Exam 1 Practice questions
Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? 1."I feel like I need to push." 2."My contractions seem to be getting stronger." 3."I am glad that I have several minutes to rest between contractions." 4."Warm fluid is running down my legs each time I have a contraction."
1."I feel like I need to push." The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. At this time, the laboring woman typically experiences the desire to push. Contractions becoming stronger are experienced throughout labor and do not indicate that she has reached stage 2. Having several minutes to rest between contractions does not describe the end of transition.Leaking of amniotic fluid does not mean that she is completely dilated.
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1.3 days postpartum 2.7 days postpartum 3.On the day of birth 4.Within 2 weeks postpartum
1.3 days postpartum After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1."It connects the pulmonary artery to the aorta." 2."It is an opening between the right and left atria." 3."It connects the umbilical vein to the inferior vena cava." 4."It connects the umbilical artery to the inferior vena cava."
3."It connects the umbilical vein to the inferior vena cava." The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1."I will begin abdominal exercises immediately." 2."I will notify the health care provider if I develop a fever." 3."I will turn on my side and push up with my arms to get out of bed." 4."I will lift nothing heavier than my newborn baby for at least 2 weeks."
A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.
The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1.Stop the oxytocin infusion. 2.Check the client's blood pressure. 3.Check the client for bladder distention. 4.Place the client in a side-lying position.
Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse should monitor the client's blood pressure and intake and output; however, the nurse should first stop the infusion.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1."You will need to bottle-feed your newborn." 2."You will need to feed your newborn by nasogastric tube feeding." 3."You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4."You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."
Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed.
The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1.Chest pain 2.A rigid abdomen 3.A soft and boggy uterus 4.Complaints of severe abdominal pain
Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting.
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? 1."I will be sure to wash my hands before and after bathroom use." 2."I need to breast-feed, especially for the first 6 weeks postpartum." 3."Support groups are available to assist me with understanding my diagnosis of HIV." 4."My newborn infant should be on antiviral medications for the first 6 weeks after delivery."
2."I need to breast-feed, especially for the first 6 weeks postpartum." The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the prenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. In the United States and most developed countries, HIV-positive clients are encouraged to bottle-feed their infants (the health care provider's prescription is always followed). Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.
The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. 1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2."One vein carries oxygenated blood from the placenta to the fetus." 3."The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." 4."Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5."Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."
1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2."One vein carries oxygenated blood from the placenta to the fetus." 4."Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." The ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart tone range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily." The postpartum client should wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers.
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1.Administer oxygen via face mask. 2.Place the mother in a supine position. 3.Increase the rate of the oxytocin intravenous infusion. 4.Document the findings and continue to monitor the fetal patterns.
1.Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication.
The nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding, the nurse should prepare for which appropriate nursing action? 1.Administering oxygen via face mask 2.Placing the mother in a supine position 3.Increasing the rate of the intravenous (IV) oxytocin infusion 4.Documenting the findings and continuing to monitor the fetal patterns
1.Administering oxygen via face mask Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned on her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Documenting and monitoring would delay necessary treatment.
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function 5.Prevents large particles such as bacteria from passing to the fetus 6.Provides an exchange of nutrients and waste products between the mother and the fetus
1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.
The nurse is assisting the health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure? 1.Ask the client to urinate. 2.Ask the client to drink 8 oz of water. 3.Locate the fetal heart tones with a fetoscope. 4.Warm the sonogram gel before placing it on the client's abdomen
1.Ask the client to urinate. An empty bladder contributes to a woman's comfort during this examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonography (ultrasound). Often Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.
The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1.Assess the fetal heart rate. 2.Check the client's temperature. 3.Change the pads under the client. 4.Check the client's respiratory rate.
1.Assess the fetal heart rate. After amniotomy or rupture of the membranes in the birth setting, the nurse immediately assesses the fetal heart rate for at least 1 minute to detect changes associated with prolapse or compression of the umbilical cord. The quantity, color, and odor of the amniotic fluid also are noted. The client's temperature should be assessed every 2 to 4 hours, and the nurse also should check the client's vital signs. The pads under the client should be changed regularly to promote comfort and reduce the moist environment that favors bacterial growth, but this is not the priority.
