Families Module 1 Exam

The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele's rule, the nurse determines her EDD to be which of the following? A. September 27 B. October 21 C. November 7 D. December 27

B. October 21

When measuring a client's fundal height, which of the following techniques denotes the correct method of measurement used by the nurse? A. From the xiphoid process to the umbilicus B. From the symphysis pubis to the xiphoid process C. From the symphysis pubis to the fundus D. From the fundus to the umbilicus

C. From the symphysis pubis to the fundus

During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition? A. Prepregnant period B. First trimester C. Second trimester D. Third trimester

B. First trimester -First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. -Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? A. Proteinuria, headaches, vaginal bleeding B. Headaches, double vision, vaginal bleeding C. Proteinuria, headaches, double vision D. Proteinuria, double vision, uterine contractions

C. Proteinuria, headaches, double vision A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Options A, B, and D: Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension.

The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 centimeters. A repeat I.E. done at 10 A. M. showed that cervical dilation was 7 cm. The correct interpretation of this result is: A. Labor is progressing as expected B. The latent phase of Stage 1 is prolonged C. The active phase of Stage 1 is protracted D. The duration of labor is normal

C. The active phase of Stage 1 is protracted The active phase of Stage I starts from 4 cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour. Since the time lapsed is already 2 hours, the dilatation is expected to be already 8 cm. Hence, the active phase is protracted.

A nurse is assigned to a patient who is receiving Oxytocin (Pitocin) to induce labor. The nurse terminates the oxycotin infusion if which of the following is noted on the assessment of the client? A. Early decelerations of the fetal heart rate. B. Backache. C. Fatigue. D. Uterine hyperstimulation

D. Uterine hyperstimulation Oxytocin is used to induce labor by stimulating uterine contraction. Oxytocin infusion must be discontinued if any signs of uterine stimulation are present. Option A: Eary decelerations of the fetal heart rate are a reassuring sign, but it does not indicate fetal distress. Options B and C are probably caused by the labor experience itself.

Which of the following best describes preterm labor? A. Labor that begins after 20 weeks gestation and before 37 weeks gestation B. Labor that begins after 15 weeks gestation and before 37 weeks gestation C. Labor that begins after 24 weeks gestation and before 28 weeks gestation D. Labor that begins after 28 weeks gestation and before 40 weeks gestation

A. Labor that begins after 20 weeks gestation and before 37 weeks gestation

The post term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? A. Respiratory problems B. Gastrointestinal problems C. Integumentary problems D. Elimination problems

A. Respiratory problems Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for gastrointestinal problems. Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems.

For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? A. The membranes must rupture B. The fetus must be at 0 station C. The cervix must be dilated fully D. The patient must receive anesthesia

A. The membranes must rupture Internal EFM can be applied only after the patient's membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. Although the patient may receive anesthesia, it is not required before application of an internal EFM device.

From the 33rd week of gestation till full term, a healthy mother should have prenatal check up every: A. week B. 2 weeks C. 3 weeks D. 4 weeks

A. week In the 9th month of pregnancy the mother needs to have a weekly visit to the prenatal clinic to monitor fetal condition and to ensure that she is adequately prepared for the impending labor and delivery.

In Leopold's maneuver step # 3 you palpated a hard round movable mass at the supra pubic area. The correct interpretation is that the mass palpated is: A. The buttocks because the presentation is breech. B. The mass palpated is the head. C. The mass is the fetal back. D. The mass palpated is the fetal small part

B. The mass palpated is the head. When the mass palpated is hard round and movable, it is the fetal head.

When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound, the nurse should instruct her to: A. Observe NPO from midnight to avoid vomiting B. Do perineal flushing properly before the procedure C. Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done D. Void immediately before the procedure for better visualization

C. Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done

A multigravida at 38 weeks' gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided? A. Maternal vital sign B. Fetal heart rate C. Contraction monitoring D. Cervical dilation

D. Cervical dilation The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal physiologic status. Fetal heart rate is important to assess fetal well-being and should be done. Monitoring the contractions will help evaluate the progress of labor.

What would be the appropriate first nursing action when caring for a 20-year old G1P0 woman at 39 weeks gestation who is in active labor and for whom an assessment reveals mild variable fetal heart rate decelerations? A. Notify the physician B. Prepare the client for immediate delivery C. Readjust the fetal monitor D. Change the maternal position

D. Change the maternal position The cause of variable fetal heart decelerations is umbilical cord compression, which can usually be corrected by changing the maternal position.

