome results from miscarriage of one fetus with the tissue absorbed by the mother or the other fetus and occurs in up to 30% of twin pregnancies. The patient may or may not have indications of miscarriage (cramping, bleeding) when one twin dies. If the vanishing twin occurs in the second or third trimester, the pregnancy is considered high risk, and the remaining twin is at risk for cerebral palsy.

A primary problem assoicated with cocaine use by a pregnant patient is a. vasodilation b. vasoconstriction c. hemolysis

B This results in compromised circulation to the placenta, which in turn causes hypoxia and growth retardation of the fetus. Cocaine also causes apoptosis (programmed cell death) of the fetal heart muscles, resulting in cardiac dysfunction. The fetus is at increased risk of preterm birth; if the child survives delivery, he/she may have multiple abnormalities, such as defects in limbs and the genitourinary tract, anal/intestinal atresia, and cerebral infarctions.

In a nonstress test (NST) of a fetus at 34 weeks, a normal or reactive acceleration is at least a. 10 bpm for 10 seconds b. 15 bpm for 15 seconds c. 20 bpm for 20 seconds

B This test measures the response of the fetal heart rate to fetal movement, so the test must be done when the fetus is not in a sleep cycle. Accelerations usually do not occur until the fetal central nervous system is sufficiently mature, usually at 30-32 weeks. At 30 weeks, a normal or reactive acceleration is at least 10 bpm for 10 seconds.

After 20 weeks of gestation, amniotic fluid is primarily produced by a. maternal serum b. fetal excretion of urine c. fluids from fetal respiratory tract

B Thus, if the volume of amniotic fluid is low (oligo), less than 500 mL, urinary tract abnormality (renal agenesis, polycystic kidneys) or obstruction (obstructive uropathy) should be suspected. Other conditions associated with oligo include pulmonary hypoplasia, post-term gestation, meconium staining, umbilical cord compression, and prolonged leaking of amniotic fluid, increasing risk of neonatal infection. Adequate amniotic fluid is essential for normal pulmonary development.

Low amplitude, irregular uterine contractions resulting in less than 1 cm dilation per hour, and arrest of progress for more than 2 hours often results from a. hypertonic contractions b. hypotonic contractions c. macrosomia

B Treatment includes administration of oxytocin and/or amniotomy (if membranes remain intact) after assessment to ensure that cephalopelvic disproportion (CPD) or malpresentation is not present. The cause of hypotonic uterine contractions is not clear, but familial tendencies exist so genetic factors may play a role. Hypotonic uterine contractions are more common in patients older than 25 years.

If a postpartal rubella antibody screen shows a patient is not immune to rubella, the patient should a. receive the vaccination in 28 days b. receive the vaccination immediately c. receive the vaccination after stopping breastfeeding

B Usually the screening is done prenatally although the patient cannot receive the vaccine during the pregnancy but is advised to receive it after childbirth to prevent risks to future pregnancies. Women who receive the vaccine should avoid becoming pregnant for at least 28 days after the vaccination because rubella vaccine contains a live virus.

If signals from a fetal scalp electrode suddenly become completely erratic and stop, what is the most likely reason? a. Fetal distress b. Electrode dislodgement c. Equipment malfunction

B When applied to the scalp, the electrode only penetrates approximately 1 mm, so the electrode can easily become dislodged with fetal movement, and attachment is more difficult if the fetus has a lot of hair. Once an electrode is secured to the scalp, the lead wire extends through the patients' vagina and is attached to a leg plate for grounding. The unit beeps with each fetal heartbeat.

Postpartal dyspareunia may occur when a woman is breastfeeding because a. the woman is overtired b. estrogen production is low c. the woman experiences psychological withdrawal

B While many women are overtired when breastfeeding and some may experience psychological withdrawal from intimacy, the primary cause of postpartal dyspareunia is low production of estrogen. Until estrogen production increases, the vaginal mucosa is atrophic and dry, and the walls are thin, contributing to dyspareunia. Lactation suppresses ovarian function and production of estrogen, so the mucosa doesn't usually return to normal or the vaginal walls to prepregnancy thickness while breastfeeding.

Neonatal thrombocytopenia is defined as a platelet count of a. less than 250,000/mm3 b. less than 150,000/mm3 c. less than 100,000/mm3

B While platelet counts tend to be higher in neonates and children up to 5 years of age (217,000/mm3 to 497,000/mm3) than in older children and adults (150,000/mm3 to 450,000/mm3), and similar to adults in healthy preterm infants, neonatal thrombocytopenia is defined as a platelet count less than 150,000/mm3. Most cases (75%) of neonatal thrombocytopenia result from impaired production of platelets, while remaining cases result from increased destruction. Incidence of thrombocytopenia is low in well newborns, but may affect over a third of infants in the NICU and up to three quarters of infants who have extremely low birth weight.

Afterpains may persist for a. 24 hours b. 2 to 3 days c. 7 days

B With the first pregnancy, the uterus often stays contracted after delivery, but with following pregnancies or when there are complications (hydramnios, clot retention), the uterus may alternate between contractions and relaxations, resulting in severe cramping afterpains that may persist for 2-3 days. Treatment with oxytocin or breastfeeding, which causes natural release of oxytocin, may also cause afterpains. Afterpains are usually treated with a mild analgesic, such as acetaminophen or ibuprofen.

Twelve hours postpartum, a patient's fundus is 2 centimeters above the umbilicus and boggy, likely indicating a. normal findings b. excessive bleeding c. distended bladder

B Within 6-12 hours after delivery, blood and clots pool in the uterus, causing it to rise to the level of the umbilicus, midline. After about 12 hours, the fundus lowers and should be about 1 cm below the umbilicus by the first postpartal day. If the fundus rises above the umbilicus but deviates to one side, this often indicated a distended bladder.

The most common reason for elevated bilirubin levels in a breastfed infant within a week of birth is a. fatty acids resulting from cold stress b. inadequate intake of breast milk c. immature gastrointestinal tract

B aka breastfeeding jaundice. If the child does not nurse adequately because of excessive sleepiness, poor sucking, or infrequent nursing, the child may not ingest enough colostrum to benefit from its laxative effect, which helps to eliminate meconium, which is high in bilirubin. The mother may need assistance with breastfeeding to increase the neonate's intake and the production of milk.

A cordocentesis can be performed after how many weeks' gestation? a. 16 b. 18 c. 20

B aka percutaneous umbilical cord blood sampling (PUBS), guided by ultrasound, can be performed after 18 wks of pregnancy, as risks are higher at earlier gestation. If the placenta is located on the posterior wall of the uterus, the needle is inserted through the amniotic fluid to the umbilical cord near attachment to the placenta, but if the placenta is located on the anterior or lateral walls, the needle must first go through the placenta. Cordocentesis can be used to identify fetal abnormalities, infections, anemia, and congenital alloimmune thrombocytopenia.

Podalic version is indicated only for a. delivery of first twin, not in cephalic presentation b. delivery of second twin, not in cephalic presentation c. delivery of either twin, not in cephalic presentation

B rarely used today when the second twin is not in the cephalic presentation but in transverse lie or some other abnormal presentation. If done internally, the physician or midwife reaches inside the uterus and grasps the fetus's feet, turning the fetus into a breech position while applying downward pressure externally to the abdomen and pulling the feet through the cervix and vagina. The fetus is then delivered feet first.