The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply. 1.Clear, dark amber amniotic fluid 2.Amniotic fluid volume of 800 mL 3.Light green amniotic fluid with no odor 4.Thick white amniotic fluid with no odor 5.Straw-colored amniotic fluid with flecks of vernix
1.Clear, dark amber amniotic fluid 3.Light green amniotic fluid with no odor 4.Thick white amniotic fluid with no odor Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin, watery consistency and may have a mild odor. The normal amount of amniotic fluid ranges from 500 to 1000 mL. Dark amber color, light green color, and thick white color are not descriptions of normal amniotic fluid and should be brought to the HCP's attention.
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1.Client pain level 2.Inadequate urinary output 3.Client perception of body changes 4.Potential for imbalanced body fluid volume
1.Client pain level The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.
The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1.Forceps delivery 2.Schultz presentation 3.Hypotonic contractions 4.Weak bearing-down efforts
1.Forceps delivery Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.
A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1.Measure fundal height. 2.Attach electronic fetal monitoring. 3.Prepare the client for a possible cesarean section. 4.Visually examine the perineum and vaginal opening.
1.Measure fundal height. Measuring fundal height is least appropriate because it should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1.Notify the health care provider (HCP). 2.Continue monitoring the fetal heart rate. 3.Encourage the client to continue pushing with each contraction. 4.Instruct the client's coach to continue to encourage breathing techniques.
1.Notify the health care provider (HCP). A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1.Provide pain relief measures. 2.Prepare the client for an amniotomy. 3.Promote ambulation every 30 minutes. 4.Monitor the oxytocin infusion closely.
1.Provide pain relief measures. Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest
A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1.Supine position with a wedge under the right hip 2.Trendelenburg's position with the legs in stirrups 3.Prone position with the legs separated and elevated 4.Semi Fowler's position with a pillow under the knees
1.Supine position with a wedge under the right hip
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1.The diet should include additional fluids. 2.Prenatal vitamins should be discontinued. 3.Soap should be used to cleanse the breasts. 4.Birth control measures are unnecessary while breast-feeding.
1.The diet should include additional fluids. The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed
The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? 1.Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2.Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3.Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4.Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.
1.Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned onto her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is then applied to the mother.
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1."Come to the clinic immediately." 2."The vaginal discharge may be bothersome, but is a normal occurrence." 3."Report to the emergency department at the maternity center immediately." 4."Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."
2."The vaginal discharge may be bothersome, but is a normal occurrence." Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.
A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased? 1.Increased urinary output 2.A fetal heart rate of 180 beats/min 3.Three contractions occurring in a 10-minute period 4.Adequate resting tone of the uterus palpated between contractions
2.A fetal heart rate of 180 beats/min A normal fetal heart rate is 110 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.
The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? 1.Increased urinary output 2.A fetal heart rate of 90 beats/minute 3.3 contractions occurring within a 10-minute period 4.Adequate resting tone of the uterus palpated between contractions
2.A fetal heart rate of 90 beats/minute A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve 3 good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1.Identify the types of accelerations. 2.Assess the baseline fetal heart rate. 3.Determine the intensity of the contractions. 4.Determine the frequency of the contractions.
2.Assess the baseline fetal heart rate. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor.
After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1.Reposition the laboring woman to knee-chest. 2.Assess the vagina and cervix with a gloved hand. 3.Notify the health care provider of the need for an amnioinfusion. 4.Document the description of the fetal bradycardia in the nursing notes.
2.Assess the vagina and cervix with a gloved hand. It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1.Feed the newborn less frequently. 2.Continue to breast-feed every 2 to 4 hours. 3.Switch to bottle-feeding the infant for 2 weeks. 4.Stop breast-feeding and switch to bottle-feeding permanently.
2.Continue to breast-feed every 2 to 4 hours. Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary.
A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1.Contact the obstetrician. 2.Continue to monitor the client. 3.Report the FHR to the anesthesiologist. 4.Prepare for imminent delivery of the fetus.
