HESI Prep Pregnancy, Labor, Childbirth, Postpartum-uncomplicated

Which factor most often interferes with access to prenatal care for pregnant women, placing the mother and infant at risk? Select all that apply. One, some, or all responses may be correct. Correct1 Language differences Correct2 Transportation barriers 3 Lack of nurse practitioners Correct4 Lack of culturally sensitive care providers Correct5 Discrimination based on sexual orientation

Language differences, transportation barriers, lack of culturally sensitive care providers, and discrimination based on sexual orientation most often interfere with access to prenatal care for pregnant women and place the mother and infant at risk. The availability of advanced practice nurses improves the availability and accessibility to care.

Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? 1 Massage Correct2 Effleurage 3 Acupressure 4 Counterpressure

Effleurage is the gentle stroking of the abdomen in rhythm with her breathing during a contraction. Massage is the application of therapeutic touch and pressure on the body. Acupressure is the application of pressure along special acupressure points. Counterpressure is the application of pressure to the sacrum during a contraction.

The nonstress test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with which finding? 1 Fetal lie Correct2 Fetal movement 3 Maternal blood pressure 4 Maternal uterine contractions

In a healthy, well-oxygenated fetus, the heart rate increases with fetal movement; there should be an acceleration of 15 beats with fetal movement. Fetal lie and maternal blood pressure are not a part of the evaluation of the fetus in the nonstress test. Maternal uterine contractions are used in the contraction stress test.

Which change would the nurse expect in the client when the transition phase of active labor is beginning? 1 Bulging perineum 2 Pinkish vaginal discharge 3 Crowning of the fetal head Correct4 Rectal pressure during contractions

Rectal pressure occurs at the beginning of the transition phase of labor when the fetal head starts to press on the rectum during contractions. The perineum bulges when transition is complete and the cervix is fully dilated. Pink vaginal discharge occurs when labor begins, not at the beginning of the transition phase. The fetal head crowns at the end of the second stage, shortly before birth.

A client states she is 5 months pregnant. Which positive sign of pregnancy would the nurse evaluate in this client? 1 Quickening 2 Enlarged abdomen 3 Cervical color change Correct4 Audible fetal heartbeat

The presence of the fetal heartbeat is a positive sign of pregnancy. The feeling of movement is a presumptive sign of pregnancy. An enlarged abdomen is a probable sign of pregnancy. The bluish color of the cervix (Chadwick sign) is caused by pelvic congestion and edema; it is a probable sign of pregnancy.

While performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. Which is the fetal position? 1 Left occiput posterior (LOP) 2 Right sacral anterior (RSA) Correct3 Right occiput anterior (ROA) 4 Left occiput anterior (LOA)

The fetus is in a ROA position; the prominence over the symphysis suggests a vertex presentation, and the fetal occiput and back are in the right anterior quadrant. LOP position is ruled out because the occiput is not located in the left posterior quadrant; the occiput and back are on the mother's right side. RSA position is ruled out because the fetus is in a vertex, not a breech, presentation. LOA position is ruled out by the presence of irregular lumps on the left side, suggesting that the fetus's back is in the mother's right quadrant.

During the examination of a client in labor, the nurse determines that the cervix is dilated to 4 cm. Which stage of labor will the nurse document in the record? Correct1 First 2 Second 3 Prodromal 4 Transitional

The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is first stage of labor, from 8 cm of dilation to 10 cm of dilation.

A client in active labor starts screaming, "The baby is coming! Do something!" Which nursing action is the priority? 1 Notifying the practitioner of the imminent birth 2 Telling the client that it is too soon and encouraging her to pant Correct3 Checking the perineal area for the presenting part 4 Helping the client hold her knees together and explaining what to expect

The primary action by the nurse should be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse should remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.

Which nursing intervention would be completed before administering uterine stimulants to induce labor? Select all that apply. One, some, or all responses may be correct. Correct1 Checking the cervix to determine if it is ripe for labor 2 Preparing for placement of an epidural 3 Preparing the client for a cesarean delivery Correct4 Assessing the fetal heart rate Correct5 Assessing the mother's blood pressure, pulse rate, and respirations.

Cervical ripening is important for the induction of labor and delivery of the fetus. The nurse would document the fetal heart rate to assure the safety of the fetus. The nurse would regularly monitor the mother's vital signs to detect medical conditions. An epidural is not necessary for an induction; it is the mother's choice and would not be placed before labor is well established. The client would not need to be prepared for a cesarean delivery at this time, only if needed as a result of complications from the induction of labor.