A pregnant woman with cervical funneling is at risk for a. hemorrhage b. miscarriage/preterm delivery c. prolonged labor

B risk for cervical incompetence, which means that the muscles of the cervix are weak and the pressure of the growing fetus may produce early effacement and dilation before contractions begin, resulting in miscarriage or preterm delivery during the second and third trimester. A normal cervix is 30 mm long; cervical incompetence means the cervix is less than 25 mm long at 24 weeks or less of gestation. The shorter the cervix, the greater the risk of preterm birth.

Following birth, which hormone stimulates the alveolar cells of the breast, promoting production of milk? a. Estrogen b. Prolactin c. Progesterone

B which increases in response to the neonate's suckling. Suckling also promotes release of oxytocin, which promotes the letdown reflex by increasing contractibility of the muscles of the mammary ducts. After milk production is well established, prolactin levels decrease, and most milk production is then facilitated by oxytocin. During pregnancy, estrogen promotes proliferation of breast ducts and progesterone the development of lobules and alveoli

Breast self-stimulation is often done to facilitate the a. nonstress test b. vibroacoustic stimulation test c. contraction stimulation test

C (CST), which evaluates the fetal heart rate response to contractions. The test requires contractions lasting at least 40 seconds in a 10 minute period of time. In order to stimulate contractions, the patient may be administered oxytocin or asked to carry out self-stimulation of the breasts because nipple stimulation results in increased production of endogenous oxytocin. Baseline measurements are taken for the first 15-20 minutes before the CST is carried out.

With abruptio placentae, fetal death is common with separation of a. at least 15% b. at least 25% c. at least 50%

C (premature detachment of placenta from the uterus). It is associated with maternal hypertension and cocaine use. Intrauterine growth retardation occurs with partial detachment because the fetus lacks adequate nourishment. If total detachment occurs, hemorrhage may occur, with half of those affected exhibiting coagulopathy. Complications can include fetal distress, fetal death, hypotension, DIC, and maternal death. Partial placental abruption is treated with bedrest and monitoring; complete separation requires immediate vaginal delivery or cesarean.

During the active phase of the first stage of labor, the patient should dilate to a. 2 to 3 cm b. 3 to 5 cm c. 4 to 7 cm

C (which follows the latent phase and precedes the transitional phase) of the first stage of labor. The nullipara typically dilates about 1.2 cm per hour while the multipara dilates 1.5 cm per hour. Contractions occur every 1-5 minutes and last for 40-60 seconds with contractions stronger, increasing both pain and anxiety. Most multiparous patients are admitted to labor and delivery in this phase, although nulliparous patients often are admitted earlier.

The probable gestational age of an infant born with dry, wrinkled, peeling skin, no vernix, and loss of subcutaneous fat is a. 24 to 26 weeks b. 35 to 40 weeks c. 42 to 44 weeks

C -24 to 26 weeks: translucent, red, many visible blood vessels, scant vernix -35 to 40 weeks: deep cracks, no visible blood vessels, thick vernix -42 to 44 weeks: dry, wrinkled, peeling skin, no vernix, loss of subcutaneous fat

A neonate's umbilical cord blood values were pH 7.16, pO2 18 mmHg, and pCO2 55 mmHg, with base excess of 11 mEq/L, indicating a. normal values b. respiratory acidosis c. metabolic acidosis

C -Respiratory acidosis: pH < 7.25, pO2 varies, pCO2 > 50 mmHg, Base excess < 10 mEq/L -Metabolic acidosis: pH < 7.25, pO2 < 20 mmHg, pCO2 44-55 mmHg, base excess > 10 mEq/L

Postpartal infection is most commonly associated with trauma and a. hypertension of pregnancy b. placental retention c. blood loss

C ..., allows bacteria to more easily invade the tissue, and blood loss, which lowers the immune response to bacteria. Risk factors associated with labor and delivery include cesarean, rupture of fetal membranes, intraamniotic infection, prolonged labor, internal fetal monitoring, and multiple pelvic examinations. Maternal risk factors include obesity, chronic disease, vaginal infection, anemia, immunosuppression, and low economic status. A patient with a fever higher than 38C should be carefully examined to determine the cause.

Folic acid/folate deficiency in the mother places the fetus at risk for a. hypoxic encephalopathy b. IUGR c. neural tube defects

C ...., cleft lip, and cleft palate and is more common with multiple gestations than singleton. With folate deficiency, red blood cells enlarge (macrocytic) instead of divide so the number of circulating blood cells decreases. Pregnant women should take 0.4 mg daily and those at high risk 1-4 mg daily along with an iron supplement. Women with a previous infant born with neural tube defect should take 4 mg daily for the month preceding pregnancy and for the first trimester.

If the partner of a patient undergoing an emergency cesarean delivery is afraid of fainting at the sight of blood, the best information is that a. almost no one who is afraid of fainting actually faints b. the person can leave the room at any time if feeling faint c. the sterile drape can serve as a partition to shield the view

C ....although in some cases the patient may want the drapes arranged so she can observe the birth. In that case, the partner may sit facing the patient. The partner who is attending the birth must dress in scrubs and mask and sit on a stool near the patient's head in order to provide support and encouragement.

In a neonate with poor ventilation, the blood gas findings that indicate respiratory acidosis are a. decreased pH, increased base (pHCO3), and pCO2 and pO2 within normal limits b. increased pH, decreased pCO2, increased pO2, and base within normal limits c. decreased pH, increased pCO2, and pO2 and base within normal limits

C ....decreased pH (< 7.25), increased pCO2 (> 40 mmHg) and pO2 and base (pHCO3) within normal limits. Metabolic acidosis is indicated by decreased pH, increased base (pHCO3), and pCO2 and pO2 within normal limits. Respiratory alkalosis is indicated by increased pH, decreased pCO2, increased pO2, and base within normal limits Metabolic alkalosis is indicated by increased pH and base and pCO2 and pO2 within normal limits.

The last fetal system to mature functionally is the a. cardiovascular. b. renal. c. respiratory.

C ....so assessment of the respiratory system is especially important for preterm births under 36 weeks. If the respiratory system is immature, the neonate is unable to adequately ventilate the lungs and lacks adequate surfactant (phospholipids), which lower surface tension in alveolar sacs and facilitate ventilation This condition is referred to as respiratory distress syndrome (RDS). With RDS, the neonate may exhibit chest retraction, nasal flaring, grunting respirations, and hypoxia.