What is an appropriate indicator for performing a contraction stress test? A. Increased fetal movement and small for gestational age B. Maternal diabetes mellitus and postmaturity C. Adolescent pregnancy and poor prenatal care D. History of preterm labor and intrauterine growth restriction

B. Maternal diabetes mellitus and postmaturity Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator. Although adolescent pregnancy and poor prenatal care are risk factors for poor fetal outcomes, they are not indicators for performing a contraction stress test. Intrauterine growth restriction is an indicator; history of a previous stillbirth, not preterm labor, is another indicator.

Which of the following prenatal laboratory test values would the nurse consider as significant? A. Hematocrit 33.5% B. Rubella titer less than 1:8 C. White blood cells 8,000/mm3 D. One hour glucose challenge test 110 g/dL

B. Rubella titer less than 1:8 A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.

During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following? A. Eliminate pain and give the expectant parents something to do B. Reduce the risk of fetal distress by increasing uteroplacental perfusion C. Facilitate relaxation, possibly reducing the perception of pain D. Eliminate pain so that less analgesia and anesthesia are needed

C. Facilitate relaxation, possibly reducing the perception of pain Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation. Breathing techniques do not eliminate pain, but they can reduce it. Positioning, not breathing, increases uteroplacental perfusion.

The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? A. Doppler blood flow analysis B. Contraction stress test (CST) C. Amniocentesis D. Daily fetal movement counts

A. Doppler blood flow analysis Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high-risk pregnancy due to intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed in a woman whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although it may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.

After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing? A. Obtaining an order to begin IV oxytocin infusion B. Administering a light sedative to allow the patient to rest for several hour C. Preparing for a cesarean section for failure to progress D. Increasing the encouragement to the patient when pushing begins

A. Obtaining an order to begin IV oxytocin infusion The client's labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. Administering light sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions.

A nurse is caring for a patient receiving oxytocin therapy suddenly is experiencing hypertonic contractions. Which of the following priority nursing actions should the nurse do? Select all that apply. A. The nurse leaves the client to ask for help. B. Stop the oxytocin infusion. C. Increase the flow rate of the intravenous additive solution. D. Place the client in the supine position. E. Administer oxygen at 8 to 10 liters per minute

B, C, E The presence of hypertonic contractions indicates the need to initiate emergency measures. The oxytocin infusion must be stopped to reduce uterine stimulation, administering oxygen will promote increase fetal and maternal oxygenation. Option A: The nurse should stay with client. Option D: Placing the client in a supine position will not promote an increase in placental oxygenation.

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation C. Between 21 and 23 weeks' gestation D. Between 24 and 26 weeks' gestation

B. Between 16 and 20 weeks' gestation A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

Which of the following is the nurse's initial action when umbilical cord prolapse occurs? A. Begin monitoring maternal vital signs and FHR B. Place the client in a knee-chest position in bed C. Notify the physician and prepare the client for delivery D. Apply a sterile warm saline dressing to the exposed cord

B. Place the client in a knee-chest position in bed The immediate priority is to minimize pressure on the cord. Thus the nurse's initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.

Which of the following statements best describes hyperemesis gravidarum? A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. C. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients D. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding

B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.

In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe explained as: A. A normal occurrence in pregnancy because the fetus is using more oxygen B. The fundus of the uterus is high pushing the diaphragm upwards C. The woman is having allergic reaction to the pregnancy and its hormones D. The woman maybe experiencing complication of pregnancy

B. The fundus of the uterus is high pushing the diaphragm upwards From the 32nd week of the pregnancy, the fundus of the enlarged uterus is pushing the respiratory diaphragm upwards. Thus, the lungs have reduced space for expansion consequently reducing the oxygen supply.

