Exam 2 Maternity Review

A normal uterine activity pattern in labor is characterized by: a. Contractions every 2 to 5 minutes. b. Contractions lasting about 2 minutes. c. Contractions about 1 minute apart. d. A contraction intensity of about 1000 mm Hg with relaxation at 50 mm Hg.

ANS: A Contractions normally occur every 2 to 5 minutes and last less than 90 seconds (intensity 800 mm Hg) with about 30 seconds in between (20 mm Hg or less). PTS: 1 DIF: Cognitive Level: Knowledge REF: 383 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for the laboring woman should understand that early decelerations are caused by: a. Altered fetal cerebral blood flow. b. Umbilical cord compression. c. Uteroplacental insufficiency. d. Spontaneous rupture of membranes.

ANS: A Early decelerations are the fetuss response to fetal head compression. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal heart rate unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 391 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse providing care for the laboring woman comprehends that accelerations with fetal movement: a. Are reassuring. b. Are caused by umbilical cord compression. c. Warrant close observation. d. Are caused by uteroplacental insufficiency.

ANS: A Episodic accelerations in the fetal heart rate (FHR) occur during fetal movement and are indications of fetal well-being. Umbilical cord compression results in variable decelerations in the FHR. Accelerations in the FHR are an indication of fetal well-being and do not warrant close observation. Uteroplacental insufficiency would result in late decelerations in the FHR. PTS: 1 DIF: Cognitive Level: Knowledge REF: 390 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a. Is inconsistent with the Baby Friendly Hospital Initiative. b. Promotes longer periods of breastfeeding. c. Is perceived as supportive to both bottle-feeding and breastfeeding mothers. d. Is associated with earlier cessation of breastfeeding.

ANS: A Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers. PTS: 1 DIF: Cognitive Level: Comprehension REF: 502 OBJ: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurses first priority is to: a. Change the womans position. b. Notify the care provider. c. Assist with amnioinfusion. d. Insert a scalp electrode.

ANS: A Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurses first priority. PTS: 1 DIF: Cognitive Level: Application REF: 392 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Leopold maneuvers would be an inappropriate method of assessment to determine: a. Gender of the fetus. b. Number of fetuses. c. Fetal lie and attitude. d. Degree of the presenting parts descent into the pelvis.

ANS: A Leopold maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus is not a goal of the examination at this time. PTS: 1 DIF: Cognitive Level: Knowledge REF: 409 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: a. Change in position. b. Oxytocin administration. c. Regional anesthesia. d. Intravenous analgesic.

ANS: A Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the womans heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration, regional anesthesia, and intravenous analgesic may reduce maternal cardiac output. PTS: 1 DIF: Cognitive Level: Comprehension REF: 396 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

ANS: A The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed. PTS: 1 DIF: Cognitive Level: Knowledge REF: 385 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. Afterpains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The nonnursing mother may have engorgement problems. The patient whose infant is in the NICU should pump regularly to stimulate milk production and ensure that she will have an adequate milk supply when the baby is strong enough to nurse. PTS: 1 DIF: Cognitive Level: Comprehension REF: 494 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. A fundus that is palpable at or below the level of the umbilicus is a normal finding for a patient who is 12 hours postpartum. Palpation of the fundus 2 fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate. PTS: 1 DIF: Cognitive Level: Application REF: 484 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

In evaluating the effectiveness of oxytocin induction, the nurse would expect: a. Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart. b. The intensity of contractions to be at least 110 to 130 mm Hg. c. Labor to progress at least 2 cm/hr dilation. d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.

ANS: A The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 40 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min. PTS: 1 DIF: Cognitive Level: Analysis REF: 466 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Immediately after the forceps-assisted birth of an infant, the nurse should: a. Assess the infant for signs of trauma. b. Give the infant prophylactic antibiotics. c. Apply a cold pack to the infants scalp. d. Measure the circumference of the infants head.

ANS: A The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma. Prophylactic antibiotics are not necessary with a forceps delivery. A cold pack would put the infant at risk for cold stress and is contraindicated. Measuring the circumference of the head is part of the initial nursing assessment. PTS: 1 DIF: Cognitive Level: Application REF: 467 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The exact cause of preterm labor is unknown and believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Select the type of infection that has not been linked to preterm births. a. Viral b. Periodontal c. Cervical d. Urinary tract

ANS: A The infections that increase the risk of preterm labor and birth are all bacterial. They include cervical, urinary tract, periodontal, and other bacterial infections. Therefore, it is important for the client to participate in early, continual, and comprehensive prenatal care. Evidence has shown a link between periodontal infections and preterm labor. Researchers recommend regular dental care before and during pregnancy, oral assessment as a routine part of prenatal care, and scrupulous oral hygiene to prevent infection. Cervical infections of a bacterial nature have been linked to preterm labor and birth. The presence of urinary tract infections increases the risk of preterm labor and birth. PTS: 1 DIF: Cognitive Level: Knowledge REF: 443 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed? a. Nail brittleness b. Darker pigmentation of the areolae and linea nigra c. Striae gravidarum on the breasts, abdomen, & thighs d. Spider nevi

ANS: A The nails return to their prepregnancy consistency and strength. Some women have permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum (stretch marks) usually do not completely disappear. For some women spider nevi persist indefinitely. PTS: 1 DIF: Cognitive Level: Comprehension REF: 489 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

The nurse knows that proper placement of the tocotransducer for electronic fetal monitoring is located: a. Over the uterine fundus. b. On the fetal scalp. c. Inside the uterus. d. Over the mothers lower abdomen.

ANS: A The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. PTS: 1 DIF: Cognitive Level: Comprehension REF: 386 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

With regard to a womans intake and output during labor, nurses should be aware that: a. The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly.

ANS: A Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful. Routine use of an enema is at best ineffective and may be harmful. A multiparous woman may feel the urge to defecate and it may mean birth will follow quickly, but not for a first-timer. PTS: 1 DIF: Cognitive Level: Comprehension REF: 417 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

A maternal indication for the use of vacuum extraction is: a. A wide pelvic outlet. b. Maternal exhaustion. c. A history of rapid deliveries. d. Failure to progress past 0 station.

ANS: B A mother who is exhausted may be unable to assist with the expulsion of the fetus. The patient with a wide pelvic outlet will likely not require vacuum extraction. With a rapid delivery, vacuum extraction is not necessary. A station of 0 is too high for a vacuum extraction. PTS: 1 DIF: Cognitive Level: Knowledge REF: 468 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called: a. An epidural. b. A pudendal. c. A local. d. A spinal block.

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs. PTS: 1 DIF: Cognitive Level: Knowledge REF: 370 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug? a. Assessing deep tendon reflexes (DTRs) b. Assessing for chest discomfort and palpitations c. Assessing for bradycardia d. Assessing for hypoglycemia

ANS: B Terbutaline is a b2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. b2-Adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia. PTS: 1 DIF: Cognitive Level: Analysis REF: 447 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she would be able to go home. Which response by the nurse is most accurate? a. After the baby is born. b. When we can stabilize your preterm labor and arrange home health visits. c. Whenever the doctor says that it is okay. d. It depends on what kind of insurance coverage you have.

ANS: B The clients preterm labor is being controlled with tocolytics. Once she is stable, home care may be a viable option for this type of client. Care of a woman with preterm labor is multifactorial; the goal is to prevent delivery. In many cases this may be achieved at home. Care of the preterm client is multidisciplinary and multifactorial. Managed care may dictate earlier hospital discharges or a shift from hospital to home care. Insurance coverage may be one factor in the care of clients, but ultimately client safety remains the most important factor. PTS: 1 DIF: Cognitive Level: Application REF: 447 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

To assist the woman after delivery of the infant, the nurse knows that the blood patch is used after spinal anesthesia to relieve: a. Hypotension. b. Headache. c. Neonatal respiratory depression. d. Loss of movement.

ANS: B The subarachnoid block may cause a postspinal headache resulting from loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia. PTS: 1 DIF: Cognitive Level: Knowledge REF: 371 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse providing care for the laboring woman realizes that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow. b. Umbilical cord compression. c. Uteroplacental insufficiency. d. Fetal hypoxemia.

ANS: B Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Uteroplacental insufficiency would result in late decelerations in the FHR. Fetal hypoxemia would result in tachycardia initially and then bradycardia if hypoxia continues. PTS: 1 DIF: Cognitive Level: Knowledge REF: 393 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A nulliparous woman who has just begun the second stage of her labor would most likely: a. Experience a strong urge to bear down. b. Show perineal bulging. c. Feel tired yet relieved that the worst is over. d. Show an increase in bright red bloody show.

ANS: C Common maternal behaviors during the latent phase of the second stage of labor include feeling a sense of accomplishment and optimism because the worst is over. During the latent phase of the second stage of labor, the urge to bear down often is absent or only slight during the acme of contractions. Perineal bulging occurs during the transition phase of the second stage of labor, not at the beginning of the second stage. An increase in bright red bloody show occurs during the descent phase of the second stage of labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 425 OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

If the patients white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should: a. Tell the physician immediately. b. Have the laboratory draw blood for reanalysis. c. Recognize that this is an acceptable range at this point postpartum. d. Begin antibiotic therapy immediately.

ANS: C During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common. Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated. PTS: 1 DIF: Cognitive Level: Knowledge REF: 488 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: a. Kidney function returns to normal a few days after birth. b. Diastasis recti abdominis is a common condition that alters the voiding reflex. c. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. d. With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

ANS: C Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth. PTS: 1 DIF: Cognitive Level: Comprehension REF: 486 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Fetal bradycardia is most common during: a. Intraamniotic infection. b. Fetal anemia. c. Prolonged umbilical cord compression. d. Tocolytic treatment using terbutaline.

ANS: C Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 390 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Arrest of active phase d. Protracted descent

ANS: C With an arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 455 OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: 487 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts and glands. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement. PTS: 1 DIF: Cognitive Level: Knowledge REF: 502 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A postpartum patient asks, Will these stretch marks go away? The nurses best response is: a. They will continue to fade and should be gone by your 6-week checkup. b. No, never. c. Yes, eventually. d. They will fade to silvery lines but won`t disappear completely.

ANS: D Stretch marks never disappear altogether; however, they gradually fade to silvery lines. PTS: 1 DIF: Cognitive Level: Knowledge REF: 489 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The factors that affect the process of labor and birth, known commonly as the five Ps, include all except: a. Passenger. b. Passageway. c. Powers. d. Pressure.

ANS: D The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. PTS: 1 DIF: Cognitive Level: Knowledge REF: 342 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

ANS: D Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying her bladder. PTS: 1 DIF: Cognitive Level: Application REF: 498 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Nurses should be aware that chronic hypertension:

Can occur independently of or simultaneously with gestational hypertension. Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks postpartum. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:

Intense abdominal pain. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

Methotrexate is recommended as part of the treatment plan for which obstetric complication?

Unruptured ectopic pregnancy Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for complete hydatidiform mole, missed abortion, and abruptio placentae.

The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits:

A respiratory rate of 10 breaths/min. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2 and absent ankle clonus are normal findings.

Before the physician performs an external version, the nurse should expect an order for a: a. Tocolytic drug. b. Contraction stress test (CST). c. Local anesthetic. d. Foley catheter.

ANS: A A tocolytic drug will relax the uterus before and during version, thus making manipulation easier. CST is used to determine the fetal response to stress. A local anesthetic is not used with external version. The bladder should be emptied; however, catheterization is not necessary. PTS: 1 DIF: Cognitive Level: Comprehension REF: 460 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance? a. Mexico b. China c. Iran d. India

ANS: A A woman from Mexico may be stoic about discomfort until the second stage, at which time she will request pain relief. Fathers and female relatives are usually in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well. Fathers are usually not present in China. The Iranian father will not be present. Female support persons and female care providers are preferred. For many, a male caregiver is unacceptable. The father is usually not present in India, but female relatives are usually present. Natural childbirth methods are preferred. PTS: 1 DIF: Cognitive Level: Application REF: 408 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat: a. Variable decelerations. b. Late decelerations. c. Fetal bradycardia. d. Fetal tachycardia.

ANS: A Amnioinfusion is used during labor either to dilute meconium-stained amniotic fluid or to supplement the amount of amniotic fluid to reduce the severity of variable decelerations caused by cord compression. Amnioinfusion has no bearing on late decelerations, fetal bradycardia, or fetal tachycardia alterations in fetal heart rate (FHR) tracings. PTS: 1 DIF: Cognitive Level: Knowledge REF: 396 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the womans vital signs, the nurse would be concerned to see: a. Temperature 37.9 C, heart rate 120, respirations 20, blood pressure (BP) 90/50. b. Temperature 37.4 C, heart rate 88, respirations 36, BP 126/68. c. Temperature 38 C, heart rate 80, respirations 16, BP 110/80. d. Temperature 36.8 C, heart rate 60, respirations 18, BP 140/90.

