CH 66
25. A nurse is performing fundal massage for a client. What precaution should the nurse take when giving a fundal massage? A) Never massage a contracted fundus. B) Avoid placing a hand over the symphysis pubis. C) Report cramps immediately to physician. D) Avoid applying heat to relieve cramps.
Ans: A Feedback: The nurse should never massage a contracted fundus because massage of an already contracted uterus may cause it to invert.. which can become an emergency situation. A hand should be placed over the symphysis pubis to stabilize the uterus. The mother may have painful cramps as the uterine muscles contract. These cramps are called after-pains and are more likely to occur in multigravidas.. they need not be reported. Heat application helps to relieve cramps.
24. Following delivery.. a client feels the urge to void.. but is unable to do so after an extended period of time. What immediate action should the nurse take? A) Report it to the practitioner. B) Catheterize the bladder. C) Apply suprapubic pressure. D) Reassure the client.
Ans: A Feedback: The nurse should report to the practitioner if the client feels the urge to void but is unable to do so. Other measures.. such as catheterization or suprapubic pressure.. should not be performed unless advised by the practitioner. Failure to void may indicate swelling or injury to the urinary system. therefore.. reassurance is not sufficient.
12. A nurse is caring for a client in labor. During assessment which of the following should the nurse consider to be a common discomfort of labor? A) Exaggerated fetal movement B) Pain in the lower back C) Prolonged slowing of the fetal heart rate D) Irregular fetal heartbeat
Ans: B Feedback: True labor contractions feel like lower-back pain that moves gradually around to the abdomen.. this is a common discomfort of labor. On the other hand... exaggerated fetal movement... prolonged slowing of the fetal heart rate.. and irregular heartbeat indicate fetal distress and should be immediately reported to the practitioner.
2. A nurse is informing a client about different choices available to pregnant women choosing a birth setting. Which of the following birth settings promote safe satisfying and the most cost-effective childbirth? A) Free-standing birth centers B) Labor and delivery unit C) Home setting D) Birthing room
Ans: A Feedback: Free-standing birth centers promote safe satisfying and cost-effective childbirth. Labor and delivery units and birthing rooms are found in hospital settings and are not cost-effective. A home setting is cost-effective but cannot be assured to be safe.
5. The nurse practitioner examining a pregnant woman in labor notes that the fetal spine is parallel to the woman's spine. What is the term for this relationship of the fetal body to the maternal body? A) Lie B) Presentation C) Station D) Engagement
Ans: A Feedback: Lie is a term used to compare the position of the fetal spinal cord (the "long part") to that of the woman. The normal lie of the fetus is longitudinal (up and down), which means that the fetal spine is parallel to the woman's. Presentation refers to the body part of the fetus that lies closest to the pelvis and will enter the birth canal first. Station refers to the level of descent of the fetal presenting part into the birth canal. Engagement is the term used when the fetal head has moved downward in the birth canal until it can no longer be pushed up and out of the pelvis.
19. The obstetrical nurse records the expulsion of the placenta in stage III labor as a Duncan presentation. What does this data represent? A) The placenta is expelled with the dull side out. B) The placenta is expelled with the shiny side out. C) The placenta is not fully expelled. D) The placenta contains placental fragments.
Ans: A Feedback: If the placenta is expelled with the dull side out.. it is called a Duncan presentation ("dirty Duncan"). This is the maternal side.. which is rough and irregular. Excessive bleeding is more likely with this type of placental presentation. If the placenta is expelled with the shiny (membranous) side out.. it is called a Schultze presentation ("shiny Schultze").. this is the fetal side of the placenta. Schultze presentation occurs in approximately 80% of births. The birth attendant examines the expelled placenta and membranes to determine if the placenta is intact. Retained placental fragments are a major cause of hemorrhage following delivery.
26. The nurse performing a postpartum assessment on a client elicits the Homan's sign. For what condition is the nurse assessing? A) Thrombophlebitis B) Urinary distention C) Soft boggy uterus D) Hematoma
Ans: A Feedback: Pain behind the knee on flexion of the feet indicates a positive Homans' sign and suggests thrombophlebitis. The nurse would palpate the bladder for a rounded bulge in the suprapubic region.. which indicates distention.. and palpate the fundus to determine if the uterus is soft or boggy. A hematoma is a complication that may be observed at the site of an episiotomy.