Before placing the intrauterine pressure catheter, the physician or midwife should review the maternal a. complete blood count b. platelet count c. ultrasound report

C ....to determine the location of the placenta because insertion of the catheter is contraindicated with placenta previa. Before catheter placement, the membranes must have ruptured spontaneously or by amniotomy. Once in place, the IUPC is connected to an electronic monitor. Normal resting pressure is 20 mmHg. Pressure ranges by phase: -Latent: 20-40 mmHg -Active: 50-70 mmHg -Transition: 70-90 mmHg -Second Stage, pushing: 70-100 mmHg

A neonate born at 36 or more weeks gestation with moderate hypoxemic-ischemic encephalopathy should be treated with hypothermia for how long? a. 24 hours b. 48 hours c. 72 hours

C ....with induced temperatures of 33.5C/92.3F to 34.5C/94.1F for 72 hours, with the treatment initiated within 6 hours and the neonate slowly warmed over a 4 hour period at the conclusion of the therapy. Studies show that neonates treated with hypothermia had lower rates of neurological impairment and lower rates of mortality than those who received alternative treatments.

The primary sign or symptom of oligohydramnios is often a. lower abdominal pain. b. increased Braxton-Hicks contractions. c. decreased fetal movements.

C ....with no other maternal symptoms although in some cases the uterus may seem smaller than expected. Numerous causes include some medications (NSAIDS and ACE Inhibitors), uteroplacental insufficiency, fetal abnormalities, and premature rupture of membranes. If it occurs early in pregnancy, the fetus may develop contractures of the limbs, because of restricted movement, and impaired maturation of the lungs.

The purpose of a birth plan is to a. tell the expectant mother what to expect during labor and delivery b. provide a checklist for the physician and midwife c. allow the expectant mother and partner to make advance decisions

C ...about what the patient wants during labor and delivery in terms of labor (bedrest, ambulation, frequency of vaginal exams), fetal monitoring (continuous, intermittent), induction (conditions for artificial rupturing of the membranes, medications), comfort measures/analgesia/anesthesia (natural childbirth/epidural, opioids), surgical interventions (conditions for cesarean, episiotomy), delivery (positioning, method), and postpartal period preferences (rooming in/nursery, cutting cord, breast/bottle feeding)

An over-the-counter drug that should be avoided during pregnancy is a. Benadryl (diphenhydramine) b. Tylenol (acetaminophen) c. Motrin (ibuprofen)

C ...and other NSAIDs because they may cause heart defects in the fetus. They especially pose a risk during the third trimester. Tylenol is generally safe to take during pregnancy for mild pain or fever, but aspirin should also be avoided because it can cause birth defects. Pregnant women who need an antihistamine may take Benadryl but should be aware it may cause drowsiness.

A 32 week pregnant patient with sudden onset of severe lower abdominal pain and tenderness, vaginal bleeding, tachycardia, hypotension, and fetal bradycardia probably indicates a. placenta previa b. uterine rupture c. abruptio placentae

C ...as these are typical symptoms although pain and tenderness are absent in some patients. About 70% with abruptio placentae present with vaginal bleeding. Pain may be localized or diffuse. In some cases, blood accumulates between the placenta and the myometrium (Couvelaire uterus), resulting in ecchymosis, discoloration of the uterus,and loss of contractility.

During prolonged labor, the fetus is at risk for a. breech presentation b. hemorrhage c. asphyxia

C ...at risk for trauma associated with difficult delivery (such as subdural hematoma), asphyxia, and infection, including sepsis. Because amniotic fluid levels decrease with prolonged labor, the fetus is also at increased risk of meconium aspiration syndrome (MAS). Management may include an amnioinfusion to reduce meconium and/or to reduce other dangers associated with oligo, such as umbilical cord compression. Maternal risks include lacerations, uterine atony, hemorrhage, infection, and exhaustion.

If the mother is Rh- and the father Rh+, what are the odds that the fetus will be Rh+? a. 25% b. 50% c. 100%

C ...because every fetus will receive the Rh+ antigen from the father who provides half of the genetic makeup. With a first pregnancy, typically the fetus develops no problems because antibodies have not yet formed against the Rh+ antigen, but subsequent pregnancies are at high risk for the development of erythroblastosis fetalis, a hemolytic disease, unless the mother receives RhoGAM (Rh immune globulin) during the first pregnancy at 28 weeks gestation and within 3 days after delivery.

If fragments of the placenta remain in the uterus after placental expulsion, this often results in a. infection b. hypertonic uterus c. hemorrhage

C ...because fragments prevent the uterus from completely contracting and constricting vessels. The placenta should be carefully examined after expulsion to determine if it is intact or if fragments are missing. A manual exploration of the uterus may be indicated if fragments remain in order to separate the fragments from the uterus while supporting the fundus externally with the other hand.

A contraindication for external cephalic version (ECV) is a. non-engaged fetal breech b. reactive nonstress test (NST) c. multiple gestation pregnancy is present

C ...because of the potential for complications. Other contraindications include engaged fetal breech, inadequate or abnormal amniotic fluid (oligo or poly), nonreactive NST, abnormal fetal heart rate tracing (indicating fetus already stressed), ruptured membranes (resulting in inadequate amniotic fluid), fetal anomalies, suspected intrauterine growth restriction (IUGR), and maternal health problems, such as pre-E, diabetes requiring insulin, and hypertension.

The vibroacoustic stimulation test (VST) is sometimes used in conjunction with a. contraction stress test (CST) b. ultrasound c. nonstress test (NST)

C ...because the fetus may be nonreactive during the NST if it is in a sleep cycle. During VST, sound and vibration are applied to the maternal abdomen through a device that delivers 90 dB of sound for 1-3 seconds, stimulating movement of the fetus so that the NST can be more adequately assessed. As an alternative, the NST may be repeated at a later time when the fetus is more active.

Uterine atony may result in a. uterine rupture b. uterine inversion c. hemorrhage

C ...because uterine contractions are needed to occlude blood flow to the placenta. Uterine atony is most common with overdistension of the uterus resulting from multiple gestation or macrosomia and from dysfunctional or prolonged labor (especially third stage) but may occur with gran-multiparity, induction of labor (oxytocin), anesthesia (especially halothane), Pre-E, and placenta previa. It is most common in women of Asian or Hispanic heritage.

When auscultating the fetal heartbeat in the third trimester, the fetoscope should be positioned a. above the symphysis pubis b. below the umbilicus c. against the fetus's back

C ...below the shoulder after carefully palpating to determine the fetal position as heart tones are most easily heard in this position. In early pregnancy, the heartbeat is best auscultated above the symphysis pubis. The heartbeat can usually be auscultated at about 20 weeks but can be detected earlier with Doppler.

Nonperiodic accelerations of the fetal heart rate usually indicate a. fetal cardiac abnormality b. fetal movement in response to uterine contractions c. spontaneous fetal movements

C ...causing the heart rate to increase because of the activity. When the fetus stops moving, the heart rate decreases again. The accelerations do not correspond to uterine contractions. Periodic accelerations, on the other hand, are those that coincide with uterine contractions, as the fetus moves in response to the pressure caused by the contracting uterus. Periodic accelerations may also result from periodic compression of the umbilical cord during contractions.