2.Continue to monitor the client. The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1.Notify the health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.
2.Discontinue the infusion of oxytocin. The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time
A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? 1.Hourly 2.Every 15 minutes 3.Every 30 minutes 4.Before each contraction
2.Every 15 minutes The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? 1.Hemoglobin of 11 g/dL (110 mmol/L) 2.Fetal heart rate of 180 beats/minute 3.Maternal pulse rate of 85 beats/minute 4.White blood cell count of 12,000 mm3 (12.0 × 109/L)
2.Fetal heart rate of 180 beats/minute A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11-13 g/dL (110-130 mmol/L) ) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 mm3 (11 to 15 x 10 9/L), up to 18,000 mm3 (18 x 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 x 109/L) because of increased leukocytosis that occurs during delivery.
The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? 1.Monitoring the newborn's vital signs routinely 2.Maintaining standard precautions at all times while caring for the newborn 3.Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4.Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
2.Maintaining standard precautions at all times while caring for the newborn An infant born to a mother infected with HIV must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn. Mothers infected with HIV should not breast-feed.
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1.Elevate the client's legs. 2.Massage the fundus until it is firm. 3.Ask the client to turn on her left side. 4.Push on the uterus to assist in expressing clots.
2.Massage the fundus until it is firm. If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? 1.Episodic, late decelerations that indicate uteroplacental insufficiency 2.Periodic, early decelerations that indicate fetal head compression 3.Periodic, variable decelerations that indicate cord compression 4.Episodic, early decelerations that may be a result of maternal hypotension
2.Periodic, early decelerations that indicate fetal head compression An early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described; therefore, eliminate option 3. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4.
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1.Ambulation 2.Rest between contractions 3.Change positions frequently 4.Consume oral food and fluids
2.Rest between contractions The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.
The charge nurse on a labor and delivery unit has numerous admissions of laboring clients and must transfer 1 of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client is the most appropriate one to transfer? 1.The 36-year-old, gravida I, para 0 client who is at 24 weeks' gestation and is being monitored for preterm labor 2.The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding 3.The 40-year-old, gravida III, para 0 client who is at 38 weeks' gestation and is complaining of decreased fetal movement 4.The 29-year-old, gravida I, para 0 client who is at 42 weeks' gestation and had a biophysical profile score of 5 earlier today
2.The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding The fetus of the client at 10 weeks' gestation is in a previability stage, whereas those of the other clients are at a stage of viability. There is limited monitoring that can be done with a 10-week fetus; Doppler monitoring is not feasible during the first trimester. Bed rest and continued monitoring are most likely the primary treatments for this client at this point in her pregnancy. Bed rest could be maintained, and bleeding could be monitored by a postpartum nurse. The clients with preterm and postterm gestations (24 and 42 weeks, respectively) are those most at risk, so these clients require more fetal monitoring. The woman who is at 38 weeks' gestation is also in need of fetal monitoring because of a possibility of decreased fetal movement. Until the fetal well-being can be confirmed with fetal monitoring, this client should remain on the labor and delivery unit where she can be continuously monitored. In addition, the 2 older clients (36 and 40 years) are considered to be of advanced maternal age, indicating a need for closer monitoring
The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1.Fentanyl 2.Morphine sulfate 3.Butorphanol tartrate 4.Meperidine hydrochloride
3.Butorphanol tartrate Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.
The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? 1.An IV infusion of antibiotics 2.Placing the client on complete bed rest 3.Continuous electronic fetal monitoring 4.Placing a code cart at the client's bedside
3.Continuous electronic fetal monitoring Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1.Apply gentle pressure. 2.Reinforce the dressing. 3.Document the findings. 4.Contact the health care provider (HCP).
3.Document the findings. The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the HCP. Because the findings identified in the question are normal, the nurse would document the assessment findings.
The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1.Warming the crib pad 2.Closing the doors to the room 3.Drying the infant with a warm blanket 4.Turning on the overhead radiant warmer
3.Drying the infant with a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).