14. The obstetrical nurse is administering oxytocin for her client to induce labor. Which of the following is a recommended guideline for administration of the drug? A) For labor induction: Initial dose of 1 to 2 mU.. increased 1 to 2 mU/min until an adequate labor pattern is achieved. B) For labor augmentation: Initial dose: 1.5 to 2.0 mU..increased 1 to 2 mU/min until an adequate labor pattern is achieved. C) For labor induction and labor augmentation: Maximum recommended dose is 25 mU/min. D) For postpartum: 15 to 25 mU IM or IV after delivery of the placenta.
Ans: A Feedback: The recommended dosages of oxytocin are as follows: for labor induction: Initial dose of 1 to 2 mU... increased 1 to 2 mU/min until an adequate labor pattern is achieved... for labor augmentation: Initial dose: 0.5 to 1.0 mU.. increased 1 to 2 mU/min until an adequate labor pattern is achieved.. for labor induction and labor augmentation: maximum recommended dose is 20 mU/min.. and for postpartum: 10 to 20 mU IM or IV after delivery of the placenta.
29. The nurse is teaching a new mother about the advantages/disadvantages of breastfeeding versus formula feeding. Which of the following statements accurately describe the process? Select all that apply. A) Breast milk is readily available and convenient. B) Breast milk is always the right temperature. C) Nursing slows involution. D) Breast milk contains antibodies. E) Beast milk is more likely to cause allergic reactions. F) Nursing ensures another pregnancy will not occur.
Ans: A B D Feedback: Breast milk is readily available and convenient... it is always the correct temperature and contains antibodies. Nursing helps in the bonding process and speeds involution. Also.. breast milk is less likely to cause allergic reactions and other difficulties... and is cheaper than formula. Nursing mothers are less likely to get pregnant.. but this is not a guaranteed form of birth control.
3. The certified nurse midwife is discussing the birth plan with a client. Which of the following data would most likely be documented in the plan? Select all answers that apply. A) The woman's choice of a partner for support during labor B) The woman's living will or advance directives C) The type of pain relief measures desired D) The parents' choice of birth announcements E) The outcome of labor and delivery F) The woman's feelings about fetal monitoring
Ans: A C F Feedback: A birth plan is a written document in which the expectant mother expresses her desires for labor and birth, including partners pain measures and fetal monitoring. Advance directives and living wills and the outcome of labor and delivery would be documented in the medical record. Choice of birth announcements would not usually be stated in the plan.
7. The obstetrical nurse checks the station of a laboring pregnant woman and documents +5 on the patient chart. What does this number mean in terms of the delivery? A) The baby is "floating" above the mother's ischial spines. B) The fetal head is at the vaginal opening. C) The lowest part of the fetal skull is at the level of the mother's ischial spines. D) The presenting part is 5 cm above the level of the ischial spines.
Ans: B Feedback: A station of +5 means the fetal head is at the vaginal opening. A station of -5 is considered "floating," or the presenting part is 5 cm above the level of the ischial spines. The station at which the fetus is said to be fully engaged is called station 0 that is the widest part of the presenting part of the fetus has lodged in the pelvic inlet, and the lowest part of the fetal skull is at the level of the mother's ischial spines.
16. A pregnant woman is having moderately strong contractions every 3 minutes lasting 50 seconds. Her cervix is dilated 6 cm. What state of labor is she experiencing? A) Stage I.. latent phase B) Stage I.. active phase C) Stage I.. transitional phase D) Stage II ..
Ans: B Feedback: In the stage I active phase.. the woman experiences regular..moderate to strong contractions: frequency 2 to 4 minutes.. duration 45 to 60 seconds with dilation 4 to 8 cm. In the stage I latent phase.. the woman experiences irregular.. mild contractions: frequency 5 to 20 minutes.. duration 30 to 50 seconds with dilation 0 to 4 cm. In the stage I transitional phase.. the woman experiences regular.. very strong contractions: frequency 2 to 3 minutes.. duration 60 to 90 seconds with dilation 8 to 10 cm. During stage II.. the woman's abdominal muscles and diaphragm join the uterine muscles to push the newborn out of the woman's body. The woman may say she feels "pushing pains" or a "bearing down" feeling.
