Chapter 17: NCLEX practice questions
A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.) A) Estriol is found in maternal saliva. B) Irregular, mild uterine contractions are occurring every 12 to 15 minutes. C) Fetal fibronectin is present in vaginal secretions. D) The cervix is effacing and dilated to 2 cm. E) Fetal heart rate of 150 beats/minute
*A) Estriol is found in maternal saliva.* *D) The cervix is effacing and dilated to 2 cm.* Rationale: Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. *Levels of salivary estriol have been shown to increase before preterm birth*. Irregular, mild contractions that do not cause cervical change are not considered a threat. The *presence of fetal fibronectin in vaginal secretions* between *24 and 36 weeks* of gestation *could predict preterm labor*, BUT it has ONLY a 20% to 40% POSITIVE PREDICTIVE VALUE. Of more importance are other physiologic clues of preterm labor, such as cervical changes. Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. *Changes in the cervix accompanied by regular contractions indicate labor at any gestation.* Fetal heart rate 0f 150 BPM is normal.
A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? A) Place the woman in the knee-chest position. B) Cover the cord in a sterile towel saturated with warm normal saline. C) Prepare the woman for a cesarean birth. D) Start oxygen by face mask.
*A) Place the woman in the knee-chest position.* Rationale: A. The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. B. If the cord is protruding from the vagina, it may be covered with a sterile towel soaked in saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing priority. C. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. *Cesarean birth is indicated only if cervical dilation is not complete.* D. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. This intervention should be initiated after pressure is relieved on the cord. Not only should the woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers to lift the presenting part off the cord.
The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.) A) Unstable coronary artery disease B) Previous cesarean birth C) Placenta previa D) Initial blood pressure of 132/87 E) History of three spontaneous abortions
*A) Unstable coronary artery disease* *B) Previous cesarean birth* *C) Placenta previa* Rationale: Indications for cesarean birth include: *Maternal* · Specific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease) · Specific respiratory disease (e.g., Guillain-Barré syndrome) · Conditions associated with increased intracranial pressure · Mechanical obstruction of the lower uterine segment (tumors, fibroids) · Mechanical vulvar obstruction (e.g., extensive condylomata) · History of previous cesarean birth *Fetal* · Abnormal fetal heart rate (FHR) or pattern · Malpresentation (e.g., breech or transverse lie) · Active maternal herpes lesions · Maternal human immunodeficiency virus (HIV) with a viral load of more than 1000 copies/mL · Congenital anomalies *Maternal-Fetal* · Dysfunctional labor (e.g., cephalopelvic disproportion, "failure to progress" in labor) · Placental abruption · Placenta previa · Elective cesarean birth (cesarean on maternal request) The blood pressure can be elevated because of pain and is not necessarily a contraindication to vaginal birth until further assessment is completed. Having a history of three spontaneous abortions is not a contraindication to vaginal birth.
A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to: A) assess the fetal heart rate (FHR) pattern. B) perform a vaginal examination. C) inspect the characteristics of the fluid. D) assess maternal temperature.
*A) assess the fetal heart rate (FHR) pattern* Rationale: The first nursing action after the membranes are ruptured is to check the FHR. Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy). These are all important and should be done after the FHR and pattern are assessed. These are all important and should be done after the FHR and pattern are assessed. These are all important and should be done after the FHR and pattern are assessed.
In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information? A) "Because this is a repeat procedure, you are at the lowest risk for complications." B) "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." C) "Because this is your second cesarean birth, you will recover faster." D) "You will not need preoperative teaching because this is your second cesarean birth."
*B) "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures."* Rationale: This statement is not accurate. Maternal and fetal risks are associated with every cesarean section. This statement is the most appropriate. This statement is not accurate. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure.
A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: A) uterine contractions occurring every 8 to 10 minutes B) a fetal heart rate (FHR) of 180 with absence of variability C) the client needing to void D) rupture of the client's amniotic membranes
*B) a fetal heart rate (FHR) of 180 with absence of variability* Rationale: The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. This FHR is non-reassuring. The oxytocin should be immediately discontinued and the physician should be notified. This is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is non-reassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the client's membranes have ruptured.
A woman is evaluated to be using an effective bearing-down effort if she: A) begins pushing as soon as she is told that her cervix is fully dilated and effaced. B) takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. C) uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. D) continues to push for short periods between uterine contractions throughout the second stage of labor.
*B) takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction.* Rationale: Bearing-down efforts should begin during the active-descent phase of the second stage of labor when the urge to bear down (Fresno reflex) is perceived. Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal. Pushing gently between contractions is only advised when the fetal head is being delivered.
With regard to dysfunctional labor, nurses should be aware that: A) women who are underweight are more at risk. B) women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted. C) hypertonic uterine dysfunction is more common than hypotonic dysfunction. D) abnormal labor patterns are most common in older women.
*B) women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted.* Rationale: Short women more than *30 lbs overweight are more at risk for dysfunctional labor*. Precipitous labor lasts less than 3 hours. *Hypotonic uterine dysfunction*, in which the contractions become weaker, is *more common*. *Abnormal labor patterns* are *more common* in women *younger than 20* years of age.
A nurse providing care to a woman in labor should be aware that cesarean birth: A) is declining in frequency in the United States. B) is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier clients do. C) is performed primarily for the benefit of the fetus. D) can be either elected or refused by women as their absolute legal right.
*C) is performed primarily for the benefit of the fetus.* Rationale: Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.
With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: A) the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. B) there are no important maternal (as opposed to fetal) contraindications. C) its most important function is to afford the opportunity to administer antenatal glucocorticoids. D) if the client develops pulmonary edema while on tocolytics, IV fluids should be given.
*C) its most important function is to afford the opportunity to administer antenatal glucocorticoids.* Rationale: Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Tocolytic-induced edema can be caused by IV fluids.
Which statement is most likely to be associated with a breech presentation? A) Least common malpresentation B) Descent is rapid C) Diagnosis by ultrasound only D) High rate of neuromuscular disorders
*D) High rate of neuromuscular disorders* Rationale: *Breech is the most common malpresentation* affecting 3% to 4% of all labors. *Descent is often slow* because the breech is not as good a dilating wedge as is the fetal head. *Diagnosis* is made by *abdominal palpation and vaginal examination*. It is confirmed by ultrasound. *Fetuses with neuromuscular disorders have a higher rate of breech presentation*, perhaps because they are less capable of movement within the uterus.
For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? A) Fetal heart rate of 116 beats/min B) Cervix dilated 2 cm and 50% effaced C) Score of 8 on the biophysical profile D) One fetal movement noted in 1 hour of assessment by the mother
*D) One fetal movement noted in 1 hour of assessment by the mother* Rationale: A fetal heart rate of 116 beats/min is a normal finding at 42 weeks of gestation. Cervical dilation of 2 cm with 50% effacement is a normal finding in a 42-week gestation woman. A score of 8 on the BPP is a normal finding in a 42-week gestation pregnancy. Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation.