ANS: A An EBL of 1500 mL with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. An increased respiratory rate of 36 may be secondary to pain from the birth. Temperature may increase to 38 C during the first 24 hours as a result of the dehydrating effects of labor. A BP of 140/90 is slightly elevated, which may be caused by the use of oxytocic medications. PTS: 1 DIF: Cognitive Level: Comprehension REF: 488 OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Physiologic Integrity

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh?2-, baby Rh+ b. Mother Rh?2-, baby Rh?2- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh?2-

ANS: A An Rh?2- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh?2- the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh?2- blood of the infant, no antibodies would develop because the antigens are in the mothers blood, not the infants. PTS: 1 DIF: Cognitive Level: Comprehension REF: 503 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: a. Stimulate fetal surfactant production. b. Reduce maternal and fetal tachycardia associated with ritodrine administration. c. Suppress uterine contractions. d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

ANS: A Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 450 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

With regard to the process of augmentation of labor, the nurse should be aware that it: a. Is part of the active management of labor that is instituted when the labor process is unsatisfactory. b. Relies on more invasive methods when oxytocin and amniotomy have failed. c. Is a modern management term to cover up the negative connotations of forceps-assisted birth. d. Uses vacuum cups.

ANS: A Augmentation is part of the active management of labor that stimulates uterine contractions after labor has started but is not progressing satisfactorily. Augmentation uses amniotomy and oxytocin infusion, as well as some gentler, noninvasive methods. Forceps-assisted births and vacuum-assisted births are appropriately used at the end of labor and are not part of augmentation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 465 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The self-destruction of excess hypertrophied tissue in the uterus is called: a. Autolysis. b. Subinvolution. c. Afterpain. d. Diastasis.

ANS: A Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpain is caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles. PTS: 1 DIF: Cognitive Level: Knowledge REF: 483 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Knowing that the condition of the new mothers breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except: a. Breast tenderness is likely to persist for about a week after the start of lactation. b. As lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day. c. In nonlactating mothers colostrum is present for the first few days after childbirth. d. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

ANS: A Breast tenderness should persist for 24 to 48 hours after lactation begins. That movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether the mother breastfeeds or not. A mother who does not want to breastfeed should also avoid stimulating her nipples. PTS: 1 DIF: Cognitive Level: Comprehension REF: 487 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Health Promotion and Maintenance

Which patient status is an acceptable indication for serial oxytocin induction of labor? a. Past 42 weeks gestation b. Multiple fetuses c. Polyhydramnios d. History of long labors

ANS: A Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. Multiple fetuses overdistend the uterus and make induction of labor high risk. Polyhydramnios overdistends the uterus, again making induction of labor high risk. History of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances. PTS: 1 DIF: Cognitive Level: Comprehension REF: 453 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which order should the nurse expect for a patient admitted with a threatened abortion? a. Bed rest b. Ritodrine IV c. NPO d. Narcotic analgesia every 3 hours, prn

ANS: A Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. There is no reason for having the woman placed NPO. At times dehydration may produce contractions, so hydration is important. Narcotic analgesia will not decrease the contractions. It may mask the severity of the contractions. PTS: 1 DIF: Cognitive Level: Comprehension REF: 319 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: a. At the time of admission to the nurses unit. b. When the infant is presented to the mother at birth. c. During the first visit with the physician in the unit. d. When the take-home information packet is given to the couple.

ANS: A Discharge planning, the teaching of maternal and newborn care, begins on the womans admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel. PTS: 1 DIF: Cognitive Level: Comprehension REF: 506 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Which deceleration of the fetal heart rate would not require the nurse to change the maternal position? a. Early decelerations b. Late decelerations c. Variable decelerations d. It is always a good idea to change the womans position.

ANS: A Early decelerations (and accelerations) generally do not need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral); variable decelerations also require a maternal position change (side to side). Although changing positions throughout labor is recommended, it is not required in response to early decelerations. PTS: 1 DIF: Cognitive Level: Comprehension REF: 391 OBJ: Nursing Process: Assessment, Planning MSC: Client Needs: Physiologic Integrity

Fetal well-being during labor is assessed by: a. The response of the fetal heart rate (FHR) to uterine contractions (UCs). b. Maternal pain control. c. Accelerations in the FHR. d. An FHR above 110 beats/min.

ANS: A Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR above 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information would be needed to determine fetal well-being. PTS: 1 DIF: Cognitive Level: Comprehension REF: 400 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

What is an essential part of nursing care for the laboring woman? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Sharing personal experiences regarding labor and delivery to decrease her anxiety d. Feeling comfortable with the predictable nature of intrapartum care

ANS: A Helping a woman manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Decreasing anxiety is important; however, managing pain is a top priority. The labor nurse should consistently deliver care based on the standard of care related to the maternity patient. Because of the unpredictable nature of labor, the nurse should always be alert for unanticipated events. PTS: 1 DIF: Cognitive Level: Application REF: 414 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenanc

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a. Has recovered from epidural or spinal anesthesia. b. Has hidden bleeding underneath her. c. Has regained some flexibility. d. Is a candidate to go home after 6 hours.

ANS: A If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 500 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

Which maternal condition is considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. External monitors in current use d. Fetus with a known heart defect

ANS: A In order to apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm permits the insertion of fetal scalp electrodes and intrauterine catheter. The external monitor can be discontinued after the internal ones are applied. A compromised fetus should be monitored with the most accurate monitoring devices. PTS: 1 DIF: Cognitive Level: Comprehension REF: 386 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? a. The woman leaves the infant on her bed while she takes a shower. b. The woman continues to hold and cuddle her infant after she has fed her. c. The woman reads a magazine while her infant sleeps. d. The woman changes her infants diaper and then shows the nurse the contents of the diaper.

ANS: A Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infants elimination patterns. PTS: 1 DIF: Cognitive Level: Comprehension REF: 493 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Perinatal nurses are legally responsible for: a. Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. b. Greeting the client on arrival, assessing her, and starting an intravenous line. c. Applying the external fetal monitor and notifying the care provider. d. Making sure that the woman is comfortable.

ANS: A Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. Greeting the client, assessing her, and starting an IV; applying the external fetal monitor and notifying the care provider; and making sure the woman is comfortable may be activities that a nurse performs, but they are not activities for which the nurse is legally responsible. PTS: 1 DIF: Cognitive Level: Comprehension REF: 396 OBJ: Nursing Process: Assessment, Planning, Implementation MSC: Client Needs: Safe and Effective Care Environment

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

ANS: A Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side. PTS: 1 DIF: Cognitive Level: Comprehension REF: 436 OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Health Promotion and Maintenance

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment. b. Determine which pad is best. c. Demonstrate that other nurses usually underestimate blood loss. d. Reveal to the nurse supervisor that one of them needs some time off.

ANS: A Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything. PTS: 1 DIF: Cognitive Level: Application REF: 497 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A means of controlling the birth of the fetal head with a vertex presentation is: a. The Ritgen maneuver. b. Fundal pressure. c. The lithotomy position. d. The De Lee apparatus

ANS: A The Ritgen maneuver extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth. The lithotomy position has been commonly used in Western cultures, partly because it is convenient for the health care provider. The De Lee apparatus is used to suction fluid from the infants mouth. PTS: 1 DIF: Cognitive Level: Knowledge REF: 434 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the newborns airway clear. b. Fostering parent-newborn attachment. c. Drying the newborn and wrapping the infant in a blanket. d. Administering eye drops and vitamin K.

ANS: A The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-infant attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The nursing activities would be (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering the infant with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborns physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the infant to the partner or mother when he or she is ready. PTS: 1 DIF: Cognitive Level: Comprehension REF: 434 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective would be: a. Dilation of the cervix. b. Descent of the fetus. c. Rupture of the amniotic membranes. d. Increase in bloody show.

ANS: A The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor. Descent of the fetus, or engagement, may occur before labor. Rupture of membranes may occur with or without the presence of labor. Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 404 OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Health Promotion and Maintenance

A pregnant womans amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would be the top priority? a. Placing the woman in the knee-chest position b. Covering the cord in sterile gauze soaked in saline c. Preparing the woman for a cesarean birth d. Starting oxygen by face mask

ANS: 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. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression. PTS: 1 DIF: Cognitive Level: Application REF: 478 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

In assisting with the two factors that have an effect on fetal status (i.e., pushing and positioning), nurses should: a. Encourage the womans cooperation in avoiding the supine position. b. Advise the woman to avoid the semi-Fowler position. c. Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response. d. Instruct the woman to open her mouth and close her glottis, letting air escape after the push.

ANS: A The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. The Valsalva maneuver, which encourages the woman to hold her breath and tighten her abdominal muscles, should be avoided. Both the mouth and glottis should be open, letting air escape during the push. PTS: 1 DIF: Cognitive Level: Comprehension REF: 399 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A laboring woman is lying in the supine position. The most appropriate nursing action at this time is to: a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine whether fetal tachycardia is present.

ANS: A The womans supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental blood flow. Elevating her legs will not relieve the pressure from the inferior vena cava. If the woman is allowed to stay in the supine position and blood flow to the placental is reduced significantly, fetal tachycardia may occur. The most appropriate nursing action is to prevent this from occurring by turning the woman to her side. Blood pressure readings may be obtained when the patient is in the appropriate and safest position. PTS: 1 DIF: Cognitive Level: Application REF: 430 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. b. A blood transfusion is necessary. c. Rh immune globulin is necessary within 72 hours of birth. d. A Kleihauer-Betke test should be performed.

ANS: A This clients rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test. PTS: 1 DIF: Cognitive Level: Comprehension REF: 503 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

A pregnant woman is in her third trimester. She asks the nurse to explain how she can tell true labor from false labor. The nurse would explain that true labor contractions: a. Increase with activity such as ambulation. b. Decrease with activity. c. Are always accompanied by the rupture of the bag of waters. d. Alternate between a regular and an irregular pattern.

ANS: A True labor contractions become more intense with walking. False labor contractions often stop with walking or position changes. Rupture of membranes may occur before or during labor. True labor contractions are regular. PTS: 1 DIF: Cognitive Level: Comprehension REF: 402 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

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

ANS: A Upright positions and squatting both may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to labor down (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if the woman is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressures, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta and results in fetal hypoxia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 426 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the womans risk for _________________________ has increased. a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension

ANS: A When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension. PTS: 1 DIF: Cognitive Level: Comprehension REF: 414 OBJ: Nursing Process: Diagnosis, Planning MSC: Client Needs: Physiologic Integrity

A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this womans fundus? a. One centimeter above the umbilicus b. Two centimeters below the umbilicus c. Midway between the umbilicus and the symphysis pubis d. Nonpalpable abdominally

ANS: A Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. The fundus descends about 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus normally is halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point. PTS: 1 DIF: Cognitive Level: Comprehension REF: 483 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Women who have participated in childbirth education classes often bring a birth bag or Lamaze bag with them to the hospital. These items often assist in reducing stress and providing comfort measures. The nurse caring for women in labor should be aware of common items that a client may bring, including (Select all that apply): a. Rolling pin. b. Tennis balls. c. Pillow. d. Stuffed animal or photo. e. Candles.

ANS: A, B, C, D The rolling pin and tennis balls are used to provide counterpressure, especially if the woman is experiencing back labor. Although the facility has plenty of pillows, when the client brings her own, it is a reminder of home and provides added comfort. A stuffed animal or framed photo can be used to provide a focal point during contractions. Although many women find the presence of candles conducive to creating calm and relaxing surroundings, these are not suitable for a hospital birthing room environment. Oxygen may be in use, resulting in a fire hazard. Flameless candles are often sold in hospital gift shops. It is also important for the nurse to orient the patient and her family to the call bell and light switches to familiarize herself with the environment. PTS: 1 DIF: Cognitive Level: Knowledge REF: 403 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a womans experience of pain. These include (Select all that apply): a. Culture. b. Anxiety and fear. c. Previous experiences with pain. d. Intervention of caregivers. e. Support systems.

ANS: A, B, C, E Culture: a womans sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: extreme anxiety and fear magnify sensitivity to pain and impair a womans ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present Labor experience. Support systems: an anxious partner is less able to provide help and support to a woman during labor. A womans family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, intravenous lines). PTS: 1 DIF: Cognitive Level: Application REF: 357 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule patients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. These include (Select all that apply): a. Rupture of membranes at or near term. b. Convenience of the woman or her physician. c. Chorioamnionitis (inflammation of the amniotic sac). d. Post-term pregnancy. e. Fetal death.

ANS: A, C, D, E These are all acceptable indications for induction. Other conditions include intrauterine growth retardation (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks completed gestation. PTS: 1 DIF: Cognitive Level: Application REF: 461 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would include (Select all that apply): a. Yawning, runny nose. b. Increase in appetite. c. Chills and hot flashes. d. Constipation. e. Irritability, restlessness.

ANS: A, C, E The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It is important for the nurse to assess both mother and baby and to plan care accordingly. PTS: 1 DIF: Cognitive Level: Application REF: 369 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? a. The mother should check the photo ID of any person who comes to her room. b. The baby should be carried in the parents arms from the room to the nursery. c. Because of infant security systems, the baby can be left unattended in the patients room. d. Parents should use caution when posting photos of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person.