A client at 36 weeks gestation is scheduled for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta B. The ultrasound identifies blood flow through the umbilical cord C. The test will determine where to insert the needle D. The ultrasound locates a pool of amniotic fluid

B. The ultrasound identifies blood flow through the umbilical cord Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

Rho(D) immune globulin (RhoGAM) is given to a pregnant woman after delivery and the nurse is giving information to the patient about the indication of the medication. The nurse determines that the patient understands the purpose of the medication if the patient tells that it will protect her baby from which of the following? A. Developing German Measles. B. Developing Pernicious anemia. C. Developing Rh incompatibility. D. Having an RH+ blood

C. Developing Rh incompatibility. Rh incompatibility can develop when a Rh-negative mother becomes sensitized to the RH antigen. Sensitization may occur when a Rh-negative woman becomes pregnant with a fetus who is Rh positive. Blood cells from the baby may cross the maternal bloodstream, which can happen during pregnancy, labor, and delivery, causing the mother's immune system to form antibodies, against Rh-positive blood. Administration of the Rhogam prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen. Options A and B are not related to the Rh incompatibility. Option D is not indicated for the administration of Rhogam.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering erythromycin ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis

C. Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against (A, B, or D).

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client? A. Glucosuria B. Depression C. Hand/face edema D. Dietary intake

C. Hand/face edema After 20 weeks' gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is checked for glucose at each clinic visit, this is not the priority. Depression may cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is not, however, the priority consideration at this time. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time.

In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests? A. Threatened B. Imminent C. Missed D. Incomplete

C. Missed -In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. -A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. -An incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.

When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care? A. Instruct the mother's support person to remain in the family lounge until after the delivery B. Arrange for a staff member of the anesthesia department to explain what to expect postoperatively C. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth D. Explain the surgery, expected outcome, and kind of anesthetics

C. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. Allowing the mother's support person to remain with her as much as possible is an important concept, although doing so depends on many variables. Arranging for necessary explanations by various staff members to be involved with the client's care is a nursing responsibility. The nurse is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.

A pregnant client is receiving magnesium sulfate therapy for the control of preeclampsia. A nurse discover that the client is encountering toxicity from the medication in which of the following assessment? A. Urine output of 25 ml/hr. B. The presence of deep tendon reflex. C. Respirations of 10 breaths per minute. D. Serum magnesium level of 7 mEq/L.

C. Respirations of 10 breaths per minute. Magnesium sulfate is a central nervous system depressant and anticonvulsant. It can cause smooth muscle relaxation. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, decreased urine output, loss of deep tendon reflexes, hypotension and a decrease maternal and fetal heart rate. Option A: Urine output should be maintained at 25-30ml/hr. Option B: Deep tendon reflexes must be present. Option D: Normal range for magnesium is between 4-7 mEq/L

Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester? A. Introversion, egocentrism, narcissism B. Awkwardness, clumsiness, and unattractiveness C. Anxiety, passivity, extroversion D. Ambivalence, fear, fantasies

D. Ambivalence, fear, fantasies -During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. -The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. -During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.

Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following shouldthe nurse do first? A. Assess the vital signs B. Administer analgesia C. Ambulate her in the hall D. Assist her to urinate

D. Assist her to urinate Before uterine assessment is performed, it is essential that the woman empty her bladder. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. Uterine assessment should not cause acute pain that requires administration of analgesia. Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.

Which of the following nursing interventions would the nurse perform during the third stage of labor? A. Obtain a urine specimen and other laboratory tests. B. Assess uterine contractions every 30 minutes. C. Coach for effective client pushing D. Promote parent-newborn interaction.

D. Promote parent-newborn interaction. -During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parent-newborn interaction by placing the newborn on the mother's abdomen and encouraging the parents to touch the newborn. -Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. -Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. -Coaching the client to push effectively is appropriate during the second stage of labor.

Which of the following is a positive sign of pregnancy? A. Fetal movement felt by mother B. Enlargement of the uterus C. Positive pregnancy test D. Positive ultrasound

D. Positive ultrasound A positive ultrasound will definitely confirm that a woman is pregnant since the fetus in utero is directly visualized.

A client LMP began July 5. Her EDD should be which of the following? A. January 2 B. March 28 C. April 12 D. October 12

C. April 12 To determine the EDD when the date of the client's LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client's EDD is April 12.

The lower limit of viability for infants in terms of age of gestation is: A. 21-24 weeks B. 25-27 weeks C. 28-30 weeks D. 38-40 weeks

A. 21-24 weeks

The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A. "Nausea and vomiting can be decreased if I eat a few crackers before arising." B. "If I start to leak colostrum, I should cleanse my nipples with soap and water." C. "If I have a vaginal discharge, I should wear nylon underwear." D. "Leg cramps can be alleviated if I put an ice pack on the area."