10. A primigravida who is 2 weeks away from her delivery date tells the obstetrical nurse that she feels like "the baby has dropped." What would be the nurse's best response to this client? A) "This feeling may be a sign that there is a complication with your pregnancy." B) "This feeling is called lightening and means that the fetus has settled into the pelvis." C) "This is a normal feeling at this stage and it is called 'Braxton-Hicks' contractions." D) "This is a normal feeling called lightening signaling that labor has begun."
Ans: B Feedback: Lightening is the settling of the fetus into the pelvis. Lay people often say, "the baby has dropped." Lightening usually occurs 2 to 3 weeks before the onset of labor in primigravidas (women having their first child). During pregnancy's late stages... the uterine muscles prepare for labor and delivery by tightening and relaxing at intervals. These contractions... called Braxton-Hicks contractions... are usually painless... short... and irregular.
23. The nurse caring for a postpartum client explains the occurrence of lochia following delivery. Which of the following statements accurately describe a characteristic of this process? A) "Lochia ruba.. which is mostly red and bloody.. is seen for the first week." B) "Lochia serosa.. which is pink or brown tinged.. starts after the bleeding diminishes." C) "Lochia alba which is yellow or white.. starts on about day 15. D) "Lochia alba has a pungent foul odor."
Ans: B Feedback: Lochia rubra is seen for the first 2 days. It is mostly red and bloody. It should smell like blood (slightly metallic) a foul odor indicates infection. Lochia serosa starts after the bleeding diminishes. The color of the lochia changes to pink or brown-tinged for approximately the next 7 days. Lochia serosa has a slightly earthy odor. Lochia alba.. which is yellow or white.. starts on about day 10. At this point.. the lochia has decreased greatly in amount. Lochia alba also has an earthy smell.
17. A client in the first stage of labor has an episode of bright-red bleeding. What is the best action for the nurse to take? A) Perform a vaginal examination per protocol. B) Report any bleeding at once. C) Perform an ultrasound examination.. as ordered. D) Inject vitamin K as ordered to stop bleeding.
Ans: B Feedback: The nurse should report any bright-red bleeding at once. A client who is bleeding should never be examined vaginally until ultrasound rules out placenta previa. The practitioner.. not the nurse..should do an ultrasound examination. Vitamin K is given to the newborn to reduce the infant's chances of bleeding. However.. the nurse cannot inject vitamin K into the client in labor unless specifically directed by the primary care provider.
22. A fetus is experiencing variable decelerations in the fetal heart rate during contractions. What is the appropriate nursing intervention for this situation? A) Have the pregnant woman walk around the room. B) Change the woman's position and give oxygen. C) Notify the healthcare practitioner immediately. D) Administer prescribed pain medications.
Ans: B Feedback: Variable decelerations in fetal heart rate occur anytime during or after contractions. They usually indicate umbilical cord compression and can usually be altered by changing the woman's position or by giving her oxygen. Late decelerations begin late in the contraction... and the fetal heart rate recovery occurs after the contraction is over. Decelerations are related to placental insufficiency and indicate fetal distress. The fetal heart rate should not fall below 100 bpm.
27. The nurse is providing teaching to a new mother regarding changing her perineal pad. Which of the following client statement indicates effective teaching? A) "I will pull my underwear down and to the front." B) "I will unhook my pad from the front first." C) "I will remove the pad from the back to the front." D) "I will apply the new pad by hooking it to the back first."
Ans: B Feedback: When removing a soiled pad.. the client should pull her panties straight down. If using a sanitary belt, she should unhook the pad from the front first. The nurse should advise the client always to start removal of the perineal pad by first removing the pad from "clean" areas in the front and then removing the pad from the "dirty" area near the rectum. When applying a clean pad.. she should hook it onto the front first.. which helps prevent infection.