A series of ultrasound scans after the 20th week show that the fetal head is growing normally but the abdominal circumference is lower than expected. This may indicated which of the following? a. Down syndrome b. Neural tube defect c. Placental insufficiency

C ...common in patients who are diabetic, hypertensive, or anemic. With placental insufficiency, the supply of oxygen and nutrients to the fetus is impaired, so the fetus responds by sending the nutrients to the most critical organs (heart, brain, lungs) and the other abdominal organs receive less, so they develop more slowly

Most twin pregnancies are delivered at a. 30 weeks b. 34 weeks c. 37 weeks

C ...compared with an average of 40 weeks for singletons, so multiple gestation pregnancies are at risk of preterm delivery and must be monitored carefully. With each subsequent fetus, the duration of gestation decreases by about an additional 4 weeks, so the average gestation for triplets is 33 weeks. With twin pregnancies, the mother is asked to do a kick count beginning at about week 30-32 to assess fetal well-being.

The primary risk associated with a midline episiotomy is a. hemorrhage b. urinary incontinence c. laceration

C ...despite the fact that episiotomy is often done to prevent lacerations. Additionally, small lacerations often cause less discomfort than episiotomy and heal more rapidly. The episiotomy may extend into third or fourth degree lacerations, involving the rectal sphincter and mucosa. Episiotomy should not be done routinely to speed delivery but may be indicated with forceps-assisted delivery or arrested descent. Episiotomies may also be done with a mediolateral incision, but this is rarely done in the US.

If a patient is experiencing prolapse of the umbilical cord, the best position is to place the patient in a. left Sims position b. dorsal recumbent position c. steep Trendelenburg or knees to chest

C ...in order to take the pressure off the umbilical cord. Sometimes the cord can be manually repositioned, but care must be taken to avoid compressing the cord further. Treatment includes immediate cesarean or, if delivery is in process, rapid vaginal delivery. If cesarean must be delayed (such as for transit), instilling 500-750 mL of fluid into the bladder may elevate the presenting part and relieve pressure on the cord

The amniotic fluid index (AFI) of the biophysical profile is important because it reflects a. cardiovascular status b. pulmonary status c. renal perfusion

C ...indicating that shunting has not occurred and the kidneys are functioning adequately. A normal AFI is the finding of a single vertical pocket of amniotic fluid at a volume of more than 2 cm (score 2), while an abnormal finding (score 0) is a volume of less than 2 cm, indicating oligohydramnios. Normal volume per vertical pocket usually ranges from 5-25 cm.

During pregnancy, a patient who is receiving hemodialysis for end-stage kidney disease should generally receive hemodialysis how often? a. 3 days a week b. 4 days a week c. 6 days a week

C ...instead of 3 days a week that is most common in non-pregnant patients in order to protect the fetus and because waste products from the fetus enter the maternal circulatory system. Only up to 7% of women receiving dialysis are able to conceive and 1:5 have spontaneous abortions, so pregnancies are high risk. Preterm birth, usually at about 32 weeks is common.

For an elective Caesarean, the most important preoperative measure is to a. determine the method of anesthesia. b. position the patient correctly. c. confirm fetal maturity.

C ...is at least 39 weeks. Confirmation may be done by (1) finding documentation of fetal heart sounds for 30 weeks by Doppler ultrasound/20 weeks by auscultation, (2) noting a 36 wk internal since positive pregnancy test by lab, (3) supporting gestation of at least 39 weeks by ultrasound completed between 6-11 wks, and (4) noting clinical history and later ultrasound that supports at least 39 weeks gestation

Post-term pregnancy extends more than how many weeks? a. 40 b. 41 c. 42

C ...or 294 days after last menstrual period. Increased risks for both the mother and the fetus occur during labor and delivery. Labor is often induced, and delivery is more likely to include the use of forceps or vacuum-assisted delivery because the fetus is large for gestation age (LGA) or macrosomic. Cesarean may be indicated for cephalopelvic disproportion (CPD) or malpresentation.

Red splotchy areas with white papules in the center on the back and chest of a neonate 24 hours after delivery probably indicate a. nevus flammeus (port-wine stain) b. nevus vascularis (strawberry hemangioma) c. erythema toxicum

C ...sometimes up to 2 weeks. Usually disappears within a few hours or days. Nevus flammeus (port-wine stain) is a permanent pink to dark red to purple birthmark. Can occur throughout body. Nevus vascularis (strawberry hemangioma) is a raised dark red rough-surfaced lesion, usually on the scalp. Grows for 5-6 months but recedes by school age without treatment.

A patient who has hypertonic labor and is not progressing but experiencing a prolonged latent phase, increasing pain, and fatigue is likely a candidate for a. Caesarean. b. increased sedation. c. induction.

C ...unless contraindications, such as extreme fatigue or cephalopelvic disproportion (CPD), are present. With hypertonic labor, the uterus does not adequately relax following contractions, and contractions are painful and ineffective so that effacement and dilation do not occur adequately. Induction with oxytocin is often used to strengthen the contractions.

The most common cause of fever greater than 38C/100.4F in the postpartal period is a. urinary tract infection b. respiratory infection c. genital tract infection

C ...usually of the uterine cavity and adjacent tissues (endometritis, metritis with pelvic cellulitis). Fever usually develops on the first or second day after delivery and persists. Manual removal of the placenta, membrane rupture, prolonged labor, internal fetal monitoring, and Cesarean increase risk of infection. Multiple digital vaginal examinations are also a risk factor. Mortality rates are especially high for both mother (90%) and fetus (50%) with infection caused by group A-hemolytic streptococcus.

Which substance poses the highest risk for birth defects if used during pregnancy? a. Marijuana b. Cocaine c. Alcohol

C ...which can cause fetal alcohol syndrome and a wide range of defects, including impairment of the CNS with intellectual disability and hyperactivity, facial abnormalities, and growth retardation. Marijuana poses fewer risks but may be associated with learning disabilities and behavioral problems. Cocaine has a low risk of birth defects but does impair fetal growth resulting in low birth weight, smaller head, and shorter length.

The anesthetic technique that poses the least risk to the fetus is a. spinal b. epidural c. pudendal block

C ...which involves injection of a local anesthetic to block the pudendal nerve. The block is done in the second stage of labor, usually shortly before delivery to relieve perineal pain and pain associated with episiotomy. While risks to the fetus are minimal, it is possible to directly inject the anesthetic into the fetus. Some infants may show intoxication after delivery with hypotonia, apnea, and even seizures in severe cases, but the infant usually recovers well.

Absent variability, recurrent late and variable decelerations, bradycardia, and sinusoidal pattern in the fetal heart rate are characteristic of NICHD category a. I b. II c. III

C ...which is an abnormal finding suggesting abnormal acid-base status. Category I, normal finding of acid-base status, is characterized by baseline heart rate of 110-160 bpm with moderate baseline variability and no late or variable decelerations, although early decelerations may be present. Category II are all finding inconsistent with Category I or III and cannot be used to predict acid-base status, as data are insufficient.

A fetus in breech position is especially at risk for a. fractures b. hypoxia c. fetal abnormalities

C ...with incidence 3 times that of fetuses in cephalic position. Additionally, the fetus is at increased risk of cord prolapse (4%). About 17% of preterm breech fetuses have congenital abnormalities and 9% of term breech fetuses. While some patients are able to deliver a breech presentation vaginally, planned cesarean delivery carries a lower risk of fetal morbidity and mortality. The fetus is at increased risk of head trauma with vaginal delivery because it does not undergo molding during labor.