A. "Nausea and vomiting can be decreased if I eat a few crackers before arising" Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

The expected weight gain in a normal pregnancy during the 3rd trimester is: A. 1 pound a week B. 2 pounds a week C. 10 lbs a month D. 10 lbs total weight gain in the 3rd trimester

A. 1 pound a week

A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest B. Platelet infusion C. Immediate cesarean delivery D. Labor induction with oxytocin

A. Activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.

A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase

D. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient. Option B: The latent phase extends from 0 to 3 cm; it is mild in nature. Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

In Leopold's maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass. The correct interpretation of this finding is: A. The mass palpated at the fundal part is the head part. B. The presentation is breech. C. The mass palpated is the back D. The mass palpated is the buttocks

D. The mass palpated is the buttocks The palpated mass is the fetal buttocks since it is broad and soft and moves with the rest of the mass.

You want to perform a pelvic examination on one of your pregnant clients. You prepare your client for the procedure by: A. Asking her to void B. Taking her vital signs and recording the readings C. Giving the client a perineal care D. Doing a vaginal prep

A. Asking her to void

Shoes with low, broad heels, plus a good posture will prevent which prenatal discomfort? A. Backache B. Vertigo C. Leg cramps D. Nausea

A. Backache Backache usually occurs in the lumbar area and becomes more problematic as the uterus enlarges. The pregnant woman in her third trimester usually assumes a lordotic posture to maintain balance causing an exaggeration of the lumbar curvature. Low broad heels provide the pregnant woman with a good support.

During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal heart rate is normal if which of the following is noted? A. 80 BPM B. 100 BPM C. 150 BPM D. 180 BP

C. 150 BPM

A client in her third trimester tells the nurse, "I'm constipated all the time!" Which of the following should the nurse recommend? A. Daily enemas B. Laxatives C. Increased fiber intake D. Decreased fluid intake

C. Increased fiber intake

The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent phase D. Transitional phase

D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. Option B: The complete phase occurs during the second, not first, stage of labor. Option C: The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

Which of the following factors would the nurse suspect as predisposing a client to placenta previa? A. Multiple gestation B. Uterine anomalies C. Abdominal trauma D. Renal or vascular disease

A. Multiple gestation -Multiple gestation is one of the predisposing factors that may cause placenta previa. -Uterine anomalies abdominal trauma, renal or vascular disease may predispose a client to abruptio placentae.

When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority? A. Dietary intake B. Medication C. Exercise D. Glucose monitoring

A. Dietary intake Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should always be the priority. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. Exercise, is important for all pregnant women and especially for diabetic women, because it burns up glucose, thus decreasing blood sugar. However, dietary intake, not exercise, is the priority. All pregnant women with diabetes should have periodic monitoring of serum glucose. However, those with gestational diabetes generally do not need daily glucose monitoring. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks.

A nurse is preparing Dinoprostone to a client to induce labor. Which of the following nursing intervention must be questioned? A. Have the client hold void before administration. B. Place the client on a side lying position for 30 to 60 minutes after the administration. C. Monitor maternal vital signs. D. Have the client void before administration

A. Have the client hold void before administration. Dinoprostone is a prostaglandin use in the induction of labor. It is administered vaginally so in order for the medication not to be contaminated with urine, the nurse should let the client void before administration. Options B, C, and D are the correct nursing interventions.

Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration? A. Oxytocin causes water intoxication B. Oxytocin causes excessive thirst C. Oxytocin is toxic to the kidneys D. Oxytocin has a diuretic effect

A. Oxytocin causes water intoxication The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. Options C and D: Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure? (Select all that apply.) A. Perform ultrasound to determine fetal positioning. B. Observe the patient for possible uterine contractions. C. Administer RhoGAM to the patient if she is Rh negative. D. Perform a mini catheterization to obtain a urine specimen to assess for bleeding. E. Advise the patient to increase activity following procedure.

B and C Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of transabdominal needle. There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication. The nurse would want to advise the patient to drink plenty and fluids and rest for 24 hours post procedure

Which of the following would the nurse assess in a client experiencing abruptio placenta? A. Bright red, painless vaginal bleeding B. Concealed or external dark red bleeding C. Palpable fetal outline D. Soft and nontender abdomen

B. Concealed or external dark red bleeding -A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to board-like, and the fetal presenting part may be engaged. -Bright red, painless vaginal bleeding, a palpable fetal outline and a soft non-tender abdomen are manifestations of placenta previa.