ANS: A, D, E Nurses must discuss infant security precautions with the mother and her family because infant abduction continues to be a concern. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification patches. On some units staff members also wear matching scrubs or special badges that are unique to the perinatal unit. As a rule the baby is never carried in arms between the mothers room and the nursery, but rather is always wheeled in a bassinet. The infant should never be left unattended, even if the facility has an infant security system. Parents should be instructed to use caution when posting photos of their new baby on the Internet and other public forums. PTS: 1 DIF: Cognitive Level: Application REF: 492 OBJ: Nursing Process: Intervention MSC: Client Needs: Safe and Effective Care Environment

Concerning the third stage of labor, nurses should be aware that: a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.

ANS: B Active management facilitates placental separation and expulsion, thus reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important. The major risk for women during the third stage of labor is postpartum hemorrhage. PTS: 1 DIF: Cognitive Level: Comprehension REF: 436 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Physiologic Integrity

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: a. Rectal suppositories. b. Early and frequent ambulation. c. Tightening and relaxing abdominal muscles. d. Carbonated beverages.

ANS: B Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention. PTS: 1 DIF: Cognitive Level: Knowledge REF: 500 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

With regard to the postpartum uterus, nurses should be aware that: a. At the end of the third stage of labor it weighs approximately 500 g. b. After 2 weeks postpartum it should not be palpable abdominally. c. After 2 weeks postpartum it weighs 100 g. d. It returns to its original (prepregnancy) size by 6 weeks postpartum.

ANS: B After 2 weeks postpartum, the uterus should not be palpable abdominally; however, it has not yet returned to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. It takes 6 full weeks for the uterus to return to its original size. After 2 weeks postpartum the uterus weighs about 350 g, not its original size. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 483 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which woman is most likely to experience strong afterpains? a. A woman who experienced oligohydramnios b. A woman who is a gravida 4, para 4-0-0-4 c. A woman who is bottle-feeding her infant d. A woman whose infant weighed 5 pounds, 3 ounces

ANS: B Afterpains are more common in multiparous women. Afterpains are more noticeable with births in which the uterus was greatly distended, as in a woman who experienced polyhydramnios or a woman who delivered a large infant. Breastfeeding may cause afterpains to intensify. PTS: 1 DIF: Cognitive Level: Comprehension REF: 484 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A woman who is gravida 3 para 2 enters the intrapartum unit. The most important nursing assessments are: a. Contraction pattern, amount of discomfort, and pregnancy history. b. Fetal heart rate, maternal vital signs, and the womans nearness to birth. c. Identification of ruptured membranes, the womans gravida and para, and her support person. d. Last food intake, when labor began, and cultural practices the couple desires.

ANS: B All options describe relevant intrapartum nursing assessments; however, this focused assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. This includes: gravida, para, support person, pregnancy history, pain assessment, last food intake, and cultural practices. PTS: 1 DIF: Cognitive Level: Application REF: 430 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

What is an expected characteristic of amniotic fluid? a. Deep yellow color b. Pale, straw color with small white particles c. Acidic result on a Nitrazine test d. Absence of ferning

ANS: B Amniotic fluid normally is a pale, straw-colored fluid that may contain white flecks of vernix. Yellow-stained fluid may indicate fetal hypoxia up to 36 hours before rupture of membranes, fetal hemolytic disease, or intrauterine infection. Amniotic fluid produces an alkaline result on a Nitrazine test. The presence of ferning is a positive indication of amniotic fluid. PTS: 1 DIF: Cognitive Level: Comprehension REF: 414 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. An admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture

ANS: B An accelerated FHR is a positive sign; however, variable decelerations merit a vaginal examination. Vaginal examinations should be performed when the woman is admitted, when she perceives perineal pressure or the urge to bear down, when her membranes rupture, when a significant change in her uterine activity has occurred, or when variable decelerations of the FHR are noted. PTS: 1 DIF: Cognitive Level: Knowledge REF: 411 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

ANS: B Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottlefeeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation. PTS: 1 DIF: Cognitive Level: Application REF: 499 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

While caring for the patient who requires an induction of labor, the nurse should be cognizant that: a. Ripening the cervix usually results in a decreased success rate for induction. b. Labor sometimes can be induced with balloon catheters or laminaria tents. c. Oxytocin is less expensive than prostaglandins and more effective but creates greater health risks. d. Amniotomy can be used to make the cervix more favorable for labor.

ANS: B Balloon catheters or laminaria tents are mechanical means of ripening the cervix. Ripening the cervix, making it softer and thinner, increases the success rate of induced labor. Prostaglandin E1 is less expensive and more effective than oxytocin but carries a greater risk. Amniotomy is the artificial rupture of membranes, which is used to induce labor only when the cervix is already ripe. PTS: 1 DIF: Cognitive Level: Comprehension REF: 462 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Nurses should know some basic definitions concerning preterm birth, preterm labor, and low birth weight. For instance: a. The terms preterm birth and low birth weight can be used interchangeably. b. Preterm labor is defined as cervical changes and uterine contractions occurring between 20 and 37 weeks of pregnancy. c. Low birth weight is anything below 3.7 pounds. d. In the United States early in this century, preterm birth accounted for 18% to 20% of all births.

ANS: B Before 20 weeks, it is not viable (miscarriage); after 37 weeks, it can be considered term. Although these terms are used interchangeably, they have different meanings: preterm birth describes the length of gestation (37 weeks) regardless of weight; low birth weight describes weight only (2500 g or less) at the time of birth, whenever it occurs. Low birth weight is anything less than 2500 g, or about 5.5 pounds. In 2003 the preterm birth rate in the United States was 12.3%, but it is increasing in frequency. PTS: 1 DIF: Cognitive Level: Knowledge REF: 441 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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, which information would the nurse include? 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.

ANS: B Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures is the most appropriate statement. It is not accurate to state that the woman is at the lowest risk for complications. Both maternal and fetal risks are associated with every cesarean section. Because this is your second cesarean birth, you will recover faster is not an accurate statement. 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. PTS: 1 DIF: Cognitive Level: Application REF: 469 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the womans bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: a. Urinary tract infection. b. Excessive uterine bleeding. c. A ruptured bladder. d. Bladder wall atony.

ANS: B Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding. PTS: 1 DIF: Cognitive Level: Comprehension REF: 486 OBJ: Nursing Process: Diagnosis, Planning MSC: Client Needs: Health Promotion and Maintenance

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurses best response is: a. Dont worry about it. Youll do fine. b. Its normal to be anxious about labor. Lets discuss what makes you afraid. c. Labor is scary to think about, but the actual experience isnt. d. You can have an epidural. You wont feel anything.

ANS: B Its normal to be anxious about labor. Lets discuss what makes you afraid allows the woman to share her concerns with the nurse and is a therapeutic communication tool. Dont worry about it. Youll do fine negates the womans fears and is not therapeutic. Labor is scary to think about, but the actual experience isnt negates the womans fears and offers a false sense of security. It is not true that every woman may have an epidural. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural. PTS: 1 DIF: Cognitive Level: Application REF: 407 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

What correctly matches the type of deceleration with its likely cause? a. Early decelerationumbilical cord compression b. Late decelerationuteroplacental inefficiency c. Variable decelerationhead compression d. Prolonged decelerationcause unknown

ANS: B Late deceleration is caused by uteroplacental inefficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes. PTS: 1 DIF: Cognitive Level: Knowledge REF: 392 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The primary difference between the labor of a nullipara and that of a multipara is the: a. Amount of cervical dilation. b. Total duration of labor. c. Level of pain experienced. d. Sequence of labor mechanisms.

ANS: B Multiparas usually labor more quickly than nulliparas, thus making the total duration of their labor shorter. Cervical dilation is the same for all labors. The level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms remains the same with all labors. PTS: 1 DIF: Cognitive Level: Comprehension REF: 406 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? a. My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter. b. My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles. c. I will not have a menstrual cycle for 6 months after childbirth. d. My first menstrual cycle will be heavier than normal and then will be light for several months after.

ANS: B My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles is an accurate statement and indicates her understanding of her expected menstrual activity. She can expect her first menstrual cycle to be heavier than normal (which occurs by 3 months after childbirth), and the volume of her subsequent cycles will return to prepregnant levels within three or four cycles. PTS: 1 DIF: Cognitive Level: Application REF: 486 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. Relieve pain. b. Stimulate uterine contraction. c. Prevent infection. d. Facilitate rest and relaxation.

ANS: B Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain or prevent infection. They cause the uterus to contract, which reduces blood loss. Oxytocics do not facilitate rest and relaxation. PTS: 1 DIF: Cognitive Level: Knowledge REF: 436 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Health Promotion and Maintenance

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.

ANS: B Precipitous labor lasts less than 3 hours. Short women more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women less than 20 years of age. PTS: 1 DIF: Cognitive Level: Comprehension REF: 455 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. a. Call the provider, reposition the mother, and perform a vaginal examination. b. Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. c. Administer oxygen to the mother, increase IV fluid, and notify the care provider. d. Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.

ANS: B Repositioning the mother, increasing intravenous (IV) fluid, and providing oxygen via face mask are correct nursing actions for intrauterine resuscitation. The nurse should initiate intrauterine resuscitation in an ABC manner, similar to basic life support. The first priority is to open the maternal and fetal vascular systems by repositioning the mother for improved perfusion. The second priority is to increase blood volume by increasing the IV fluid. The third priority is to optimize oxygenation of the circulatory volume by providing oxygen via face mask. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately. PTS: 1 DIF: Cognitive Level: Evaluation REF: 396 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

With regard to the postpartum changes and developments in a womans cardiovascular system, nurses should be aware that: a. Cardiac output, the pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth. b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. c. The lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. d. A hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

ANS: B Respirations should decrease to within the womans normal prepregnancy range by 6 to 8 weeks after birth. Stroke volume increases, and cardiac output remains high for a couple of days. However, the heart rate and blood pressure return to normal quickly. Leukocytosis increases 10 to 12 days after childbirth and can obscure the diagnosis of acute infections (false-negative results). The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth. PTS: 1 DIF: Cognitive Level: Comprehension REF: 487 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to: a. Facilitate maternal-newborn interaction. b. Stimulate the uterus to contract. c. Prevent neonatal hypoglycemia. d. Initiate the lactation cycle.

ANS: B Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage. Breastfeeding facilitates maternal-newborn interaction, but it is not the primary reason a woman is encouraged to breastfeed after an emergency birth. The primary intervention for preventing neonatal hypoglycemia is thermoregulation. Cold stress can result in hypoglycemia. The woman is encouraged to breastfeed after an emergency birth to stimulate the release of oxytocin, which prevents hemorrhage. Breastfeeding is encouraged to initiate the lactation cycle, but it is not the primary reason for this activity after an emergency birth. PTS: 1 DIF: Cognitive Level: Comprehension REF: 427 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours

ANS: B The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate, irregular contractions; dilation up to 3 cm; brownish-topale pink mucus, and a duration of 6 to 8 hours. No official lull phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: 401 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

During labor a fetus with an average heart rate of 135 beats/min over a 10-minute period would be considered to have: a. Bradycardia. b. A normal baseline heart rate. c. Tachycardia. d. Hypoxia.

ANS: B The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min. Bradycardia is a fetal heart rate (FHR) below 110 beats/min for 10 minutes or longer. Tachycardia is an FHR over 160 beats/min for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of this condition exists with a baseline heart rate in the normal range. PTS: 1 DIF: Cognitive Level: Knowledge REF: 389 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as: a. First stage, latent phase. b. First stage, active phase. c. First stage, transition phase. d. Second stage, latent phase.

ANS: B The first stage, active phase of maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress would be 0 to 3 cm dilation with contractions every 5 to 30 minutes. During the transition phase of the first stage of labor, the expected maternal progress is 8 to 10 cm dilation with contractions every 2 to 3 minutes. During the latent phase of the second stage of labor, the woman is completely dilated and experiences a restful period of laboring down. PTS: 1 DIF: Cognitive Level: Comprehension REF: 401 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A patient whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage

ANS: B The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta. This patient is in the active phase of labor. PTS: 1 DIF: Cognitive Level: Knowledge REF: 401 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately, she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help the client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care? a. Telling the client to relax and that it wont hurt much b. Limiting the number of procedures that invade her body c. Reassuring the client that as the nurse you know what is best d. Allowing unlimited care providers to be with the client

ANS: B The number of invasive procedures such as vaginal examinations, internal monitoring, and intravenous therapy should be limited as much as possible. The nurse should always avoid words and phrases that may result in the clients recalling the phrases of her abuser (e.g., Relax, this wont hurt or Just open your legs.) The womans sense of control should be maintained at all times. The nurse should explain procedures at the clients pace and wait for permission to proceed. Protecting the clients environment by providing privacy and limiting the number of staff who observe the client will help to make her feel safe. PTS: 1 DIF: Cognitive Level: Comprehension REF: 406 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Nurses alert to signs of the onset of the second stage of labor can be certain that this stage has begun when: a. The woman has a sudden episode of vomiting. b. The nurse is unable to feel the cervix during a vaginal examination. c. Bloody show increases. d. The woman involuntarily bears down.