The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? 1.Prepare the client for a cesarean delivery. 2.Monitor the FHR every 30 minutes. 3.Encourage an upright or side-lying maternal position. 4.Increase the rate of the oxytocin infusion every 10 minutes.
3.Encourage an upright or side-lying maternal position. Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations, without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.
A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1.Perform an abdominal scrub on the client. 2.Prepare the delivery room for a vaginal delivery. 3.Explain to the client why a cesarean delivery is necessary. 4.Call the health care provider to obtain a prescription for an antiviral medication.
3.Explain to the client why a cesarean delivery is necessary. Because neonatal infection of HSV is life-threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal scrub will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms, not to eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.
Which assessment following an amniotomy should be conducted first? 1.Cervical dilation 2.Bladder distention 3.Fetal heart rate pattern 4.Maternal blood pressure
3.Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.
A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1.Less pressure on her cervix 2.Decreased number of contractions 3.Increased efficiency of contractions 4.The need for increased maternal blood pressure monitoring 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
3.Increased efficiency of contractions 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1.Raise the head of the client's bed. 2.Obtain hemoglobin and hematocrit levels. 3.Instruct the client to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.
3.Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.
The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1.Lethargy 2.Sleepiness 3.Irritability 4.Constant crying 5.Difficult to comfort 6.Cuddles when being held
3.Irritability 4.Constant crying 5.Difficult to comfort A newborn of a woman who uses drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held. This infant is not lethargic or sleepy.
Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1.It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.
3.It is the way the baby gets food and oxygen. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus. Rationale:The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1.Document the findings. 2.Reassess the client in 2 hours. 3.Notify the health care provider (HCP). 4.Encourage increased oral intake of fluids.
3.Notify the health care provider (HCP). Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1.Document the finding. 2.Check the mother's heart rate. 3.Notify the health care provider (HCP). 4.Tell the client that the fetal heart rate is normal.
3.Notify the health care provider (HCP). The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.
The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1.Document the findings. 2.Arrange for hearing testing. 3.Notify the health care provider. 4.Cover the ears with gauze pads
3.Notify the health care provider. Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.
The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1.Noting whether the heart rate is greater than 140 beats/minute 2.Placing the diaphragm of the Doppler on the mother's abdomen 3.Palpating the maternal radial pulse while listening to the FHR 4.Performing Leopold's maneuvers first to determine the location of the fetal heart
3.Palpating the maternal radial pulse while listening to the FHR The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the 2 heart rates.
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1.Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. 3.Perform a vaginal examination every shift. 4.Administer an antibiotic per HCP prescription and per agency protocol.
3.Perform a vaginal examination every shift. Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.
The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. 1.Early labor 2.Amniotomy 3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies
3.Tachycardia 4.Fetal hypoxia 5.Metabolic acidemia 6.Congenital anomalies The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into 4 different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition.
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1.The contractions are regular. 2.The membranes have ruptured. 3.The cervix is dilated completely. 4.The client begins to expel clear vaginal fluid. 5.The spontaneous urge to push is initiated from perineal pressure.
3.The cervix is dilated completely. 5.The spontaneous urge to push is initiated from perineal pressure. The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1.The client is measuring large for gestational age. 2.The client is measuring small for gestational age. 3.The client is measuring normal for gestational age. 4.More evidence is needed to determine size for gestational age.
3.The client is measuring normal for gestational age. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1.Maternal fatigue 2.Coordinated uterine contractions 3.Progressive changes in the cervix 4.Persistent nonreassuring fetal heart rate
4.Persistent nonreassuring fetal heart rate Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1."I should breast-feed every 2 to 3 hours." 2."I should change the breast pads frequently." 3."I should wash my hands well before breast-feeding." 4."I should wash my nipples daily with soap and water."
4."I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1."I won't be in labor until my baby drops." 2."My contractions will be felt in my abdominal area." 3."My contractions will not be as painful if I walk around." 4."My contractions will increase in duration and intensity."
4."My contractions will increase in duration and intensity." True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.