When preparing to listen to the fetal heart rate at 12 weeks' gestation, the nurse would use which of the following? A. Stethoscope placed midline at the umbilicus B. Doppler placed midline at the suprapubic region C. Fetoscope placed midway between the umbilicus and the xiphoid process D. External electronic fetal monitor placed at the umbilicus

B. Doppler placed midline at the suprapubic region At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. The fetal heart rate at this age is not audible with a stethoscope. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Although the external electronic fetal monitor would project the FHR, the uterus has not risen to the umbilicus at 12 weeks.

Which of the following findings in a woman would be consistent with a pregnancy of two months duration? A. Weight gain of 6-10 lbs. and presence of striae gravidarum B. Fullness of the breast and urinary frequency C. Braxton Hicks contractions and quickening D. Increased respiratory rate and ballottement

B. Fullness of the breast and urinary frequency Fullness of the breast is due to the increased amount of progesterone in pregnancy. The urinary frequency is caused by the compression of the urinary bladder by the gravid uterus which is still within the pelvic cavity during the first trimester.

Which of the following signs will require a mother to seek immediate medical attention? A. When the first fetal movement is felt B. No fetal movement is felt on the 6th month C. Mild uterine contraction D. Slight dyspnea on the last month of gestation

B. No fetal movement is felt on the 6th month

While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? A. Note the fetal heart rate patterns B. Notify the physician immediately C. Administer oxygen at 6 liters by mask D. Have the client pant-blow during the contractions

B. Notify the physician immediately The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.

Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? A. Weak contraction prolonged to more than 70 seconds B. Tetanic contractions prolonged to more than 90 seconds C. Increased pain with bright red vaginal bleeding D. Increased restlessness and anxiety

B. Tetanic contractions prolonged to more than 90 seconds Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation.

A client in preterm labor (32 weeks) who is dilated to 5cm has been given magnesium sulfate and the contractions have stopped. If the labor can be delayed for the next 2 days, which of the following medication does the nurse expect that will be prescribed? A. Fentanyl (Sublimaze). B. Sufentanil (Sufenta). C. Betamethasone (Celestone). D. Butorphanol tartrate (Stadol)

C. Betamethasone (Celestone). Glucocorticoids such as betamethasone and dexamethasone are being used to increase the production of surfactant to aid in fetal lung maturation. It is being given to patients who are in preterm labor at 28-32 weeks of gestation if the labor can be stopped for 2 days. Option A, B, and D are opioid analgesic.

The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day B. Wearing a supportive brassiere with nipple shields C. Breast-feeding the neonate at frequent intervals D. Decreasing fluid intake for the first 24 to 48 hours

C. Breastfeeding the neonate at frequent intervals Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate's and mother's needs

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation. B. Is an invasive test; however, contractions are stimulated. C. Is considered to have a negative result if no late decelerations are observed with the contractions. D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.

C. Is considered to have a negative result if no late decelerations are observed with the contractions. No late decelerations indicate a positive CST result. Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is performed by IV oxytocin but not if by nipple stimulation. CST is contraindicated if the membranes have ruptured.

Barbiturates are usually not given for pain relief during active labor for which of the following reasons? A. The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. B. These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. C. They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor. D. Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure.

C. They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.

Which of the following would be the nurse's most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa? A. "You will have to ask your physician when he returns." B. "You need a cesarean to prevent hemorrhage." C. "The placenta is covering most of your cervix." D. "The placenta is covering the opening of the uterus and blocking your baby."

D. "The placenta is covering the opening of the uterus and blocking your baby." A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Telling the client to ask the physician is a poor response and would increase the patient's anxiety. Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur. With a complete previa, the placenta is covering all the cervix, not just most of it.

Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy? A. 10 pounds per trimester B. 1 pound per week for 40 weeks C. ½ pound per week for 40 weeks D. A total gain of 25 to 30 pounds

D. A total gain of 25 to 30 pounds To ensure adequate fetal growth and development during the 40 weeks of a pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5 pounds in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by 40 weeks. The pregnant woman should gain less weight in the first and second trimester than in the third. During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. A weight gain of ½ pound per week would be 20 pounds for the total pregnancy, less than the recommended amount.