When counseling an HIV/AIDS patient about breastfeeding, the mother should be advised that a. breastfeeding poses little risk to the infant b. breastfeeding should only be done if the mother's CD4 count is more than 1,000. c. breastfeeding should be avoided because of risk of transmission

C ...with risk at about 0.7% for each month of breastfeeding. Antiviral therapy should be continued throughout pregnancy as this decreases the risk of transmission to the fetus. Infants are most at risk from untreated HIV positive mothers, with transmission rates of about 30% with infection usually occurring during delivery

The most common source of Escherichia coli infection in the neonate is a. hands of caregivers b. contaminated equipment c. maternal gastrointestinal tract

C ...with the infection usually obtained during vaginal delivery. E. coli infections in the neonate may be severe and can include urinary tract infections, bacteremia, sepsis, and meningitis. Preterm infants or those with impaired immune systems are especially at risk during or after delivery. Symptoms may vary widely depending on the extent of the infection but often include diarrhea, irritability, fever, and poor feeding.

Hypertension without proteinuria that develops after 20 or more weeks' gestation and persists 6 weeks into the postpartum period is classified as a. chronic hypertension. b. preeclampsia. c. gestational hypertension.

C AKA transient hypertension and pregnancy induced hypertension. If the hypertension persists more than 12 weeks PP, without any development of Pre-E, or if it began prior to 20 weeks, then the hypertension is classified as chronic rather than gestational. Therefore, the final diagnosis of hypertension may only be determined in the postpartal period

At birth, a neonate infected with hepatitis C usually exhibits a. generalized edema. b. jaundice. c. no symptoms.

C About 10% of infants born to infected mothers develop hepatitis C and most require no treatment to clear the virus or have very slow progression of liver disease. The fetus of a woman with hepatitis C is at risk for being small for gestational age and having a low birth weight as well as preterm birth. Any pregnant woman at high risk, such as those with a history of injection drug use, should be tested during pregnancy for hepatitis C virus.

A pregnant patient who is in a methadone program to control drug addiction should be advised to a. stop taking methadone immediately b. slowly decrease dose of methadone and then stop taking c. continue taking methadone

C Abrupt withdrawal from methadone may result in death of the fetus. Ideally, the mother should decrease dosage until free of drugs, but pregnancy is a stressful time and not usually the best time to add the stress of eliminating drug use. While less dangerous to the fetus than heroin, methadone does cross the placental barrier and poses risks to the fetus, including IUGR, stillbirth, preterm birth, low birth rate, and fetal distress.

Criteria for outlet forceps-assisted birth include a. the fetal sagittal suture is more than 45 degrees from midline b. the fetal skull is above the pelvic floor c. the scalp is visible between contractions without separating labia

C Additional criteria include (2) the perineum bulging because the fetal skull has reached the pelvic floor, (3) the fetal sagittal sutures 45 degrees or less from the midline indicating the head moving from extension to external rotation. Low forceps-assisted birth may occur if the fetal skull is at station +2 or lower but above the pelvic floor. Midforceps-assisted birth may occur if the fetal head is engaged but leading edge is above station +2

Postpartum blues usually occur a. 24 hours or less after delivery with duration of 2 to 3 weeks b. 2 to 3 days after delivery with duration of 3 to 12 months c. 5 days or less after delivery with duration of 2 to 3 days

C Affect up to 80% of new mothers. Postpartum blues, usually occurs 5 days or less after delivery with a duration of 2 to 3 days. However, it may persist over a week in some women. Symptoms include irritability, insomnia, mood swings, depressed feeling, tearfulness, inability to concentrate, and anger. Because most new mothers stay in the hospital only for 1-2 days, they should be advised about the possibility of postpartum blues and advised to seek help if the symptoms are prolonged.

A woman who develops appendicitis in the third trimester will often complain of pain in or near the a. LLQ b. RLQ c. RUQ

C Appendicitis may be misdiagnosed during pregnancy because the position of the appendix changes as the uterus enlarges, sometimes moving superiorly as much as 8 inches. While in non-pregnant woman, pain from appendicitis is typically felt in the RLQ, the pain is more likely to be felt in or near the RUQ as pregnancy advances. While surgery poses some risks, a ruptured appendix may result in the death of the mother and the fetus.

The first step in quality improvement measures on the nursing unit is to a. brainstorm methods to enhance the unit's level of care b. formulate a plan to implement quality-improvement measures c. identify the areas in need of improvement on the unit

C Begin with identifying those things in need of improvement. Without an assessment of needs, quality improvement measures may be misguided. This may begin with failure mode and effects analysis (FMEA), gap analysis, internal research (data analysis, surveys, interviews, observation), root-cause analysis, tracer methodology, or other methods of brainstorming. Once problems or areas for potential improvement are identified, then some method of brainstorming is used to generate solutions from which one or more is selected. Plans are formulated, tested, and implemented. Following implementation, the changes are monitored and modified as needed.

A patient with a Bishop score of 9 generally indicates that a. labor will not begin without induction b. induction will probably be unsuccessful c. labor will begin spontaneously

C Bishop scores range from 0-13. These scores are often used to determine if induction is necessary. If the score is 5 or less, then spontaneous labor is unlikely without induction. A score of 9 or more indicates that labor will most likely commence spontaneously. Scores between 5-9 require additional consideration and professional judgement for clinical management. The Bishop score is based on assessment of 5 parameters: dilation, effacement, station, cervical consistency (firm, medium, soft), and cervix position (posterior, mid-position, anterior)

A presumptive diagnosis of vasa previa is usually confirmed with a. abdominal CT scan. b. transabdominal ultrasound. c. transvaginal ultrasound.

C Condition in which fetal blood vessels cross or run near the internal cervix. Vasa previa is generally characterized by painless vaginal bleeding, fetal bradycardia, and rupture of the membranes. With vasa previa, the umbilical vein and arteries are not protected with Wharton's jelly or supportive tissue, so they are at risk of laceration, especially during rupture of the membranes. Treatment varies but often includes NST twice weekly until about 30-32 weeks when the patient is hospitalized for continuous monitoring. Cesarean may be emergent or scheduled after fetal lung maturity.

When Demerol (meperidine) is used to control pain during labor, it should only be administered a. more than 1 hour before delivery b. more than 2 hours before delivery c. more than 4 hours before delivery

C Demerol is one of the most common drugs used during labor because the onset is rapid (1-20 minutes IV and 1-3 hours IM) and it peaks quickly. Opioids and sedatives are usually given only within the early stages of labor because they cross the placental barrier and may result in fetal CNS depression.

When using Cervidil (dinoprostone) as a cervical ripening agent, it should be placed in the vagina and left in place for about how long? a. 2 hours b. 6 hours c. 12 hours

C During the first two hours after insertion, the patient should remain lying down so that the insertion stays in place. The insert, which is shaped like a thin tampon, is often used the night before a scheduled induction to begin cervical ripening. Cervidil should only be used when the patient is near due date or when induction is a medical necessity.