15. A nurse is assessing a pregnant client whose membranes have ruptured. Which of the following findings may indicate an infection? A) Nitrazine paper remains yellow B) White or cloudy amniotic fluid C) Clear and colorless amniotic fluid D) Nitrazine paper turns blue
Ans: B Feedback: White or cloudy fluid may indicate the presence of pus in response to an infection. Normal amniotic fluid is clear and colorless. A nitrazine test will determine if the amniotic sac has ruptured... if it turns blue.. it is probably stained with amniotic fluid.. indicating that the amniotic sac has ruptured. If the test or urine strip remains yellow.. it is probably in contact with vaginal secretions only.
4. The nurse assessing a laboring client documents that the client is in stage II of labor. What typically occurs during this stage? A) Dilation of the cervix B) Movement of fetus to the birth canal C) Delivery of the baby through the vaginal opening D) Delivery of the placenta following delivery of the newborn
Ans: C Feedback: There are four stages of labor: In stage II, expulsion: Uterine contractions continue and increase in intensity until the baby is delivered through the vaginal opening. In stage I dilation: Uterine contractions cause the cervical os (mouth) of the cervix to open (dilate) and move the fetus downward into the birth canal. In stage III placental: Uterine contractions expel the placenta after the delivery of the newborn. In stage IV recovery: Uterine contractions continue and close off open blood vessels to prevent excessive blood loss.
21. A nurse is monitoring the fetal heart rate of a client. What signs of fetal distress on the fetal monitor should the nurse report immediately? A) Accelerations of 15 bpm B) Early decelerations C) Decreased variability D) Fetal heart rate above 100 bpm
Ans: C Feedback: Decreased variability means little to no fluctuation in the FHR on an internal electronic monitor tracing.. which is a danger sign. It may indicate an abnormality in the fetal nervous system. It might also indicate that the mother has taken or been given central nervous system depressants. Report this observation to the team leader for further evaluation. Accelerations are brief increases of the FHR of 15 bpm or more. It is a sign of a healthy fetus for the FHR to accelerate after movement or stimulation. Early decelerations are caused by vagal nerve stimulation resulting from pressure on the fetal head and are considered a normal response of the fetus to labor. A fetal heart rate above 100 bpm is normal. It should not fall below 100 bpm.
20. The nurse is caring for a client who just delivered a healthy 7 pound 9 ounce baby girl. What is the priority nursing intervention for this new mother? A) Give the mother a bed bath. B) Allow the mother a period of rest with no distractions. C) Encourage bonding with the infant. D) Perform a comprehensive assessment.
Ans: C Feedback: Immediately following delivery.. the woman may experience extreme fatigue..close to exhaustion.. just as she would after any extremely vigorous physical activity or hard work. At the same time.. she is usually relieved and excited. She is usually interested in seeing and holding her newborn and having a visit with her partner. The bonding between parents and newborn should be encouraged immediately.
11. A pregnant client in her 38th week of gestation complains of abdominal pains and suspects she is in labor. Which of the following findings are characteristic of true labor contractions? A) Contractions are short and irregular. B) Contractions are generally felt low in the abdomen. C) Contractions help create effacement and dilation of the cervix. D) Contractions are relieved by change of position or activity.
Ans: C Feedback: In true labor... the contractions help create effacement and dilation of the cervix. Painless...short... and irregular uterine contractions... which are generally felt low in the abdomen and are relieved by change of position or activity... are characteristic of false labor.
30. The nurse is discharging a new mother from the hospital. Which of the following is a recommended teaching guideline that should be discussed? A) Tell the client to return for a follow-up examination in 1 month. B) Advise the client to resume sexual intercourse as soon as it feels comfortable. C) Tell the nonnursing client that menstruation should resume in 6 to 8 weeks. D) Tell the nursing mother that contraception is not necessary until her period returns.
Ans: C Feedback: The mother should be informed that menstruation will resume in 6 to 8 weeks if she does not nurse her newborn. If she does nurse.. menstruation is usually delayed for 4 to 5 months or until she stops nursing. The client should return for a follow-up examination in 6 to 8 weeks and should abstain from intercourse and douching until then. Although ovulation does not usually occur during the nursing period.. prolonging nursing is no guarantee that pregnancy will not occur.