ANS: B The only certain objective sign that the second stage has begun is the inability to feel the cervix because it is fully dilated and effaced. Vomiting, an increase in bloody show, and involuntary bearing down are only suggestions of second-stage labor. PTS: 1 DIF: Cognitive Level: Knowledge REF: 425 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A new client and her partner arrive on the labor, delivery, recovery, and postpartum unit for the birth of their first child. You apply the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the babys heart rate should be. Your best response is: a. Dont worry about that machine; thats my job. b. The top line graphs the babys heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor. c. The top line graphs the babys heart rate, and the bottom line lets me know how strong the contractions are. d. Your doctor will explain all of that later.

ANS: B The top line graphs the babys heart rate. Generally the heart rate is between 110 and 160. The heart rate will fluctuate in response to what is happening during labor educates the partner about fetal monitoring and provides support and information to alleviate his fears. Dont worry about that machine; thats my job discredits the partners feelings and does not provide the teaching he is requesting. The top line graphs the babys heart rate, and the bottom line lets me know how strong the contractions are provides inaccurate information and does not address the partners concerns about the fetal heart rate. The EFM graphs the frequency and duration of the contractions, not the intensity. Nurses should take every opportunity to provide client and family teaching, especially when information is requested. PTS: 1 DIF: Cognitive Level: Application REF: 397 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Why is continuous electronic fetal monitoring usually used when oxytocin is administered? a. The mother may become hypotensive. b. Uteroplacental exchange may be compromised. c. Maternal fluid volume deficit may occur. d. Fetal chemoreceptors are stimulated.

ANS: B The uterus may contract more firmly, and the resting tone may be increased with oxytocin use. This response reduces entrance of freshly oxygenated maternal blood into the intervillous spaces, thus depleting fetal oxygen reserves. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk. Oxytocin affects the uterine muscles. PTS: 1 DIF: Cognitive Level: Comprehension REF: 382 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

If an opioid antagonist is administered to a laboring woman, she should be told that: a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push.

ANS: B The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect. PTS: 1 DIF: Cognitive Level: Comprehension REF: 370 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

The nurse is caring for a client whose labor is being augmented with oxytocin. He or she 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 clients needing to void. d. Rupture of the clients amniotic membranes.

ANS: B This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation. The clients needing to void 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 nonreassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the clients membranes have ruptured. PTS: 1 DIF: Cognitive Level: Evaluation REF: 449 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Which description of postpartum restoration or healing times is accurate? a. The cervix shortens, becomes firm, and returns to form within a month postpartum. b. Vaginal rugae reappear by 3 weeks postpartum. c. Most episiotomies heal within a week. d. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

ANS: B Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent as in nulliparous women. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size. PTS: 1 DIF: Cognitive Level: Comprehension REF: 485 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

As relates to rubella and Rh issues, nurses should be aware that: a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

ANS: B Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination. PTS: 1 DIF: Cognitive Level: Comprehension REF: 503 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the clients blood pressure (Select all that apply)? a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen. e. Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the womans legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 373 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Complications and risks associated with cesarean births include (Select all that apply): a. Placental abruption. b. Wound dehiscence. c. Hemorrhage. d. Urinary tract infections. e. Fetal injuries.

ANS: B, C, D, E Placental abruption and placenta previa are both indications for cesarean birth and are not complications thereof. Wound dehiscence, hemorrhage, urinary tract infection, and fetal injuries are all possible complications and risks associated with delivery by cesarean section. PTS: 1 DIF: Cognitive Level: Comprehension REF: 471 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

A tiered system of categorizing FHR has been recommended by regulatory agencies. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. These categories include (Select all that apply): a. Reassuring. b. Category I. c. Category II. d. Nonreassuring. e. Category III.

ANS: B, C, E The three tiered system of FHR tracings include Category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate. This category includes tracings that do not meet Category I or III criteria. Category III tracings are abnormal and require immediate intervention. PTS: 1 DIF: Cognitive Level: Comprehension REF: 396 OBJ: Nursing Process: Assessment, Planning MSC: Client Needs: Physiologic Integrity

The nurse recognizes that uterine hyperstimulation with oxytocin requires emergency interventions. What clinical cues would alert the nurse that the woman is experiencing uterine hyperstimulation (Select all that apply)? a. Uterine contractions lasting <90 seconds and occurring >2 minutes in frequency b. Uterine contractions lasting >90 seconds and occurring <2 minutes in frequency c. Uterine tone <20 mm Hg d. Uterine tone >20 mm Hg e. Increased uterine activity accompanied by a nonreassuring fetal heart rate (FHR) and pattern

ANS: B, D, E Uterine contractions that occur less than 2 minutes apart and last more than 90 seconds, a uterine tone of over 20 mm Hg, and a nonreassuring FHR and pattern are all indications of uterine hyperstimulation with oxytocin administration. Uterine contractions that occur more than 2 minutes apart and last less than 90 seconds are the expected goal of oxytocin induction. A uterine tone of less than 20 mm Hg is normal. PTS: 1 DIF: Cognitive Level: Analysis REF: 464 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

ANS: C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 431 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

With regard to afterbirth pains, nurses should be aware that these pains are: a. Caused by mild, continuous contractions for the duration of the postpartum period. b. More common in first-time mothers. c. More noticeable in births in which the uterus was overdistended. d. Alleviated somewhat when the mother breastfeeds.

ANS: C A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions. PTS: 1 DIF: Cognitive Level: Comprehension REF: 484 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

It is paramount for the obstetric nurse to understand the regulatory procedures and criteria for admitting a woman to the hospital labor unit. Which guideline is an important legal requirement of maternity care? a. The patient is not considered to be in true labor (according to the Emergency Medical Treatment and Active Labor Act [EMTALA]) until a qualified health care provider says she is. b. The woman can have only her male partner or predesignated doula with her at assessment. c. The patients weight gain is calculated to determine whether she is at greater risk for cephalopelvic disproportion (CPD) and cesarean birth. d. The nurse may exchange information about the patient with family members.

ANS: C According to EMTALA, a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise. A woman can have anyone she wishes present for her support. The risk for CPD is especially great for petite women or those who have gained 16 kg or more. All patients should have their weight and BMI calculated on admission. This is part of standard nursing care on a maternity unit and not a regulatory concern. According to the Health Insurance Portability and Accountability Act (HIPAA), the patient must give consent for others to receive any information related to her condition. PTS: 1 DIF: Cognitive Level: Comprehension REF: 403 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The priority nursing care associated with an oxytocin (Pitocin) infusion is: a. Measuring urinary output. b. Increasing infusion rate every 30 minutes. c. Monitoring uterine response. d. Evaluating cervical dilation.

ANS: C Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurses priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of Pitocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labor progression is the standard of care for all labor patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: 464 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

As relates 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 receiving tocolytics, intravenous (IV) fluids should be given.

ANS: C Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids. PTS: 1 DIF: Cognitive Level: Comprehension REF: 450 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurses best response is: a. You have pitting edema in your ankles. b. You have deep tendon reflexes rated 2+. c. You have calf pain when the nurse flexes your foot. d. You have a fleshy odor to your vaginal drainage.

ANS: C Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul odor, is within normal limits. PTS: 1 DIF: Cognitive Level: Knowledge REF: 494 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture. b. The cervix cannot be felt during a vaginal examination. c. The woman experiences a strong urge to bear down. d. The presenting part is below the ischial spines.

ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 425 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help clients. Nurses should know that _____ women may be stoic until late in labor, when they may become vocal and request pain relief. a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

ANS: C Hispanic women may be stoic early and more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start. They may prefer pain medications. African-American women may express pain openly; use of medications for pain is more likely to vary with the individual. PTS: 1 DIF: Cognitive Level: Knowledge REF: 358 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a. Discusses her labor and birth experience excessively. b. Believes that her baby is more attractive and clever than any others. c. Has not given the baby a name. d. Has a partner or family members who react very positively about the baby.

ANS: C If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the babys sex. The client may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother. PTS: 1 DIF: Cognitive Level: Synthesis REF: 504 OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

The laboring woman who imagines her body opening to let the baby out is using a mental technique called: a. Dissociation. b. Effleurage. c. Imagery. d. Distraction.

ANS: C Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman engage in another activity. PTS: 1 DIF: Cognitive Level: Comprehension REF: 360 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Postpartal overdistention of the bladder and urinary retention can lead to which complications? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

ANS: C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant. PTS: 1 DIF: Cognitive Level: Comprehension REF: 496 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse thoroughly dries the infant immediately after birth primarily to: a. Stimulate crying and lung expansion. b. Remove maternal blood from the skin surface. c. Reduce heat loss from evaporation. d. Increase blood supply to the hands and feet.

ANS: C Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Rubbing the infant does stimulate crying; however, it is not the main reason for drying the infant. This process does not remove all the maternal blood. PTS: 1 DIF: Cognitive Level: Comprehension REF: 439 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes that this medication will be administered to: a. Enhance uteroplacental perfusion in an aging placenta. b. Increase amniotic fluid volume. c. Ripen the cervix in preparation for labor induction . d. Stimulate the amniotic membranes to rupture.

ANS: C It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. It is not administered to enhance uteroplacental perfusion in an aging placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture. PTS: 1 DIF: Cognitive Level: Application REF: 463 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

The nurse caring for the woman in labor should understand that maternal hypotension can result in: a. Early decelerations. b. Fetal dysrhythmias. c. Uteroplacental insufficiency. d. Spontaneous rupture of membranes.

ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions and results in fetal hypoxemia. Maternal hypotension is not associated with early decelerations, fetal dysrhythmias, or spontaneous rupture of membranes. PTS: 1 DIF: Cognitive Level: Comprehension REF: 394 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate may be caused by: a. Narcotics. b. Barbiturates. c. Methamphetamines. d. Tranquilizers.

ANS: C Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; methamphetamines may cause increased variability. PTS: 1 DIF: Cognitive Level: Comprehension REF: 390 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Because the risk for childbirth complications may be revealed, nurses should know that the point of maximal intensity (PMI) of the fetal heart tone (FHT) is: a. Usually directly over the fetal abdomen. b. In a vertex position heard above the mothers umbilicus. c. Heard lower and closer to the midline of the mothers abdomen as the fetus descends and rotates internally. d. In a breech position heard below the mothers umbilicus.

ANS: C Nurses should be prepared for the shift. The PMI of the FHT usually is directly over the fetal back. In a vertex position it is heard below the mothers umbilicus. In a breech position it is heard above the mothers umbilicus. PTS: 1 DIF: Cognitive Level: Comprehension REF: 409 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Surgical, medical, or mechanical methods may be used for labor induction. Which technique is considered a mechanical method of induction? a. Amniotomy b. Intravenous Pitocin c. Transcervical catheter d. Vaginal insertion of prostaglandins

ANS: C Placement of a balloon-tipped Foley catheter into the cervix is a mechanical method of induction. Other methods to expand and gradually dilate the cervix include hydroscopic dilators such as laminaria tents (made from desiccated seaweed), or Lamicel (contains magnesium sulfate). Amniotomy is a surgical method of augmentation and induction. Intravenous Pitocin and insertion of prostaglandins are medical methods of induction. PTS: 1 DIF: Cognitive Level: Application REF: 462 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen b. Progesterone c. Prolactin d. Human placental lactogen

ANS: C Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta and reach their lowest levels 1 week into the postpartum period. Human placental lactogen levels decrease dramatically after expulsion of the placenta. PTS: 1 DIF: Cognitive Level: Comprehension REF: 486 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

In planning for home care of a woman with preterm labor, which concern must the nurse address? a. Nursing assessments will be different from those done in the hospital setting. b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers will be necessary.

ANS: C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery. Nursing assessments will differ somewhat from those performed in the acute care setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many women will receive home health nurse visits, but care is individualized for each woman. PTS: 1 DIF: Cognitive Level: Analysis REF: 446 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The nurse caring for a woman in labor understands that prolonged decelerations: a. Are a continuing pattern of benign decelerations that do not require intervention. b. Constitute a baseline change when they last longer than 5 minutes. c. Usually are isolated events that end spontaneously. d. Require the usual fetal monitoring by the nurse.

ANS: C Prolonged decelerations usually are isolated events that end spontaneously. However, in certain combinations with late and/or variable decelerations, they are a danger sign that requires the nurse to notify the physician or midwife immediately. A deceleration that lasts longer than 10 minutes constitutes a baseline change. PTS: 1 DIF: Cognitive Level: Knowledge REF: 393 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse recognizes that a woman is in true labor when she states: a. I passed some thick, pink mucus when I urinated this morning. b. My bag of waters just broke. c. The contractions in my uterus are getting stronger and closer together. d. My baby dropped, and I have to urinate more frequently now.