A sign that a patient is moving from the active phase of the first stage of labor to the transition phase is a. show varies from pink to bloody b. contractions are 3 to 5 minutes apart c. feeling of anal pressure and need to defecate

C During the transition phase, the cervix becomes dilated to 8-10 cm with contractions every 1.5-2 minutes lasting 60-90 seconds. Fetal descent is 1 cm per hour for nullipara and 2 cm per hour for multipara. The patient often experiences a marked increase in pain with hyperventilation, crying, moaning, and restlessness. Some may begin to hiccup, eructate (burp), or vomit.

A pregnant woman with organic mercury poisoning (methyl mercury) but few symptoms places the fetus at a. virtually no risk of impairment. b. slight risk of impairment. c. high risk of impairment.

C Even though the mother may have few symptoms of organic mercury poisoning, the fetus may be profoundly affected because the fetus is more sensitive to mercury than the adult. Mercury impairs the development of the central nervous system, so the child may have severe neurological abnormalities, including impaired memory, thinking abilities, visuospatial skills, and attention span as well as impaired motor skills.

After delivery, an infant born to a mother with diabetes mellitus will probably exhibit a. normal glucose level b. hyperglycemia c. hypoglycemia

C Glucose crosses the placenta, so if the mother's glucose level is elevated, the fetal level also elevates. The fetus does not produce insulin for the first 20 weeks, and extended periods of hyperglycemia result in growth restriction. However, after 20 weeks, when fetal insulin production begins, the fetus begins to grow rapidly with increased glycogen stores and fat deposits as well as hepatosplenomegaly, cardiomegaly, and increase in head size. After delivery, the sudden decrease in the level of glucose from the mother combined with continued insulin production results in hypoglycemia.

Patients often experience bradycardia during the early postpartal period because of a. hypovolemia b. anesthetic effects c. increased stroke volume

C Hypervolemia is generally present at term, offsetting blood lost during delivery. Transient increased cardiac output occurs after delivery when blood that had been diverted to the placenta returns back into maternal circulation. Additionally, circulation increases because of less pressure on the vessels. Cardiac output may remain elevated for about 48 hours after delivery, resulting in increased stroke volume.

When preparing a patient for Cesarean, the internal fetal monitor is a. left in place until the abdominal incision is completed b. removed before the sterile abdominal skin prep c. removed after the sterile abdominal skin prep

C If an external monitor is used, it is removed before the skin prep. Other preparations may include antibiotic prophylaxis. If a low transverse incision is anticipated, then the pubic hair may be clipped. An indwelling catheter may be inserted to ensure that the bladder is empty in order to prevent damage to the bladder.

A decrease of fetal heart rate of at least 15 bpm for at least 10 minutes is classified as a. recurrent deceleration. b. prolonged deceleration. c. baseline change.

C If it persists more than 2 minutes but less than 10 minutes, it is classified as a prolonged deceleration. Recurrent decelerations are classified as occurring with half or more of uterine contractions in a 20 minute period. Intermittent decelerations occur with fewer than half of uterine contractions in a 20 minute period.

If a neonate delivered vaginally to a mother with recurrent genital herpes (HSV-1) infection is asymptomatic at birth, initial response should be to a. immediately begin intravenous acyclovir b. initiate testing and treatment with acyclovir if infant becomes symptomatic c. obtain specimens (skin, mucus) for culture and PCR assay 24 hours after delivery

C If the tests show that the neonate is positive for HSV, then the child should undergo a complete examination and treatment should begin with IV acyclovir as soon as possible. If, however, maternal herpes lesions are present during delivery in a woman with no history of HSV, then the infant should immediately begin treatment with IV acyclovir.

Fetal bradycardia with variable decelerations during uterine contractions may indicate a. placenta previa. b. abruptio placentae. c. prolapsed cord.

C In some cases, the cord may be seen protruding from the vagina, especially after rupture of the membranes if the presenting part is high, or felt on digital exam. Immediate action is required to prevent fetal hypoxia. The patient is placed in modified Sims' or knee chest position and the examiner inserts fingers into the vagina to hold the presenting cord off the cord while awaiting emergent treatment, such as a Cesarean.

A patient nearing term who complains of low back pain may be experiencing a. false labor b. active labor c. either false or active labor

C In some cases, the pain is caused by the fetal position, with occiput posterior position causing pressure on the sacrum, resulting in severe pain. In other cases, the pain is unrelated to the fetal position. Walking or other activities, such as doing pelvic tilts or sitting on a birth ball, may help reposition the fetus and relieve the discomfort if the pain results from fetal position. Hot or cold compresses applied to the lower back, a hot shower, or massage may also help.

Low birth weight is defined as a. 1500 g or less b. 2000 g or less c. 2500 g or less

C It is sometimes used instead of the term preterm birth because weeks of gestation are not always easy to identify, and preterm birth considers only duration of gestation and not the weight of the child. Infants who have low birth weight may be preterm as well, or the low birth weight may be attributable to other factors, such as IUGR, PIH, or maternal malnutrition

During labor, more than 5 contractions in a 10-minute period averaged over a 30-minute period is defined as a. bradysystole b. normal uterine activity c. tachysystole

C It may be associated with the use of prostaglandin for cervical ripening or oxytocin to induce contractions, although it may also occur without these agents. Normal uterine activity is 5 or fewer contractions in a 10 minute period averaged over a 30 minute period. Tachysystole is not usually assoicated with adverse outcomes for the fetus.

The effect that maternal administration of narcotics has on the fetal heart rate is a. increase in baseline rates b. transient sinusoidal fetal rate and increase in baseline rate c. decreased variability and frequency of accelerations

C Medications that the mother receives may have an effect on the fetus. Some medications, such as butorphanol and terbutaline, may increase the baseline rate. Other such as magnesium sulfate, may decrease the baseline rate but these changes may be insignificant. Some drugs and substances used by the mother prior to labor (such as cocaine, amphetamine, and nicotine) may result in fetal tachycardia and decreased variability.

To reduce the risk of hemorrhagic disease after birth, a neonate should receive a. vitamin B9 (folic acid). b. vitamin C. c. vitamin K.

C Neonates are born with low levels of vitamin K, which is necessary to activate clotting factors. Additionally, while platelet levels are near adult level, the platelets do not respond effectively to stimuli for several days after birth. Combined, these factors increase the risk of hemorrhage, but the risk is markedly reduced if the neonate receives an IM injection of vitamin K.

A vaginal pH of 7.2 probably indicates the presence of a. inconclusive results. b. vaginal fluid. c. amniotic fluid.

C Normal vaginal fluid is more acidic with pH ranging from 4.5-5.5 while amniotic fluid is more alkaline with pH ranging from 7.0-7.5. However, blood has a pH that is similar to that of amniotic fluid and semen is highly alkaline, so the presence of either of these two substances may produce a pH that is suggestive of amniotic fluid.

An indication of Braxton Hicks contractions (false labor) is that a. activities tend to increase pain b. contractions occur at regular intervals c. pain is typically in the lower abdomen

C Occur throughout the third trimester but are often mild and undetected by the mother; however, they may be mistaken for true labor as the due date nears and they become stronger. They are characterized by pain in the lower abdomen, which is usually of short duration and occurs irregularly. Activities tend to reduce discomfort and contractions. Mild analgesia often relieves the discomfort. Effacement and dilation do not occur.