6. The nurse assisting with deliveries is aware that which of the following clients is most at risk for having a difficult delivery and possibly cesarean section. A) A woman whose baby is in a longitudinal lie B) A woman whose baby has a cephalic presentation C) A woman whose baby has engaged prior to labor D) A woman whose baby is in the footling breech position
Ans: D Feedback: Some positions of the fetus make delivery difficult or dangerous. For example, in a footling breech position, there is a chance the umbilical cord could prolapse because there is so much empty space within the uterus. This could cut off the blood and oxygen supply to the fetus before it is born. The other examples are normal fetal body to maternal body presentations.
9. The husband of a pregnant woman in labor is coaching her to perform breathing exercises to distract her from the pain. Which of the four P's of labor would the parents be? A) Passage B) Passenger C) Powers D) Psyche
Ans: D Feedback: There are common variables of labor known as the 4 P's of labor: passage... passenger... powers...and psyche. The passage includes the diameter of the body pelvis and its soft tissues. The passenger includes the fetus..umbilical cord...and placenta. The powers are the uterine contractions. The psyche includes the process of birthing..the attitude and behaviors of the parents..and the evaluation process of the stages of labor.
8. A client is in labor and the nurse palpates her abdomen to assess the presentation of the fetus. Which of the following presentations indicates normal labor? A) Breech presentation B) Shoulder presentation C) Brow presentation D) Vertex presentation
Ans: D Feedback: Vertex presentation occurs when the fetal head is flexed well against the fetal chest and the top of the fetal head is the presenting part. In normal labor there is a vertex presentation. Complicated labor often occurs when body parts other than the top (crown) of the fetal head present. When the buttocks foot or knee is the presenting (lowest) part it is called a breech presentation. The shoulder may be the presenting part if the fetus is lying in a transverse position. If the head is partially extended then the brow presents.
A pregnant woman states that she wants to have her baby at home on her "own territory." What type of professional would be most likely to attend a home birth? A) Nurse practitioner B) Physician C) Registered nurse D) Certified nurse midwife
Ans: D Feedback: Women may choose to give birth at home. Home births may be attended by either a CNM or, less frequently, a physician. One reason some women choose this option is that the home is their territory, which is not the case in either a birth center or a hospital.
28. The nurse is teaching a new mother breastfeeding techniques. What would be an appropriate measure to teach to help relieve engorgement? A) Do not wear a bra or other constricting clothing. B) Apply cold packs to the breast for 15 minutes before nursing. C) Increase fluid intake by 30%. D) Avoid manual expression or pumping breasts.
Ans: D Feedback: The mother should avoid manual expression or pumping breasts during engorgement.. wear a supportive bra.. apply warm packs to the breast for 15 minutes before nursing.. and avoid excessive fluid intake.
18. A client is in the second stage of labor. The nurse should record the following information in the second stage: A) The exact time of placental delivery B) The nature of placental delivery C) The side of placental presentation D) The type of episiotomy on the client's chart
Ans: D Feedback: The nurse should note the type of episiotomy on the client's chart in the second stage. The nurse should record the information about the exact time of placental delivery.. whether spontaneous or manual placental delivery and the side of placental presentation.. in the third stage.
13. The nurse is caring for a laboring woman who has been given oxytocin to induce labor. She is having contractions at an interval of every 2 minutes with 90 seconds duration in between. What would be the appropriate intervention in this situation? A) Encourage the woman's coach to help her with breathing exercises. B) Provide a back rub for the woman when the pain is at its greatest intensity. C) Check her pain medication preferences and administer an analgesic.. if indicated. D) Report this emergency situation to the birth attendant.
Ans: D Feedback: The nurse should report immediately if contractions come more often than every 2 minutes or if each contraction lasts 90 seconds or longer.. because there is not sufficient relaxation time for the fetus to be well oxygenated. This event is rare during normal labor.. but must be carefully watched for when oxytocin is used for labor augmentation or induction.