ANS: C Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor. PTS: 1 DIF: Cognitive Level: Application REF: 402 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b. Having the patient flex, extend, and rotate her feet, ankles, and legs. c. Having the patient sit in a chair. d. Notifying the physician immediately if a positive Homans sign occurs.

ANS: C Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans sign (calf muscle pain or warmth, redness, or tenderness) requires the physicians immediate attention. PTS: 1 DIF: Cognitive Level: Comprehension REF: 500 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. What is the correct Apgar score for this infant? a. 7 b. 8 c. 9 d. 10

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue hands and feet. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. PTS: 1 DIF: Cognitive Level: Application REF: 434 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

According to standard professional thinking, nurses should auscultate the fetal heart rate (FHR): a. Every 15 minutes in the active phase of the first stage of labor in the absence of risk factors. b. Every 20 minutes in the second stage, regardless of whether risk factors are present. c. Before and after ambulation and rupture of membranes. d. More often in a womans first pregnancy.

ANS: C The FHR should be auscultated before and after administration of medications and induction of anesthesia. In the active phase of the first stage of labor, the FHR should be auscultated every 30 minutes if no risk factors are involved; with risk factors it should be auscultated every 15 minutes. In the second stage of labor the FHR should be auscultated every 15 minutes if no risk factors are involved; with risk factors it should be auscultated every 5 minutes. The fetus of a first-time mother is automatically at greater risk. PTS: 1 DIF: Cognitive Level: Comprehension REF: 385 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which description of the phases of the second stage of labor is accurate? a. Latent phase: Feeling sleepy, fetal station 2+ to 4+, duration 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions, Ferguson reflux activated, duration 5 to 15 minutes c. Descent phase: Significant increase in contractions, Ferguson reflux activated, average duration varied d. Transitional phase: Woman laboring down, fetal station 0, duration 15 minutes

ANS: C The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The latent phase is the lull, or laboring down, period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The transition phase is the final phase in the second stage of labor; contractions are strong and painful. PTS: 1 DIF: Cognitive Level: Comprehension REF: 425 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

To provide safe care for the woman, the nurse understands that which condition is a contraindication for an amniotomy? a. Dilation less than 3 cm b. Cephalic presentation c. -2 station d. Right occiput posterior position

ANS: C The dilation of the cervix must be great enough to determine labor. The presenting part of the fetus should be engaged and well applied to the cervix before the procedure in order to prevent cord prolapse. Amniotomy is deferred if the presenting part is higher in the pelvis. ROP indicates a cephalic presentation, which is appropriate for an amniotomy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 464 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which documentation on a womans chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochial flow b. Breasts firm and tender c. Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy

ANS: C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. PTS: 1 DIF: Cognitive Level: Knowledge REF: 483 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The least common cause of long, difficult, or abnormal labor (dystocia) is: a. Midplane contracture of the pelvis. b. Compromised bearing-down efforts as a result of pain medication. c. Disproportion of the pelvis. d. Low-lying placenta.

ANS: C The least common cause of dystocia is disproportion of the pelvis. PTS: 1 DIF: Cognitive Level: Knowledge REF: 455 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The nurse providing care to a woman in labor should understand that cesarean birth: a. Is declining in frequency in the twenty-first century in the United States. b. Is more likely to be performed for poor women in public hospitals who do not receive the nurse counseling as do wealthier clients. c. Is performed primarily for the benefit of the fetus. d. Can be either elected or refused by women as their absolute legal right.

ANS: C The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. Cesarean births are increasing in the United States in this century. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A womans 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. PTS: 1 DIF: Cognitive Level: Comprehension REF: 471 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should: a. Notify the womans primary health care provider immediately. b. Prepare to administer an oxytocic to stimulate uterine activity. c. Document the findings because they reflect the expected contraction pattern for the active phase of labor. d. Prepare the woman for the onset of the second stage of labor.

ANS: C The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse would document these findings in the clients medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates adequate active labor. Her contractions eventually will become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus. PTS: 1 DIF: Cognitive Level: Application REF: 399 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

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

ANS: C The nurse or primary care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus that may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor. As labor progresses this assessment is performed more frequently. PTS: 1 DIF: Cognitive Level: Application REF: 411 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Under the Newborns and Mothers Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. a. 24, 73 b. 24, 96 c. 48, 96 d. 48, 120

ANS: C The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge. PTS: 1 DIF: Cognitive Level: Knowledge REF: 492 OBJ: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment

What is an advantage of external electronic fetal monitoring? a. The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the fetal heart rate. b. The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs). c. The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor. d. Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor, particularly when the membranes are intact. Short-term changes cannot be measured with this technology. The tocotransducer cannot measure and record the intensity of UCs. The transducer must be repositioned when the woman or fetus changes position. PTS: 1 DIF: Cognitive Level: Comprehension REF: 385 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, Im bleeding a lot. The most likely cause of postpartum hemorrhage in this woman is: a. Retained placental fragments. b. Unrepaired vaginal lacerations. c. Uterine atony. d. Puerperal infection.

ANS: C This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery. PTS: 1 DIF: Cognitive Level: Analysis REF: 496 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the womans understanding of the instructions when she states, True labor contractions will: a. Subside when I walk around. b. Cause discomfort over the top of my uterus. c. Continue and get stronger even if I relax and take a shower. d. Remain irregular but become stronger.

ANS: C True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position. PTS: 1 DIF: Cognitive Level: Application REF: 402 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Excessive blood loss after childbirth can have several causes; the most common is: a. Vaginal or vulvar hematomas. b. Unrepaired lacerations of the vagina or cervix. c. Failure of the uterine muscle to contract firmly. d. Retained placental fragments.

ANS: C Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. PTS: 1 DIF: Cognitive Level: Knowledge REF: 496 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are the result of: a. Altered cerebral blood flow. b. Umbilical cord compression. c. Uteroplacental insufficiency. d. Meconium fluid.

ANS: C Uteroplacental insufficiency would result in late decelerations in the FHR. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Umbilical cord compression would result in variable decelerations in the FHR. Meconium-stained fluid may or may not produce changes in the fetal heart rate, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present. PTS: 1 DIF: Cognitive Level: Knowledge REF: 398 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: a. Elevated temperature caused by postpartum infection. b. Increased basal metabolic rate after giving birth. c. Loss of increased blood volume associated with pregnancy. d. Increased venous pressure in the lower extremities.

ANS: C Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities. PTS: 1 DIF: Cognitive Level: Comprehension REF: 486 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

A primigravida at 40 weeks of gestation is having uterine contractions every 1.5 to 2 minutes and says that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this womans labor? a. She is exhibiting hypotonic uterine dysfunction. b. She is experiencing a normal latent stage. c. She is exhibiting hypertonic uterine dysfunction. d. She is experiencing pelvic dystocia.

ANS: C Women who experience hypertonic uterine dysfunction, or primary dysfunctional labor, often are anxious firsttime mothers who are having painful and frequent contractions that are ineffective at causing cervical dilation or effacement to progress. With hypotonic uterine dysfunction, the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop altogether. The contraction pattern seen in this woman signifies hypertonic uterine activity. Typically uterine activity in this phase occurs at 4- to 5-minute intervals lasting 30 to 45 seconds. Pelvic dystocia can occur whenever contractures of the pelvic diameters reduce the capacity of the bony pelvis, including the inlet, midpelvis, outlet, or any combination of these planes. PTS: 1 DIF: Cognitive Level: Application REF: 455 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A postpartum nurse anticipates blood loss of (Select all that apply): a. 100 mL b. 250 mL or less c. 300 to 500 mL d. 500 to 1000 mL e. 1500 mL or greater

ANS: C, D The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume). During the first few days after birth the plasma volume decreases further as a result diuresis. Pregnancy-induced hypervolemia (an increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth. PTS: 1 DIF: Cognitive Level: Comprehension REF: 487 OBJ: Nursing Process: Assessment, Planning MSC: Client Needs: Physiologic Integrity

The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patients most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)? a. Spontaneous fetal movement b. Compression of the fetal head c. Placental abruption d. Cord around the babys neck e. Maternal supine hypotension

ANS: C, E Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression. This may happen when the umbilical cord is around the babys neck, arm, leg, or other body part or when there is a short cord, a knot in the cord, or a prolapsed cord. PTS: 1 DIF: Cognitive Level: Analysis REF: 393 OBJ: Nursing Process: Assessment, Diagnosis MSC: Client Needs: Physiologic Integrity

A placenta previa in which the placental edge just reaches the internal os is more commonly known as: a. Total b. Partial c. Complete d. Marginal

ANS: D A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. When the patient experiences a partial placenta previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete placenta previa is termed total. The placenta completely covers the internal cervical os. PTS: 1 DIF: Cognitive Level: Knowledge REF: 326 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: a. Altered cerebral blood flow. b. Fetal hypoxemia. c. Umbilical cord compression. d. Fetal sleep cycles.

ANS: D A temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes. Altered fetal cerebral blood flow would result in early decelerations in the FHR. Fetal hypoxemia would be evidenced by tachycardia initially and then bradycardia. A persistent decrease or loss of FHR variability may be seen. Umbilical cord compression would result in variable decelerations in the FHR. PTS: 1 DIF: Cognitive Level: Comprehension REF: 390 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Postbirth uterine/vaginal discharge, called lochia: a. Is similar to a light menstrual period for the first 6 to 12 hours. b. Is usually greater after cesarean births. c. Will usually decrease with ambulation and breastfeeding. d. Should smell like normal menstrual flow unless an infection is present.

ANS: D An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births and usually increases with ambulation and breastfeeding. PTS: 1 DIF: Cognitive Level: Comprehension REF: 484 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is: a. Respiratory depression. b. Uterine relaxation. c. Inadequate muscle relaxation. d. Aspiration of stomach contents.

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication. PTS: 1 DIF: Cognitive Level: Comprehension REF: 376 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

When a nulliparous woman telephones the hospital to report that she is in labor, the nurse initially should: a. Tell the woman to stay home until her membranes rupture. b. Emphasize that food and fluid intake should stop. c. Arrange for the woman to come to the hospital for labor evaluation. d. Ask the woman to describe why she believes she is in labor.

ANS: D Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin the assessment and gather data. The amniotic membranes may or may not spontaneously rupture during labor. The client may be instructed to stay home until the uterine contractions become strong and regular. The nurse may want to discuss the appropriate oral intake for early labor such as light foods or clear liquids, depending on the preference of the client or her primary health care provider. Before instructing the woman to come to the hospital, the nurse should initiate the assessment during the telephone interview. PTS: 1 DIF: Cognitive Level: Application REF: 402 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? a. Estriol is not 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.

ANS: D 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. 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. PTS: 1 DIF: Cognitive Level: Application REF: 461 OBJ: Nursing Process: Assessment, Planning MSC: Client Needs: Health Promotion and Maintenance

When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses comprehend that both: a. Can be used when membranes are intact. b. Measure the frequency, duration, and intensity of uterine contractions. c. May need to rely on the woman to indicate when uterine activity (UA) is occurring. d. Can be used during the antepartum and intrapartum periods.

ANS: D External monitoring can be used in both periods; internal monitoring can be used only in the intrapartum period. For internal monitoring the membranes must have ruptured, and the cervix must be sufficiently dilated. Internal monitoring measures the intensity of contractions; external monitoring cannot do this. With external monitoring, the woman may need to alert the nurse that UA is occurring; internal monitoring does not require this. PTS: 1 DIF: Cognitive Level: Comprehension REF: 385 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by: a. Maintaining normal maternal temperature. b. Preventing normal maternal hypoglycemia. c. Increasing the oxygen-carrying capacity of the maternal blood. d. Expanding maternal blood volume.

ANS: D Filling the mothers vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most intravenous fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells. PTS: 1 DIF: Cognitive Level: Application REF: 396 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor. PTS: 1 DIF: Cognitive Level: Knowledge REF: 485 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

With regard to the care management of preterm labor, nurses should be aware that: a. Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching pregnant women the symptoms probably causes more harm through false alarms. b. Braxton Hicks contractions often signal the onset of preterm labor. c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several hours before contacting the primary caregiver. d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

ANS: D Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 445 OBJ: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches

ANS: D Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition. PTS: 1 DIF: Cognitive Level: Comprehension REF: 489 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurses most appropriate response is to ask the woman: a. Didnt you like your lunch? b. Does your doctor know that you are planning to eat that? c. What is that anyway? d. Ill warm the soup in the microwave for you.

ANS: D Ill warm the soup in the microwave for you shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. What is that anyway? does not show cultural sensitivity. PTS: 1 DIF: Cognitive Level: Application REF: 502 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: a. The father of the infant. b. Her mother (the infants grandmother). c. Her eldest daughter (the infants sister). d. The nurse.

ANS: D In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care. PTS: 1 DIF: Cognitive Level: Knowledge REF: 492 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Nurses should be aware that the induction of labor: a. Can be achieved by external and internal version techniques. b. Is also known as a trial of labor (TOL). c. Is almost always done for medical reasons. d. Is rated for viability by a Bishop score.