The primary complications related to multiple gestations are a. preterm birth and uterine inversion. b. preterm birth and uterine rupture. c. preterm birth and intrauterine growth restriction.

C On average, twins are delivered at about 37 weeks gestation and triplets at 33 weeks, so they almost always have low birth weight, increasing risk of postnatal complications. Multiple fetuses tend to be smaller than singletons because the rate of growth slows earlier than with singletons: at 30-32 weeks for twins and 27-28 weeks for triplets.

The Cesarean incision that carries the greatest risk of subsequent uterine rupture with vaginal birth is a. low transverse b. low vertical c. midline vertical (classic)

C Only patients with low transverse incisions, the most common type of incision currently done, are considered for vaginal birth after Cesarean (VBAC). Risk factors that preclude VBAC include small pelvis, previous Cesarean for prolonged labor, previous uterine rupture, and obstetric complications (such as placenta previa). A physician and anesthesiologist/anesthetist must be on site and available in case emergency Cesarean is required.

Following delivery, if vaginal bleeding persists despite a firmly contracted uterus, the following should be suspected a. coagulopathy b. retained placenta c. laceration of the genital tract

C Risk factors associated with lacerations include nulliparity, precipitous childbirth, macrosomia, epidural anesthesia, and forceps-assisted or vacuum-assisted delivery. Perineal lacerations may occur as the head is delivered and may be associated with vaginal lacerations, which may extend up the lateral walls. Vaginal lacerations may be circular if resulting from forceps rotation.

The nurse must educate the new mother that a contraindication to breast feeding is a. fetal macrosomia. b. type II diabetes. c. infection with HIV/AIDS.

C Some maternal contraindications to breastfeeding include: -Infection with HIV/AIDS -Use of antiretroviral medications -Active TB not treated -Infection with human T-cell lymphotropic virus -Illicit drug use -Use of chemotherapeutic agents -Radiation therapy (may require only interruption during treatment) -Use of other medications that pass into the breast milk and may harm the child -Presence of herpes on the breast -Presence of varicella lesions on the breast (may resume after lesions crust)

For administration of prostaglandin cervical gel, the patient should be placed in a. left lateral Sims position b. lithotomy position c. dorsal recumbent position

C Some preparations are administered with a prefilled syringe attached to a catheter, which is inserted into the endocervix, which other preparations are placed in a diaphragm, which is then positioned against the cervix. After insertion or application of the gel, the woman remains lying on her back for 30-60 minutes with a small pillow or roll placed beneath her right hip in order to tip the uterus to the left.

The Montevideo units needed for normal progress of labor are at least a. 100 b. 150 c. 200

C The MVUs are calculated by multiplying the number of contractions during a 10 minute period times the average intensity, above baseline, of the contractions. To be effective, a contraction must generate at least 25 mmHg of peak pressure although 50-60 mmHg is considered optimal. Additionally, for labor to be effective, at least 3 contractions are needed in a 10 minute period.

When determining the baseline fetal heart rate, the fetal heart must be monitored for at least a. 2 minutes. b. 5 minutes. c. 10 minutes.

C The baseline rate is the average rate during that time period, rounded to the nearest 5 bpm. The normal fetal heart rate is 110-160 bpm at term with a slightly increased rate for the preterm fetus. Fetal tachycardia is defined as either over 150 bpm or over 160 bpm for at least 10 minutes, while bradycardia is defined as either under 110 bpm or under 120 bpm for at least 10 minutes

The cardinal movements of vertex presentation labor include engagement, flexion, descent, internal rotation, extension, a. external rotation, and recovery. b. external rotation, and restitution. c. external rotation, and expulsion.

C The cardinal movements of vertex presentation labor include: -Engagement: biparietal diameter of head descends below pelvic inlet to zero station -Flexion: head flexes to decrease diameter -Descent: fetus descends birth canal -Internal rotation: again decreases head diameter to allow passage through bony pelvis -Extension: head and neck extend to correspond with curve of birth canal -External rotation: head rotates after delivery to allow delivery of shoulders and body -Expulsion: delivery of shoulders and body

The cervix is considered uneffaced at a. 2 cm. b. 3 cm. c. 4 cm.

C The cervix is considered uneffaced at 4 cm (0% effacement). Effacement refers to thinning of the cervix, with the length of the cervix expressed in numbers of centimeters, and the degree of effacement in percentages. Complete effacement (100%) occurs when the cervix has completely thinned. Some patients efface slowly over the weeks prior to labor, especially if the fetal head is in the pelvis and applying pressure to the cervix, but others efface after onset of labor.

During uterine contractions, the fetal heart rate usually a. remains unchanged b. increases c. decreases

C The contractions result in compression of the head and decreased cerebral blood flow, effectively slowing the heart rate. Additionally, the contractions compress uterine myometrial vessels and may occlude the umbilical cord, causing hypertension in the fetus. Some medications given to control maternal pain or to stimulate contractions may also affect the heart rate, include opioids and oxytocin. Sources define bradycardia as being either less than 110 bpm or less than 120 bpm for at least 10 minutes with severe bradycardia begin less than 80 bpm.

When palpating to determine the pattern of contractions, the best place to position the hands is usually the a. mid-uterus b. suprapubic area c. uterine fundus

C The fingertips should be placed lightly on the area, taking care not to move the fingers or apply more than light pressure because deeper pressure might stimulate a contraction, and this may results in an inaccurate assessment of the pattern. The time a contraction begins and ends should be noted as well as an estimate of the intensity of the contraction.

Abnormal molding of the neonate's skull with a collection of fluid that crosses suture lines is probably related to a. craniosynostosis b. cephalohematoma c. caput succedaneum

C The fluid collects beneath the skin but above the periosteum, so it freely crosses suture lines, unlike cephalohematoma, which is a collection of blood between the periosteum and the skull. Caput succedaneum is common with prolonged labor because of the pressure of the head against the cervix and may be more pronounced with vacuum-assisted deliveries.

The fundal height is no longer an accurate estimate of gestation after how many weeks? a. 30 b. 34 c. 36

C The fundal height, the measure from the pubic bone to the top of the uterus, is no longer an accurate estimate of gestation after 36 weeks because the fetus usually changes position in preparation for delivery, and the uterus changes shape. However, between weeks 16-36, the fundal height is a good estimate of weeks of gestation in a normal singleton pregnancy with each cm of height equal to a week of gestation, so 22 cm height equals 22 weeks gestation.

During the second stage of labor, when does external rotation occur? a. As the fetus descends from station 2+ to 4+ b. Before delivery of the head c. After delivery of the head

C The head is delivered face down but then externally rotates so that the face is toward the right or left (facing maternal inner thighs) in order to allow passage of the shoulders and body. If shoulder dystocia occurs, delivery may halt at this time. McRoberts technique, in which the patient elevates the knees to the chest position, may reduce the angle and allow expulsion.

