Final Exam Semester 2 Maternal/Newborn

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: A Not yet engaged B Entering the pelvic inlet C Below the ischial spines D Visible at the vaginal opening

C A station of +1 indicates that the fetal head is 1 cm below the ischial spines.

A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she: A Will not feel the episiotomy B May lose bladder sensation C May lose the ability to push D Will no longer feel contractions

A A pudendal block provides anesthesia to the perineum.

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A Document the findings and tell the mother that the monitor indicates fetal well-being B Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen C Notify the physician or nurse midwife of the findings D Reposition the mother and check the monitor for changes in the fetal tracing

A Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A An acceleration B An early elevation C A sonographic motion D A tachycardic heart rate

A An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.

Fetal presentation refers to which of the following descriptions? A Fetal body part that enters the maternal pelvis first B Relationship of the presenting part to the maternal pelvis C Relationship of the long axis of the fetus to the long axis of the mother D A classification according to the fetal part

A Presentation is the fetal body part that enters the pelvis first; it's classified by the presenting part; the three main presentations are cephalic/occipital, breech, and shoulder. The relationship of the presenting fetal part to the maternal pelvis refers to fetal position. The relationship of the long axis to the fetus to the long axis of the mother refers to fetal lie; the three possible lies are longitudinal, transverse, and oblique.

A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: A 1 cm above the ischial spine B 1 fingerbreadth below the symphysis pubis C 1 inch below the coccyx D 1 inch below the iliac crest

A Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.

Which of the following fetal positions is most favorable for birth? A Vertex presentation B Transverse lie C Frank breech presentation D Posterior position of the fetal head

A Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie is an unacceptable fetal position for vaginal birth and requires a C-section. Frank breech presentation, in which the buttocks present first, can be a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis.

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A Place the client in Trendelenburg's position B Call the delivery room to notify the staff that the client will be transported immediately C Gently push the cord into the vagina D Find the closest telephone and stat page the physician

A When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A Early decelerations B Variable decelerations C Late decelerations D Short-term variability

B

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A Three contractions occurring within a 10-minute period B A fetal heart rate of 90 beats per minute C Adequate resting tone of the uterus palpated between contractions D Increased urinary output

B A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? A Identifying the types of accelerations B Assessing the baseline fetal heart rate C Determining the frequency of the contractions D Determining the intensity of the contractions

B Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority.

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A Placing the client on complete bed rest B Continuous electronic fetal monitoring C An IV infusion of antibiotics D Placing a code cart at the client's bedside

B Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.

When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A Stop the oxytocin infusion B Change the client's position C Prepare for immediate delivery D Take the client's blood pressure

B Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.

A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: A Over the fetus that is most anterior to the mother's abdomen B Over the fetus that is most posterior to the mother's abdomen C So that each fetal heart rate is monitored separately D So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

C

The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: A Until the time it is completely over B To the end of a second contraction C To the beginning of the next contraction D Until the time that the uterus becomes very firm

C

The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: A Clear and dark amber in color B Milky, greenish yellow, containing shreds of mucus C Clear, almost colorless, and containing little white specks D Cloudy, greenish-yellow, and containing little white specks

C By 36 weeks' gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.

A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly? A Preparatory phase B Latent phase C Active phase D Transition phase

C Cervical dilation occurs more rapidly during the active phase than any of the previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7 cm. The preparatory, or latent, phase begins with the onset of regular uterine contractions and ends when rapid cervical dilation begins. Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A Place the mother in the supine position B Document the findings and continue to monitor the fetal patterns C Administer oxygen via face mask D Increase the rate of pitocin IV infusion

C Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A Prepare the client for an ultrasound B Obtain equipment for external electronic fetal heart monitoring C Obtain equipment for a manual pelvic examination D Prepare to draw a Hgb and Hct blood sample

C Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia.

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: A Express a strong need to review events and her behavior during the process of labor and birth B Exhibit a reduced attention span, limiting readiness to learn C Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn D Have reestablished her role as a spouse/partner

C One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response 3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors? A Contractions, passageway, placental position and function, pattern of care B Contractions, maternal response, placental position, psychological response C Passageway, contractions, placental position and function, psychological response D Passageway, placental position and function, paternal response, psychological response

C The five essential factors (5 P's) are passenger (fetus), passageway (pelvis), powers (contractions), placental position and function, and psyche (psychological response of the mother).

Which measure would be least effective in preventing postpartum hemorrhage? A Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B Encourage the woman to void every 2 hours C Massage the fundus every hour for the first 24 hours following birth D Teach the woman the importance of rest and nutrition to enhance healing

C The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: A Hematoma B Placenta previa C Uterine atony D Placental separation

D As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? A Disseminated intravascular coagulation B Chronic hypertension C Infection D Hemorrhage

D Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding

A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: A Transfer her immediately by stretcher to the birthing unit B Tell her to breathe through her mouth and not to bear down C Instruct the client to pant during contractions and to breathe through her mouth D Support the perineum with the hand to prevent tearing and tell the client to pant

D Gentle pressure is applied to the baby's head as it emerges so it is not born too rapidly. The head is never held back, and it should be supported as it emerges so there will be no vaginal lacerations. It is impossible to push and pant at the same time.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A Tell the woman she can rest after she feeds her baby B Recognize this as a behavior of the taking-hold stage C Record the behavior as ineffective maternal-newborn attachment D Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

D Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A Uses soap and warm water to wash the vulva and perineum B Washes from symphysis pubis back to episiotomy C Changes her perineal pad every 2 - 3 hours D Uses the peribottle to rinse upward into her vagina

D Responses 1, 2, and 3 are all appropriate measures. The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? A The umbilical cord shortens in length and changes in color B A soft and boggy uterus C Maternal complaints of severe uterine cramping D Changes in the shape of the uterus

D Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping.

A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: A Noting if the heart rate is greater than 140 BPM B Placing the diaphragm of the Doppler on the mother abdomen C Performing Leopold's maneuvers first to determine the location of the fetal heart D Palpating the maternal radial pulse while listening to the fetal heart rate

D The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.

A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A The client begins to expel clear vaginal fluid B The contractions are regular C The membranes have ruptured D The cervix is dilated completely

D The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: A Trendelenburg's position with the legs in stirrups B Semi-Fowler position with a pillow under the knees C Prone position with the legs separated and elevated D Supine position with a wedge under the right hip

D Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? Carbohydrates High fat High fiber Protein

Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss (Chart 59-3). Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease.No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.