ANS: D Induction of labor is likely to be more successful with a Bishop score of 9 or higher for first-time mothers and 5 or higher for veterans. Version is turning of the fetus to a better position by a physician for an easier or safer birth. A trial of labor is the observance of a woman and her fetus for several hours of active labor to assess the safety of vaginal birth. Two thirds of cases of induced labor are elective and are not done for medical reasons. PTS: 1 DIF: Cognitive Level: Comprehension REF: 461 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Safe and Effective Care Environment

The standard of care for obstetrics dictates that an internal version may be used to manipulate the: a. Fetus from a breech to a cephalic presentation before labor begins. b. Fetus from a transverse lie to a longitudinal lie before cesarean birth. c. Second twin from an oblique lie to a transverse lie before labor begins. d. Second twin from a transverse lie to a breech presentation during vaginal birth.

ANS: D Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated. PTS: 1 DIF: Cognitive Level: Knowledge REF: 460 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a. Pouring water from a squeeze bottle over the womans perineum. b. Placing oil of peppermint in a bedpan under the woman. c. Asking the physician to prescribe analgesics. d. Inserting a sterile catheter.

ANS: D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter. PTS: 1 DIF: Cognitive Level: Comprehension REF: 498 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

For the labor nurse, care of the expectant mother begins with any or all of these situations, with the exception of: a. The onset of progressive, regular contractions. b. The bloody, or pink, show. c. The spontaneous rupture of membranes. d. Formulation of the womans plan of care for labor.

ANS: D Labor care begins when progressive, regular contractions begin; the blood-tinged mucoid vaginal discharge appears; or fluid is discharged from the vagina. The woman and nurse can formulate their plan of care before labor or during treatment. PTS: 1 DIF: Cognitive Level: Knowledge REF: 405 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which fetal heart rate (FHR) finding would concern the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations

ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the FHR are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they generally are not a concern during normal labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 383 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

When using intermittent auscultation (IA) for fetal heart rate, nurses should be aware that: a. They can be expected to cover only two or three clients when IA is the primary method of fetal assessment. b. The best course is to use the descriptive terms associated with electronic fetal monitoring (EFM) when documenting results. c. If the heartbeat cannot be found immediately, a shift must be made to EFM. d. Ultrasound can be used to find the fetal heartbeat and reassure the mother if initial difficulty was a factor.

ANS: D Locating fetal heartbeats often takes time. Mothers can be reassured verbally and by the ultrasound pictures if ultrasound is used to help locate the heartbeat. When used as the primary method of fetal assessment, auscultation requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate. PTS: 1 DIF: Cognitive Level: Comprehension REF: 384 OBJ: Nursing Process: Assessment, Planning MSC: Client Needs: Health Promotion and Maintenance

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? a. Lochia rubra b. Lochia sangra c. Lochia alba d. Lochia serosa

ANS: D Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. There is no such term as lochia sangra. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth. PTS: 1 DIF: Cognitive Level: Comprehension REF: 484 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: a. Formally initializing individualized care by confirming the womans and infants identification (ID) numbers on their respective wrist bands. (This is your baby.) b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. (Its a dangerous world out there.) c. Including other family members in the teaching of self-care and child care. (Were all in this together.) d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

ANS: D Many professionals believe that the nurses nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. Mothering the mother is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice. PTS: 1 DIF: Cognitive Level: Comprehension REF: 492 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation? a. Epidural anesthesia b. Narcotics c. Spinal block d. Breathing and relaxation techniques

ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. It is unlikely that enough time remains to administer epidural or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn. PTS: 1 DIF: Cognitive Level: Application REF: 361 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations or loss of variability is nonreassuring and is associated with: a. Hypotension. b. Cord compression. c. Maternal drug use. d. Hypoxemia.

ANS: D Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Fetal variable decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia. PTS: 1 DIF: Cognitive Level: Analysis REF: 390 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which assessment is least likely to be associated with a breech presentation? a. Meconium-stained amniotic fluid b. Fetal heart tones heard at or above the maternal umbilicus c. Preterm labor and birth d. Post-term gestation

ANS: D Post-term gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births. PTS: 1 DIF: Cognitive Level: Analysis REF: 457 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

32. Which collection of risk factors most likely would result in damaging lacerations (including episiotomies)? a. A dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. A reddish-haired mother of two who is going through a breech birth c. A dark-skinned, first-time mother who is going through a long labor d. A first-time mother with reddish hair whose rapid labor was overseen by an obstetrician

ANS: D Reddish-haired women have tissue that is less distensible than that of darker-skinned women and therefore may have less efficient healing. First time mothers are also more at risk, especially with breech births, long second-stage labors, or rapid labors in which there is insufficient time for the perineum to stretch. The rate of episiotomies is higher when obstetricians rather than midwives attend births. PTS: 1 DIF: Cognitive Level: Application REF: 435 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

For a woman at 42 weeks of gestation, which finding would require further 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

ANS: D Self-care in a post-term 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. Normal findings in a 42-week gestation include fetal heart rate of 116 beats/min, cervix dilated 20 cm and 50% effaced, and a score of 8 on the biophysical profile. PTS: 1 DIF: Cognitive Level: Application REF: 452 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should: a. Change the womans position. b. Discontinue the oxytocin infusion. c. Insert an internal monitor. d. Document the finding in the clients record.

ANS: D The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings. PTS: 1 DIF: Cognitive Level: Application REF: 399 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The priority nursing intervention after an amniotomy should be to: a. Assess the color of the amniotic fluid. b. Change the patients gown. c. Estimate the amount of amniotic fluid. d. Assess the fetal heart rate.

ANS: D The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Secondary to FHR assessment, amniotic fluid amount, color, odor, and consistency is assessed. Dry clothing is important for patient comfort; however, it is not the top priority. PTS: 1 DIF: Cognitive Level: Application REF: 469 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

With regard to postpartum ovarian function, nurses should be aware that: a. Almost 75% of women who do not breastfeed resume menstruating within a month after birth. b. Ovulation occurs slightly earlier for breastfeeding women. c. Because of menstruation/ovulation schedules, contraception considerations can be postponed until after the puerperium. d. The first menstrual flow after childbirth usually is heavier than normal.

ANS: D The first flow is heavier, but within three or four cycles, it is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns within 12 weeks after birth. Breastfeeding women take longer to resume ovulation. Because many women ovulate before their first postpartum menstrual period, contraceptive options need to be discussed early in the puerperium. PTS: 1 DIF: Cognitive Level: Comprehension REF: 486 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

If a woman complains of back labor pain, the nurse could best suggest that she: a. Lie on her back for a while with her knees bent. b. Do less walking around. c. Take some deep, cleansing breaths. d. Lean over a birth ball with her knees on the floor.

ANS: D The hands-and-knees position, with or without the aid of a birth ball, should help with the back pain. The supine position should be discouraged. Walking generally is encouraged. PTS: 1 DIF: Cognitive Level: Application REF: 421 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurses first action is to: a. Begin an intravenous (IV) infusion of Ringers lactate solution. b. Assess the womans vital signs. c. Call the womans primary health care provider. d. Massage the womans fundus.

ANS: D The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurses first action. The physician would be notified after the nurse completes the assessment of the woman. PTS: 1 DIF: Cognitive Level: Application REF: 496 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse who performs vaginal examinations to assess a womans progress in labor should: a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner.

ANS: D The nurse should discuss the findings of the vaginal examination with the woman and her partner and report them to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman. PTS: 1 DIF: Cognitive Level: Application REF: 411 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the: a. Involutionary period because of what happens to the uterus. b. Lochia period because of the nature of the vaginal discharge. c. Mini-tri period because it lasts only 3 to 6 weeks. d. Puerperium, or fourth trimester of pregnancy.

ANS: D The puerperium, also called the fourth trimester or the postpartum period of pregnancy, lasts about 3 to 6 weeks. Involution marks the end of the puerperium, or the fourth trimester of pregnancy. Lochia refers to the various vaginal discharges during the puerperium, or fourth trimester of pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge REF: 486 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse practicing in a labor setting knows that the woman most at risk for uterine rupture is: a. A gravida 3 who has had two low-segment transverse cesarean births. b. A gravida 2 who had a low-segment vertical incision for delivery of a 10-pound infant. c. A gravida 5 who had two vaginal births and two cesarean births. d. A gravida 4 who has had all cesarean births.

ANS: D The risk of uterine rupture increases for the patient who has had multiple prior births with no vaginal births. As the number of prior uterine incisions increases, so does the risk for uterine rupture. Low-segment transverse cesarean scars do not predispose the patient to uterine rupture. PTS: 1 DIF: Cognitive Level: Comprehension REF: 479 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A nurse may be called on to stimulate the fetal scalp: a. As part of fetal scalp blood sampling. b. In response to tocolysis. c. In preparation for fetal oxygen saturation monitoring. d. To elicit an acceleration in the fetal heart rate (FHR).

ANS: D The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse would stimulate the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. Fetal oxygen saturation monitoring involves the insertion of a sensor. PTS: 1 DIF: Cognitive Level: Application REF: 396 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? a. Urine output of 160 mL in 4 hours b. Deep tendon reflexes 2+ and no clonus c. Respiratory rate of 16 breaths/min d. Serum magnesium level of 10 mg/dL

ANS: D The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings. PTS: 1 DIF: Cognitive Level: Comprehension REF: 448 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurses initial response would be to: a. Prepare the woman for imminent birth. b. Notify the womans primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate and pattern.

ANS: D The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed. The nurses priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM. PTS: 1 DIF: Cognitive Level: Application REF: 414 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports: a. I contract my thighs, buttocks, and abdomen. b. I do 10 of these exercises every day. c. I stand while practicing this new exercise routine. d. I pretend that I am trying to stop the flow of urine midstream.

ANS: D The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees. PTS: 1 DIF: Cognitive Level: Analysis REF: 485 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

ANS: D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders. PTS: 1 DIF: Cognitive Level: Comprehension REF: 497 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. Admitted and prepared for a cesarean birth. b. Admitted for extended observation. c. Discharged home with a sedative. d. Discharged home to await the onset of true labor.

ANS: D This situation describes a woman with normal assessments who is probably in false labor and will likely not deliver rapidly once true labor begins. There is no indication that further assessments or observations are indicated; therefore, the patient will be discharged along with instructions to return when contractions increase in intensity and frequency. Neither a cesarean birth nor a sedative is required at this time. PTS: 1 DIF: Cognitive Level: Analysis REF: 403 OBJ: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take? a. Scream for help. b. Insert a Foley catheter. c. Start Pitocin. d. Notify the care provider immediately.

ANS: D To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley Catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus. PTS: 1 DIF: Cognitive Level: Evaluation REF: 395 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

In documenting labor experiences, nurses should know that a uterine contraction is described according to all these characteristics except: a. Frequency (how often contractions occur). b. Intensity (the strength of the contraction at its peak). c. Resting tone (the tension in the uterine muscle). d. Appearance (shape and height).

ANS: D Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. PTS: 1 DIF: Cognitive Level: Knowledge REF: 411 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?

Administration of BLOOD Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a client with DIC because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

Nurses should be aware that HELLP syndrome:

Is characterized by hemolysis, elevated liver enzymes, and low platelets. The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased, and so is perinatal mortality.

What nursing diagnosis would be the most appropriate for a woman experiencing severe preeclampsia?

Risk for injury to the fetus related to uteroplacental insufficiency Risk for injury to the fetus related to uteroplacental insufficiency is the most appropriate nursing diagnosis for this client scenario. Other diagnoses include Risk to fetus related to preterm birth and abruptio placentae. Eclampsia is a medical, not a nursing, diagnosis. There would be a risk for excess, not deficient, fluid volume related to increased sodium retention. There would be a risk for decreased, not increased, cardiac output related to the use of antihypertensive drugs.

Your patient has been receiving magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client?

A boggy uterus with heavy lochia flow Because of the tocolytic effects of magnesium sulfate, this patient most likely would have a boggy uterus with increased amounts of bleeding and a heavy lochia flow in the postpartum period.

A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?

A dipstick value of 3+ for protein in her urine Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or in diastolic pressure of 15 mm Hg. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3 C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, I'm so thirsty and warm. The nurse:

Discontinues the magnesium sulfate infusion. The client is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1 C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:

Hydralazine. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.

The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:

Hypertension. Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of:

Placental abruption. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?

Presence of fibrin split products Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC. Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies.

Magnesium sulfate is given to women with preeclampsia and eclampsia to:

Prevent and treat convulsions. Magnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.

A woman presents to the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?

Threatened A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would present with heavy bleeding, mild to severe cramping, and cervical dilation. An inevitable abortion manifests with the same symptoms as an incomplete abortion: heavy bleeding, mild to severe cramping, and cervical dilation. A woman with a septic abortion presents with malodorous bleeding and typically a dilated cervix.