What is the treatment of choice for a pregnant patient with Graves' disease? a. Methimazole b. Radioactive iodine c. Propylthiouracil

C The lowest possible dose is administered because the drug may cause hypoparathyroidism in the fetus. Methimazole may also be used, but it is usually avoided because it causes aplasia cutis (scalp disorder) in the fetus. Radioactive iodine is contraindicated during pregnancy because it may result in damage to the fetal thyroid. If surgery is necessary, the thyroid gland can be removed in the second trimester.

If a mother suffers from severe postpartum depression and expresses intense dislike of her infant, the initial intervention should be to a. provide treatment for depression b. ask the mother if she plans to hurt her infant c. ensure safety of the infant

C The mother should not be left alone with the infant at any time until her condition improves. While treatment for maternal depression is appropriate, the condition may persist for weeks or months after treatment is initiated, and if the mother is experiencing some psychosis or inappropriate thoughts, she may not be forthcoming if asked about harming her infant

If utilizing HypnoBirthing during labor and delivery, an important element of "breathing the baby down" is a. relaxing b. verbalizing c. visualizing

C The patient inhales and then, while exhaling, tips the pelvis up and gently bears down while visualizing energy flowing toward the fetus and the vagina opening. HypnoBirthing is a natural childbirth method that utilizes self-hypnosis to reduce stress and anxiety during childbirth. The patient uses a variety of relaxation and breathing techniques, and the partner supports the patient with therapeutic touch and prompts.

When a supine infant is placed in a radiant warmer for thermoregulation, the skin temperature probe may be placed a. in the mid-scapular region b. over the mediastinum c. over the liver

C The probe should not be placed over a bony area, such as the mediastinum, or over an area that has a large amount of brown adipose tissue, such as the midscapular regions of the back, the neck, and areas around the kidneys and adrenal glands. The probe should be placed carefully, ensuring good skin contact so that it accurately records temperature, as this will affect the temperature setting of the heater.

With suspected fetal hypoxia, a cord blood gas specimen is obtained during delivery by a. withdrawing blood from the vein/artery before the cord is clamped or cut and before placental expulsion. b. placing one clamp and withdrawing blood above the clamp before cutting the cord. c. double clamping a 10 to 20 cm segment, cutting it out, and then withdrawing blood from the segment.

C The segment can be placed on ice temporarily as cord blood gas can be accurately assessed for 60 minutes. An arterial sample is preferred over venous, but paired sampling is recommended. A pH of 7.24 or less is associated with neurological compromise. A base excess of 12 mmol/L or more is predictive of motor or cognitive impairment.

Touch relaxation usually begins with the a. feet and legs b. chest and abdomen c. scalp and eyebrows

C Touch relaxation follows a specific sequence and usually begins with scalp and eyebrows and then moves down the face, shoulders, abdomen, thighs, legs, and arms. Touch relaxation is carried out with a coach and requires practice before onset of labor. The patient tightens a small area of muscles, and then the coach gently strokes the area to relieve tension as the patient relaxes the muscles. Progressive relaxation also involves tightening and relaxing of muscles but begins with the feet and moves upward.

The most significant risk factor for uterine rupture is a. macrosomia b. multiple gestation c. previous cesarean

C Uterine rupture extends through the wall of the uterus and the visceral peritoneum, resulting in extensive bleeding and can include expulsion of the fetus and placenta into the abdominal cavity. Treatment includes immediate cesarean delivery and usually requires hysterectomy. In some cases, instead of full rupture, dehiscence occurs along the previous incisional line, but dehiscence usually does not involve extensive bleeding and does not breech the visceral peritoneum, so the fetus and placenta remain inside the uterus.

A contraindication of external version of a fetus is a. hydramnios (polyhydramnios) b. previous Cesarean with low transverse incision c. engagement of presenting part

C Version should only be carried out if vaginal birth is expected. Other contraindications include a malformed uterus, cephalopelvic disproportion, previous Cesarean with vertical incision (increased risk of rupture), placenta previa, multiple gestations (version may be done with second twin after first is delivered), oligohydramnios, ruptured membranes, nuchal cord, and uteroplacental insufficiency. In rare instances, placental abruption may occur with version.

The most effective relief of a spinal headache after spinal blockade is usually a. keeping flat for 6 to 12 hours b. analgesia c. blood patch to insertion site

C While recommendations are for the patient to lie flat for 6-12 hours after the blockade to prevent headache, there is little evidence that actually helps. With a blood patch, a small amount of the patient's blood is removed and then injected immediately (before coagulating) into the epidural space at the puncture site to seal leakage of spinal fluid, which is assumed to be the cause of the headache.

A velamentous cord insertion can result in a. delayed labor b. retained placental tissue c. hemorrhage

C With this placenta type, the cord inserts into the fetal membranes instead of in the middle of the placenta, and the cord must travel through the chorion and amnion to reach the placenta, resulting in vessels that are exposed and unprotected. During delivery, sheering of these vessels may cause the mother to hemorrhage, especially when the vessels lie close to the cervix (vasa previa), resulting in rupture during early stages of labor and stillbirth.

Absence of the Moro reflex on one side only in a neonate may indicate a. fractured scapula. b. cerebral palsy. c. fractured clavicle.

C a fractured clavicle or brachial plexus injury. Damage to the central nervous system, such as may occur with cerebral palsy, often results in bilateral absence of the reflex. The Moro reflex is elicited by allowing the infant's head and trunk to fall slightly backward when the infant is raised. A positive Moro reflex includes immediate extension and abduction of the arms(and sometimes the legs) with fingers fanning and forming a C-shape with a return of the limbs to the flexed states

A transient sinusoidal fetal heart rate pattern with slight increase of rate over baseline may occur after administration of a. magnesium sulfate b. terbutaline c. butorphanol

C aka Stadol. It is a synthetic opioid that is commonly used for intrapartum management of pain at usual dose of 1 mg every 3-4 hours. It may be administrated by IM, IV, or nasal spray. Because it has some narcotic antagonist effects, it can cause withdrawal symptoms in patients who are addicted to opiate drugs or if other narcotics have been administered previously.

The Doppler scan is used to a. determine the size and shape of the placenta b. determine the implantation site of the placenta in the uterus c. measure the flow of blood from the uterine arteries to the placenta

C aka uterine artery Doppler....used to determine if placental insufficiency is present. The probe emits high-frequency sound waves, which are echoed back, and the frequency at which this occurs is translated into images and graphs that show blood flow. Doppler is used in conjunction with a placental ultrasound, which is done to determine the size and shape of the placenta as well as the placental location, umbilical cord insertion, and number of umbilical blood vessels.

Velamentous insertion of the umbilical cord is commonly associated with a. singleton gestations. b. abruptio placentae. c. placenta previa.

C associated with placenta previa, vasa previa, and multiple gestations. With velamentous insertion, the umbilical cord vessels divide at a distance from the placenta, protected only by the thin placental membranes, which may become compressed or injured during pregnancy, labor, and delivery. Because the vessels lack the protection of Wharton's jelly, they are especially susceptible to tearing, resulting in fetal hemorrhage. If the vessels precede the fetus at the internal os, this is termed vasa previa.