With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas? A. Above the maternal umbilicus and to the right of midline B. In the lower-left maternal abdominal quadrant C. In the lower-right maternal abdominal quadrant D. Above the maternal umbilicus and to the left of midline

D. Above the maternal umbilicus and to the left of midline With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.

When taking an obstetrical history on a pregnant client who states, "I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,"the nurse should record her obstetrical history as which of the following? A. G2 T2 P0 A0 L2 B. G3 T1 P1 A0 L2 C. G3 T2 P0 A0 L2 D. G4 T1 P1 A1 L2

D. G4 T1 P1 A1 L2 The client has been pregnant four times, including current pregnancy (G). Birth at 38 weeks' gestation is considered full term (T), while birth form 20 weeks to 38 weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two living children (L).

Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? A. Occurring at irregular intervals B. Starting mainly in the abdomen C. Gradually increasing intervals D. Increasing intensity with walking

D. Increasing intensity with walking With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens.

A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following? A. Quickening B. Ophthalmia neonatorum C. Pica D. Prolapsed umbilical cord

D. Prolapsed umbilical cord In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common. Quickening is the woman's first perception of fetal movement. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.

What event occurring in the second trimester helps the expectant mother to accept the pregnancy? A. Lightening B. Ballottement C. Pseudocyesis D. Quickening

D. Quickening Quickening is the first fetal movement felt by the mother makes the woman realize that she is truly pregnant. In early pregnancy, the fetus is moving but too weak to be felt by the mother. In the 18th-20th week of gestation, the fetal movements become stronger thus the mother already feels the movements.

A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? A. Biophysical profile B. Amniocentesis C. Maternal serum alpha-fetoprotein (MSAFP) D. Transvaginal ultrasound

D. Transvaginal ultrasound An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women, whose thick abdominal layers cannot be penetrated adequately with the abdominal approach. A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal).

Mrs. Santos is on her 5th pregnancy and has a history of abortion in the 4th pregnancy and the first pregnancy was a twin. She is considered to be A. G 4 P 3 B. G 5 P 3 C. G 5 P 4 D. G 4 P 4

B. G 5 P 3 Gravida refers to the total number of pregnancies including the current one. Para refers to the number of pregnancies that have reached viability. Thus, if the woman has had one abortion, she would be considered Para 3. Twin pregnancy is counted only as 1.

A client 12 weeks' pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation.The nurse would document these findings as which of the following? A. Threatened abortion B. Imminent abortion C. Complete abortion D. Missed abortion

B. Imminent abortion Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion. In a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. The symptoms may subside or progress to abortion. In a complete abortion all the products of conception are expelled. A missed abortion is early fetal intrauterine death without expulsion of the products of conception.

Which of the following would the nurse identify as a presumptive sign of pregnancy? A. Hegar sign B. Nausea and vomiting C. Skin pigmentation changes D. Positive serum pregnancy test

B. Nausea and vomiting Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign,skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

When PROM occurs, which of the following provides evidence of the nurse's understanding of the client's immediate needs? A. The chorion and amnion rupture 4 hours before the onset of labor. B. PROM removes the fetus most effective defense against infection C. Nursing care is based on fetal viability and gestational age. D. PROM is associated with malpresentation and possibly incompetent cervix

B. PROM removes the fetus most effective defense against infection PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client's most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM.

Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Titanic uterine contractions D. Premature rupture of membranes

B. Rigid, board-like abdomen The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.

During which of the following stages of labor would the nurse assess "crowning"? A. First stage B. Second stage C. Third stage D. Fourth stage

B. Second stage -Crowing, which occurs when the newborn's head or presenting part appears at the vaginal opening, occurs during the second stage of labor. -During the first stage of labor, cervical dilation and effacement occur. -During the third stage of labor, the newborn and placenta are delivered. -The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother's organs undergo the initial readjustment to the nonpregnant state.

A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client's plan of care? A. Daily weights B. Seizure precautions C. Right lateral positioning D. Stress reduction

B. Seizure precautions Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Because of edema, daily weight is important but not the priority. Preeclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseated." C. "This test will help to determine whether the baby has Down syndrome or a neural tube defect." D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements. An ultrasound requires a full bladder. An amniocentesis is the test after which a pregnant woman should be driven home. A maternal serum alpha-fetoprotein test is used in conjunction with unconjugated estriol levels and human chorionic gonadotropin helps to detect Down syndrome.

Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage? A. Placenta previa B. Ectopic pregnancy C. Incompetent cervix D. Abruptio placentae

D. Abruptio placentae -Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. -Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. -Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. -Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.