The primary difference between the labor of a nullipara and that of a multipara is the: a. Amount of cervical dilation. b. Total duration of labor. c. Level of pain experienced. d. Sequence of labor mechanisms.

ANS: B In a first-time pregnancy, descent is usually slow but steady; in subsequent pregnancies, descent is more rapid, resulting in a shorter duration of labor. Cervical dilation is the same for all labors. Level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms is the same with all labors. PTS: 1 DIF: Cognitive Level: Comprehension REF: 346 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse would expect which maternal cardiovascular finding during labor? a. Increased cardiac output b. Decreased pulse rate c. Decreased white blood cell (WBC) count d. Decreased blood pressure

ANS: A During each contraction, 400 mL of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 51% above baseline pregnancy values at term. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by about 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg. PTS: 1 DIF: Cognitive Level: Comprehension REF: 353 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? a. Massaging the womans back b. Changing the womans position c. Giving the prescribed medication d. Encouraging the woman to rest between contractions

ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord and thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the womans position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory. PTS: 1 DIF: Cognitive Level: Comprehension REF: 362 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Spontaneous termination of a pregnancy is considered to be an abortion if: a. The pregnancy is less than 20 weeks. b. The fetus weighs less than 1000 g. c. The products of conception are passed intact. d. No evidence exists of intrauterine infection.

ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection. PTS: 1 DIF: Cognitive Level: Knowledge REF: 318 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic analgesia in the newborn is: a. Respiratory depression. b. Bradycardia. c. Acrocyanosis. d. Tachypnea.

ANS: A An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. PTS: 1 DIF: Cognitive Level: Knowledge REF: 367 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which occurrence is associated with cervical dilation and effacement? a. Bloody show b. False labor c. Lightening d. Bladder distention

ANS: A As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries. Cervical dilation and effacement do not occur with false labor. Lightening is the descent of the fetus toward the pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied frequently. It may slow down the descent of the fetus during labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 351 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to: a. Assess fetal heart rate (FHR) and maternal vital signs b. Perform a venipuncture for hemoglobin and hematocrit levels c. Place clean disposable pads to collect any drainage d. Monitor uterine contractions

ANS: A Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority. PTS: 1 DIF: Cognitive Level: Application REF: 326 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion? a. Chromosomal abnormalities b. Infections c. Endocrine imbalance d. Immunologic factors

ANS: A At least 50% of pregnancy losses result from chromosomal abnormalities that are incompatible with life. Maternal infection may be a cause of early miscarriage. Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss. Women who have repeated early pregnancy losses appear to have immunologic factors that play a role in spontaneous abortion incidents. PTS: 1 DIF: Cognitive Level: Knowledge REF: 318 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

With regard to nerve block analgesia and anesthesia, nurses should be aware that: a. Most local agents are related chemically to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. A pudendal nerve block is designed to relieve the pain from uterine contractions. d. A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex. PTS: 1 DIF: Cognitive Level: Comprehension REF: 370 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: a. Counterpressure against the sacrum. b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Conscious relaxation or guided imagery.

ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory. PTS: 1 DIF: Cognitive Level: Comprehension REF: 362 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

With regard to breathing techniques during labor, maternity nurses should understand that: a. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. b. By the time labor has begun, it is too late for instruction in breathing and relaxation. c. Controlled breathing techniques are most difficult near the end of the second stage of labor. d. The patterned-paced breathing technique can help prevent hyperventilation.

ANS: A First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 360 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which description of the four stages of labor is correct for both definition and duration? a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

ANS: A Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours). PTS: 1 DIF: Cognitive Level: Comprehension REF: 351 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

Which presentation is described accurately in terms of both presenting part and frequency of occurrence? a. Cephalic: occiput; at least 95% b. Breech: sacrum; 10% to 15% c. Shoulder: scapula; 10% to 15% d. Cephalic: cranial; 80% to 85%

ANS: A In cephalic presentations (head first), the presenting part is the occiput; this occurs in 96% of births. In a breech birth, the sacrum emerges first; this occurs in about 3% of births. In shoulder presentations, the scapula emerges first; this occurs in only 1% of births. PTS: 1 DIF: Cognitive Level: Comprehension REF: 343 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) b. Promethazine (Phenergan) c. Butorphanol tartrate (Stadol) d. Nalbuphine (Nubain)

ANS: A Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are opioid agonist-antagonist analgesics. PTS: 1 DIF: Cognitive Level: Comprehension REF: 368 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Nurses should be aware of the differences experience can make in labor pain such as: a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. PTS: 1 DIF: Cognitive Level: Knowledge REF: 358 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

In assessing a woman for pain and discomfort management during labor, a nurse most likely would: a. Have the woman use a visual analog scale (VAS) to determine her level of pain. b. Note drowsiness as a sign that the medications were working. c. Interpret a womans fist clenching as an indication that she is angry at her male partner and the physician. d. Evaluate the womans skin turgor to see whether she needs a gentle oil massage.

ANS: A The VAS is a means of adding the womans assessment of her pain to the nurses observations. Drowsiness is a side effect of medications, not usually (sedatives aside) a sign of effectiveness. The fist clenching likely is a sign of apprehension that may need attention. Skin turgor, along with the moistness of the membranes and the concentration of the urine, is a sign that helps the nurse evaluate hydration. PTS: 1 DIF: Cognitive Level: Application REF: 379 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

To care for a laboring woman adequately, the nurse understands that the __________ stage of labor varies the most in length? a. First b. Second c. Third d. Fourth

ANS: A The first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta. PTS: 1 DIF: Cognitive Level: Knowledge REF: 351 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

In relation to primary and secondary powers, the maternity nurse comprehends that: a. Primary powers are responsible for effacement and dilation of the cervix. b. Effacement generally is well ahead of dilation in women giving birth for the first time; they are closer together in subsequent pregnancies. c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. d. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

ANS: A The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in first-timers; they are closer together in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so. PTS: 1 DIF: Cognitive Level: Comprehension REF: 347 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

To help clients manage discomfort and pain during labor, nurses should be aware that: a. The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort between contractions. c. The somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the second stage.

ANS: A This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Thirdstage labor pain is similar to that of the first stage. PTS: 1 DIF: Cognitive Level: Knowledge REF: 356 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The reported incidence of ectopic pregnancy in the United States has risen steadily over the past 2 decades. Causes include the increase in STDs accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse who suspects that a patient has early signs of ectopic pregnancy should be observing her for symptoms such as (Select all that apply): a. Pelvic pain b. Abdominal pain c. Unanticipated heavy bleeding d. Vaginal spotting or light bleeding e. Missed period

ANS: A, B, D, E A missed period or spotting can easily be mistaken by the patient as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the patient often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage. PTS: 1 DIF: Cognitive Level: Application REF: 323 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which factors influence cervical dilation (Select all that apply) ? a. Strong uterine contractions b. The force of the presenting fetal part against the cervix c. The size of the female pelvis d. The pressure applied by the amniotic sac e. Scarring of the cervix

ANS: A, B, D, E Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part also can promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size does not affect cervical dilation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 347 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Signs that precede labor include (Select all that apply): a. Lightening. b. Exhaustion. c. Bloody show. d. Rupture of membranes. e. Decreased fetal movement.

ANS: A, C, D Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 351 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Health Promotion and Maintenance

A client who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include (Select all that apply): a. Iron supplementation. b. Resumption of intercourse at 6 weeks following the procedure. c. Referral to a support group if necessary. d. Expectation of heavy bleeding for at least 2 weeks. e. Emphasizing the need for rest.

ANS: A, C, E The woman should be advised to consume a diet high in iron and protein. For many women iron supplementation also is necessary. Acknowledge that the client has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her provider. PTS: 1 DIF: Cognitive Level: Application REF: 320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

With regard to a pregnant womans anxiety and pain experience, nurses should be aware that: a. Even mild anxiety must be treated. b. Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B Anxiety and pain reinforce each other in a negative cycle. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 358 OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

After change-of-shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. Visceral. b. Referred. c. Somatic. d. Afterpain.

ANS: B As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 356 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

It is important for the nurse to develop a realistic birth plan with the pregnant woman in her care. The nurse can explain that a major advantage of nonpharmacologic pain management is: a. Greater and more complete pain relief is possible. b. No side effects or risks to the fetus are involved. c. The woman remains fully alert at all times. d. A more rapid labor is likely.

ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The womans alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace. PTS: 1 DIF: Cognitive Level: Knowledge REF: 359 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which statement is the best rationale for assessing maternal vital signs between contractions? a. During a contraction, assessing fetal heart rates is the priority. b. Maternal circulating blood volume increases temporarily during contractions. c. Maternal blood flow to the heart is reduced during contractions. d. Vital signs taken during contractions are not accurate.

ANS: B During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mothers blood volume, which in turn temporarily increases blood pressure and slows pulse. It is important to monitor fetal response to contractions; however, this question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction. Vital signs are altered by contractions but are considered accurate for that period of time. PTS: 1 DIF: Cognitive Level: Knowledge REF: 354 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

With regard to systemic analgesics administered during labor, nurses should be aware that: a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular administration (IM) is preferred over intravenous (IV) administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

ANS: B Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic. PTS: 1 DIF: Cognitive Level: Knowledge REF: 367 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

The slight overlapping of cranial bones or shaping of the fetal head during labor is called: a. Lightening. b. Molding. c. Ferguson reflex. d. Valsalva maneuver.

ANS: B Fetal head formation is called molding. Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mothers sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor. PTS: 1 DIF: Cognitive Level: Comprehension REF: 343 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of: a. Anxiety due to hospitalization. b. Worsening disease and impending convulsion. c. Effects of magnesium sulfate. d. Gastrointestinal upset.

ANS: B Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication. PTS: 1 DIF: Cognitive Level: Analysis REF: 308 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

With regard to spinal and epidural (block) anesthesia, nurses should know that: a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. b. A high incidence of after-birth headache is seen with spinal blocks. c. Epidural blocks allow the woman to move freely. d. Spinal and epidural blocks are never used together.

ANS: B Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the womans ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular. PTS: 1 DIF: Cognitive Level: Comprehension REF: 373 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

Which maternal condition always necessitates delivery by cesarean section? a. Partial abruptio placentae b. Total placenta previa c. Ectopic pregnancy d. Eclampsia

ANS: B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal delivery occurred. If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted in cases of partial abruptio placentae. If the fetus has died, a vaginal delivery is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control. PTS: 1 DIF: Cognitive Level: Comprehension REF: 328 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve: a. Corticosteroids to reduce inflammation. b. IV therapy to correct fluid and electrolyte imbalances. c. An antiemetic, such as pyridoxine, to control nausea and vomiting. d. Enteral nutrition to correct nutritional deficits.

ANS: B Initially, the woman who is unable to keep down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: 317 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

An abortion in which the fetus dies but is retained within the uterus is called a(n): a. Inevitable abortion b. Missed abortion c. Incomplete abortion d. Threatened abortion

ANS: B Missed abortion refers to retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation. PTS: 1 DIF: Cognitive Level: Knowledge REF: 331 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The role of the nurse with regard to informed consent is to: a. Inform the client about the procedure and have her sign the consent form. b. Act as a client advocate and help clarify the procedure and the options. c. Call the physician to see the client. d. Witness the signing of the consent form.

ANS: B Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the womans advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurses responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the states guidelines, the womans husband or another hospital health care employee may sign as witness. PTS: 1 DIF: Cognitive Level: Comprehension REF: 377 OBJ: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because: a. The two together work the best for you and your baby. b. Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea. c. They work better together so you can sleep until you have the baby. d. This is what the doctor has ordered for you.

ANS: B Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications will not occur. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. This is what the doctor has ordered for you may be true, but it is not an acceptable comment for the nurse to make. PTS: 1 DIF: Cognitive Level: Application REF: 367 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Physiologic Integrity

The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. The mother gives birth without any analgesic or anesthetic. b. The mother and familys priorities and preferences are incorporated into the plan. c. The primary health care provider decides the best pain relief for the mother and family. d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting.

ANS: B The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain. PTS: 1 DIF: Cognitive Level: Comprehension REF: 380 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

To teach patients about the process of labor adequately, the nurse knows that which event is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes

ANS: B The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently; however, this is usually inconsistent. PTS: 1 DIF: Cognitive Level: Knowledge REF: 347 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal: a. Lie. b. Presentation. c. Attitude. d. Position.

ANS: C Attitude is the relation of the fetal body parts to one another. Lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relation of the presenting part to the four quadrants of the mothers pelvis. PTS: 1 DIF: Cognitive Level: Knowledge REF: 344 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse has received report regarding her patient in labor. The womans last vaginal examination was recorded as 3 cm, 30%, and ?2-2. The nurses interpretation of this assessment is that: a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines. b. The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. c. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines. d. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.