The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1."Your newborn needs the medicine to develop immunity." 2."The medicine will protect your newborn from being jaundiced." 3."Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." 4."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
4."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." Phytonadione is necessary for the body to synthesize coagulation factors. It is administered to the newborn to prevent bleeding disorders. It also promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary to synthesize fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? 1."You will be isolated from your newborn infant after delivery." 2."Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3."There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4."You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."
4."You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed." With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery.
Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? 1.Continue the oxytocin drip. 2.Slow the intravenous (IV) rate. 3.Place the client in a high Fowler's position. 4.Administer oxygen at 8 to 10 L/min via face mask.
4.Administer oxygen at 8 to 10 L/min via face mask. Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The IV infusion should be increased, not decreased, so as to increase the maternal blood volume. The woman's position should be lateral with legs raised to increase maternal blood volume and improve the maternal vascular system.
The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1.Contact the health care provider (HCP). 2.Place the client in Trendelenburg's position. 3.Administer oxygen to the client by face mask. 4.Document the findings and continue to monitor fetal patterns.
4.Document the findings and continue to monitor fetal patterns. Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, contacting the HCP, changing the client' position, or administering oxygen is not necessary.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1.Notify the health care provider of the findings. 2.Reposition the mother and check the monitor for changes in the fetal tracing. 3.Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4.Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
4.Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.
The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1.Exhaustion 2.Valsalva maneuver 3.Involuntary grunting 4.Fear of losing control
4.Fear of losing control Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action? 1.Document the findings. 2.Retake the temperature in 15 minutes. 3.Notify the health care provider (HCP). 4.Increase hydration by encouraging oral fluids.
4.Increase hydration by encouraging oral fluids. The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4°F (38°C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches.
4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches. Phototherapy (bili-light or bili-blanket), is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn may have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.
The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1.Assessing the mother's reflexes 2.Taking the mother's temperature 3.Taking the mother's apical pulse 4.Monitoring the mother's blood pressure
4.Monitoring the mother's blood pressure A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.
An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? 1.Light green, with no odor 2.Clear and dark amber in color 3.Thick and white, with no odor 4.Pale straw in color, with flecks of vernix
4.Pale straw in color, with flecks of vernix Amniotic fluid normally is pale straw in color and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white; this could be an indication of infection.
The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation
4.Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.
A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? 1.Anxiety 2.Hot flashes 3.Low self-esteem 4.Postpartum infection
4.Postpartum infection Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hot flashes. Anxiety and low self-esteem are unrelated to physiological integrity.
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1.Protects the newborn's eyes from possible infections acquired while hospitalized. 2.Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3.Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4.Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
4.Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection. Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1.The client with mild after pains 2.The client with a pulse rate of 60 beats/minute 3.The client with colostrum discharge from both breasts 4.The client with lochia that is red and has a foul-smelling odor
4.The client with lochia that is red and has a foul-smelling odor Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1.The mother requests that the window be closed before feeding. 2.The mother holds the newborn properly during feeding and burping. 3.The mother tests the temperature of the formula before initiating feeding. 4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission.
Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1.Prepare for delivery. 2.Administer a tocolytic. 3.Administer an opioid antagonist. 4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute.
4.Turn the woman to a lateral position. 5.Increase the rate of the intravenous infusion. 6.Administer oxygen by face mask at 10 L/minute. Maternal hypotension results in decreased placental perfusion, so the focus of nursing care should be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, as she just received an epidural which is typically administered at 6 cm or earlier dilation, so option 1 can be eliminated. Administering a tocolytic can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Administering an opioid antagonist can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1.Variability 2.Accelerations 3.Early decelerations 4.Variable decelerations
4.Variable decelerations Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.
A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate? 1."Breast-feeding can start 6 months after delivery." 2."Breast-feeding is allowed after the baby has been vaccinated with immune globulin." 3."Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby." 4."Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery."
Although HBV is transmitted in breast milk, after scheduled newborn vaccines and immune globulin have been administered to the newborn, the woman may breast-feed without risk to the newborn. The remaining options are incorrect responses.
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1.Contact the health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Inform the client that these contractions are common and may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.
Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is no reason to notify the health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored.