ANS: B The correct description of the vaginal examination for this woman in labor is the cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). PTS: 1 DIF: Cognitive Level: Comprehension REF: 347 OBJ: Nursing Process: Assessment, Planning MSC: Client Needs: Health Promotion and Maintenance

A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure? a. Amniocentesis for fetal lung maturity b. Ultrasound for placental location c. Contraction stress test (CST) d. Internal fetal monitoring

ANS: B The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding. PTS: 1 DIF: Cognitive Level: Application REF: 328 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

As relates to fetal positioning during labor, nurses should be aware that: a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b. Birth is imminent when the presenting part is at +4 to +5 cm below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d. Engagement is the term used to describe the beginning of labor.

ANS: B The station of the presenting part should be noted at the beginning of labor so that the rate of descent can be determined. Position is the relation of the presenting part of the fetus to the four quadrants of the mothers pelvis;station is the measure of degree of descent. The largest diameter usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparas and before or during labor in multiparas PTS: 1 DIF: Cognitive Level: Knowledge REF: 345 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of: a. Placenta previa. b. Vasa previa. c. Severe abruptio placentae. d. Disseminated intravascular coagulation (DIC).

ANS: B Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and would be considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors and causes widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome. This woman did not have any prior risk factors. PTS: 1 DIF: Cognitive Level: Analysis REF: 330 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial because of its effects on the neonate. PTS: 1 DIF: Cognitive Level: Knowledge REF: 370 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Physiologic Integrity

What condition indicates concealed hemorrhage when the patient experiences an abruptio placentae? a. Decrease in abdominal pain b. Bradycardia c. Hard, boardlike abdomen d. Decrease in fundal height

ANS: C Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. Abdominal pain may increase. The patient will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height will increase. PTS: 1 DIF: Cognitive Level: Analysis REF: 330 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the womans umbilicus and recognizes this assessment finding as: a. Normal integumentary changes associated with pregnancy. b. Turners sign associated with appendicitis. c. Cullens sign associated with a ruptured ectopic pregnancy. d. Chadwicks sign associated with early pregnancy.

ANS: C Cullens sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turners sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwicks sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 323 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? a. The fetal head is felt at 0 station during vaginal examination. b. Bloody mucus discharge increases. c. The vulva bulges and encircles the fetal head. d. The membranes rupture during a contraction.

ANS: C During the active pushing (descent) phase, the woman has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The vulva stretches and begins to bulge encircling the fetal head. Birth of the head occurs when the station is +4.0. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 351 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

While providing care to a patient in active labor, the nurse should instruct the woman that: a. The supine position commonly used in the United States increases blood flow. b. The all fours position, on her hands and knees, is hard on her back. c. Frequent changes in position will help relieve her fatigue and increase her comfort. d. In a sitting or squatting position, her abdominal muscles will have to work harder.

ANS: C Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The all fours position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions. PTS: 1 DIF: Cognitive Level: Application REF: 350 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Health Promotion and Maintenance

In providing nutritional counseling for the pregnant woman experiencing cholecystitis, the nurse would: a. Assess the womans dietary history for adequate calories and proteins. b. Instruct the woman that the bulk of calories should come from proteins. c. Instruct the woman to eat a low-fat diet and avoid fried foods. d. Instruct the woman to eat a low-cholesterol, low-salt diet.

ANS: C Instructing the woman to eat a low-fat diet and avoid fried foods is appropriate nutritional counseling for this client. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated. PTS: 1 DIF: Cognitive Level: Application REF: 333 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which condition would not be classified as a bleeding disorder in late pregnancy? a. Placenta previa. b. Abruptio placentae. c. Spontaneous abortion. d. Cord insertion.

ANS: C Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Cord insertion is a cause of bleeding disorders in later pregnancy. PTS: 1 DIF: Cognitive Level: Knowledge REF: 318 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mothers right side close to midline. What is the likely position of the fetus? a. ROA b. LSP c. RSA d. LOA

ANS: C The fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 345 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension. PTS: 1 DIF: Cognitive Level: Application REF: 373 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that: a. The fetal attitude describes the angle at which the fetus exits the uterus. b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother. c. The normal attitude of the fetus is called general flexion. d. The transverse lie is preferred for vaginal birth.

ANS: C The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal body parts to one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie. PTS: 1 DIF: Cognitive Level: Comprehension REF: 344 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the womans intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the womans hemoglobin is 12 g/dL, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

ANS: C The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia/anesthesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the womans hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women. PTS: 1 DIF: Cognitive Level: Analysis REF: 375 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that: a. The seven critical movements must progress in a more or less orderly sequence. b. Asynclitism sometimes is achieved by means of the Leopold maneuver. c. The effects of the forces determining descent are modified by the shape of the womans pelvis and the size of the fetal head. d. At birth the baby is said to achieve restitution (i.e., a return to the C-shape of the womb).

ANS: C The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the babys head; the Leopold maneuver is a means of judging descent by palpating the mothers abdomen. Restitution is the rotation of the babys head after the infant is born. PTS: 1 DIF: Cognitive Level: Comprehension REF: 351 OBJ: Nursing Process: Planning, Implementation MSC: Client Needs: Health Promotion and Maintenance

What finding on a prenatal visit at 10 weeks could suggest a hydatidiform mole? a. Complaint of frequent mild nausea b. Blood pressure of 120/80 mm Hg c. Fundal height measurement of 18 cm d. History of bright red spotting for 1 day, weeks ago

ANS: C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the patients history, bleeding is normally described as brownish. PTS: 1 DIF: Cognitive Level: Analysis REF: 325 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is: a. Not used much anymore. b. Likely to be used in the second stage of labor but not in the first stage. c. An application of nitrous oxide. d. A prelude to cesarean birth.

ANS: C This is an application of nitrous oxide, which could be used in either the first or second stage of labor (or both) as part of the preparation for a vaginal birth. Nitrous oxide is self-administered and found to be very helpful. PTS: 1 DIF: Cognitive Level: Comprehension REF: 376 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The maternity nurse understands that as the uterus contracts during labor, maternal-fetal exchange of oxygen and waste products: a. Continues except when placental functions are reduced. b. Increases as blood pressure decreases. c. Diminishes as the spiral arteries are compressed. d. Is not significantly affected.

ANS: C Uterine contractions during labor tend to decrease circulation through the spiral electrodes and subsequent perfusion through the intervillous space. The maternal blood supply to the placenta gradually stops with contractions. The exchange of oxygen and waste products decreases. The exchange of oxygen and waste products is affected by contractions. PTS: 1 DIF: Cognitive Level: Comprehension REF: 353 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which basic type of pelvis includes the correct description and percentage of occurrence in women? a. Gynecoid: classic female; heart shaped; 75% b. Android: resembling the male; wider oval; 15% c. Anthropoid: resembling the ape; narrower; 10% d. Platypelloid: flattened, wide, shallow; 3%

ANS: D A platypelloid pelvis is flattened, wide, and shallow; about 3% of women have this shape. The gynecoid shape is the classical female shape, slightly ovoid and rounded; about 50% of women have this shape. An android, or malelike, pelvis is heart shaped; about 23% of women have this shape. An anthropoid, or apelike, pelvis is oval and wider; about 24% of women have this shape. PTS: 1 DIF: Cognitive Level: Comprehension REF: 347 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

As related to the care of the patient with miscarriage, nurses should be aware that: a. It is a natural pregnancy loss before labor begins. b. It occurs in fewer than 5% of all clinically recognized pregnancies. c. It often can be attributed to careless maternal behavior such as poor nutrition or excessive exercise. d. If it occurs before the twelfth week of pregnancy, it may manifest only as moderate discomfort and blood loss.

ANS: D Before the sixth week the only evidence may be a heavy menstrual flow. After the twelfth week more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but by definition it occurs before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriage can be caused by a number of disorders or illnesses outside of the mothers control or knowledge. PTS: 1 DIF: Cognitive Level: Comprehension REF: 319 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, My contractions are so strong that I dont know what to do with myself. The nurse should: a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized for each individual.

ANS: D Each womans pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support. PTS: 1 DIF: Cognitive Level: Application REF: 357 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

In order to care for obstetric patients adequately, the nurse understands that labor contractions facilitate cervical dilation by: a. Contracting the lower uterine segment. b. Enlarging the internal size of the uterus. c. Promoting blood flow to the cervix. d. Pulling the cervix over the fetus and amniotic sac.

ANS: D Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps to push the fetus down. Blood flow decreases to the uterus during a contraction. PTS: 1 DIF: Cognitive Level: Comprehension REF: 347 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

In the current practice of childbirth preparation, emphasis is placed on: a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Having expectant parents attend childbirth preparation in any or no specific method.

ANS: D Encouraging expectant parents to attend childbirth preparation class is most important because preparation increases a womans confidence and thus her ability to cope with labor and birth. Although still popular, the method format of classes is being replaced with other offerings such as Hypnobirthing and Birthing from Within. PTS: 1 DIF: Cognitive Level: Comprehension REF: 360 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions are experiencing more pain. d. Levels of pain-mitigating b-endorphins are higher during a spontaneous, natural childbirth.

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension. PTS: 1 DIF: Cognitive Level: Comprehension REF: 357 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that: a. Bed rest and analgesics are the recommended treatment. b. She will be unable to conceive in the future. c. A D&C will be performed to remove the products of conception. d. Hemorrhage is the major concern.

ANS: D Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture in order to prevent hemorrhaging. If the tube must be removed, the womans fertility will decrease; however, she will not be infertile. D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes. PTS: 1 DIF: Cognitive Level: Comprehension REF: 323 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

In order to evaluate the condition of the patient accurately during labor, the nurse should be aware that: a. The womans blood pressure will increase during contractions and fall back to prelabor normal between contractions. b. Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. c. Having the woman point her toes will reduce leg cramps. d. The endogenous endorphins released during labor will raise the womans pain threshold and produce sedation.

ANS: D The endogenous endorphins released during labor will raise the womans pain threshold and produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mothers perception of pain. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. PTS: 1 DIF: Cognitive Level: Comprehension REF: 354 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

A new mother asks the nurse when the soft spot on her sons head will go away. The nurses answer is based on the knowledge that the anterior fontanel closes after birth by _____ months. a. 2 b. 8 c. 12 d. 18

ANS: D The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. PTS: 1 DIF: Cognitive Level: Knowledge REF: 342 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: a. Admitted and prepared for a cesarean birth. b. Admitted for extended observation. c. Discharged home with a sedative. d. Discharged home to await the onset of true labor.

ANS: D This situation describes a woman with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. These are all indications of false labor without fetal distress. There is no indication that further assessment or cesarean birth is indicated. The patient will likely be discharged; however, there is no indication that a sedative is needed. PTS: 1 DIF: Cognitive Level: Analysis REF: 351 OBJ: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment

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

ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion. PTS: 1 DIF: Cognitive Level: Application REF: 362 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks may be more effective than a long soak. Counterpressure can help the woman cope with lower back pain. PTS: 1 DIF: Cognitive Level: Application REF: 363 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors?

An African-American client who is 19 years old and pregnant with twins. 3 risk factors are present for this woman. She is of African-American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy. In planning care for this client the nurse must monitor blood pressure frequently and teach the woman regarding early warning signs. The 30-year-old client only has one known risk factor, obesity. Age distribution appears to be U-shaped, with women less than 20 years and more than 40 years being at greatest risk. Preeclampsia continues to be seen more frequently in primigravidas; this client is a multigravida woman. Two risk factors are present for the 41-year-old client. Her age and status as a primigravida put her at increased risk for preeclampsia. Caucasian women are at a lower risk than African- American women. The Asian-American client exhibits only one risk factor. Pregnancies that result from donor insemination, oocyte donation, and embryo donation are at an increased risk of developing preeclampsia.

In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:

Disseminated intravascular coagulation (DIC) The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman's arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the postpartum client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of:

HELLP syndrome. HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.

Women with hyperemesis gravidarum:

Have VOMITING severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance. Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 80% of pregnant women experience nausea and vomiting, fewer than 1% (0.5%) proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is seldom needed for very long. Women suffering from this condition want sympathy because some authorities believe that difficult relationships with mothers and/or partners may be the cause.

In planning care for women with preeclampsia, nurses should be aware that:

Induction of labor is likely, as near term as possible. Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.

A woman with preeclampsia has a seizure. The nurses primary duty during the seizure is to:

Stay with the client and call for help. If a client becomes eclamptic, the nurse should stay her and call for help. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the clients head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the clients mouth. Oxygen would be administered after the convulsion has ended.

Because pregnant women may need surgery during pregnancy, nurses should be aware that:

The diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy. Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell count. Rupture of the appendix is two to three times more likely in pregnant women. Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy predisposes a woman to ovarian problems.

Your patient is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, Why is it taking so long? The most appropriate response by the nurse would be:

The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor. Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate. I don't know why it is taking so long is not an appropriate statement for the nurse to make. Although the length of labor does vary in different women, the most likely reason this woman's labor is protracted is the tocolytic effect of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.

The perinatal nurse is giving discharge instructions to a woman after suction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse would be:

The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult. This is an accurate statement. b-Human chorionic gonadotropin (hCG) levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a zero hCG level. If the woman were to become pregnant, it could obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device is acceptable.