Once an epidural catheter has been inserted in a laboring client, which assessment or intervention would be performed? Select all that apply. One, some, or all responses may be correct. Correct1 Maintaining intravenous fluid administration Correct2 Having oxygen available in case of hypotension Correct3 Checking the bladder for distention every 2 hours 4 Positioning the client supine for ease of monitoring Correct5 Monitoring fetal heart rate and labor progress per hospital protocol 6 Administering an oxytocin infusion to maintain the labor pattern

Hypotension is a common problem in the client receiving epidural analgesia. Intravenous fluids can help counter this problem and also provide a vehicle for emergency drug administration. Oxygen should be available in case of hypotension as a result of the epidural block or as emergency care should the anesthetic agent migrate upward. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart tones and the progress of labor should be monitored. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.

During labor, a client receiving epidural analgesia has a sudden episode of severe nausea and her skin becomes pale and clammy. Which would be the nurse's immediate response? Correct1 Turning the client on her side 2 Notifying the health care provider 3 Checking the vaginal area for bleeding 4 Checking the fetal heart rate every 3 minutes

Maternal hypotension is a common complication of epidural analgesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. If signs and symptoms do not abate after the client is turned on her side, the nurse would notify the health care provider. Checking the vaginal area for bleeding is not an assessment specific to epidural analgesia; it is part of the general nursing care during labor. The client would have a continuous process of external fetal monitoring for fetal heart rate.

Which client sign or symptom occurs with supine hypotensive syndrome? Select all that apply. One, some, or all responses may be correct. 1 Reflex tachycardia Correct2 Feeling of faintness 3 Increased cardiac output Correct4 Increased venous pressure 5 Increased diastolic pressure Correct6 Decreased systolic pressure

Compression of the vena cava hinders venous return, which in turn results in a decrease in systolic pressure, an increase of venous pressure in the legs, and decreased blood flow to the brain, causing the woman to feel faint. Blood pressure decreases when venous return is compromised. Supine hypotensive syndrome results in a reflex bradycardia of the fetus. Cardiac output is decreased by half.

Which complication is the pregnant client at risk for related to the dilation of renal pelves and ureters? 1 Frequent urination Correct2 Urinary tract infection 3 Glomerular filtration rate decreases 4 Increased urinary excretion of protein and albumin

Dilation of renal pelves and ureters during pregnancy increases the risk for urinary tract infections. Frequent urination is an expected occurrence during pregnancy due to increased bladder sensitivity during early pregnancy and due to bladder compression by the uterus during later pregnancy. By the end of the first trimester, the glomerular filtration rate increases by 50% and remains elevated throughout pregnancy. During a normal pregnancy, there is an increased urinary excretion of protein and albumin, most notably after 20 weeks' gestation.

Which factor is frequently associated with hyperemesis gravidarum? 1 History of cholecystitis 2 Large amount of amniotic fluid Correct3 High level of chorionic gonadotropin 4 Decreased secretion of hydrochloric acid

A high level of chorionic gonadotropin is frequently associated with severe vomiting during pregnancy and may result in hyperemesis gravidarum. A high level may also occur in the presence of a hydatidiform mole or multiple pregnancy. Cholecystitis is unrelated to this problem. Hydramnios (excessive amniotic fluid) is associated with multiple gestations and some fetal abnormalities. There are no data to indicate that there is decreased gastric acid secretion during the first trimester, and this is not the cause of hyperemesis gravidarum.

The nurse is caring for four clients on the postpartum unit. Which client will most likely have more difficulty with afterbirth pains? Correct1 Multipara who has vaginally delivered three children appropriate for gestational age 2 Primipara whose newborn weighed 7 lb 3 Multipara with effectively controlled diabetes 4 Multipara who delivered her second baby who was small for gestational age

A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant; a large infant could cause problems with involution of the uterus or afterbirth pains. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.

Which cervical change is observed during pregnancy? Select all that apply. One, some, or all responses may be correct. Correct1 Cervical tip becomes soft. 2 Fragility of cervical tissues decreases. Correct3 Volume of cervical muscles increases. 4 External cervical os appears as a jagged slit. Correct5 Elasticity of cervical collagen-rich connective tissue increases.

By the beginning of the sixth week of pregnancy, the cervical tip softens. During pregnancy, the cervical muscles and its collagen-rich connective tissues increase in volume and become loose and highly elastic. Cervical tissue fragility also increases. The external cervical os appears as a jagged slit postpartum but not during pregnancy.

Using the GTPAL system, determine the obstetric history for this client: She has just delivered at 38 weeks' gestation. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 32 weeks with a live birth, and her first pregnancy ended at 18 weeks. Incorrect1 G4, T2, P1, A1, L2 2 G4, T1, P2, A1, L1 Correct3 G4, T1, P1, A1, L3 4 G4, T2, P1, A1, L1

Four pregnancies = G (gravida) 4. One pregnancy that ended at 38 weeks = T (term) 1. One pregnancy that ended at 32 weeks = P (preterm) 1. One pregnancy that ended at 18 weeks = A (abortion) 1. One set of twins and a singleton = L (living) 3.

A pregnant 14-year-old emancipated minor enters the examination room with her mother. She reports to the nurse that she does not want her mother present for her examination. Which response by the nurse is appropriate? 1 "Your mother needs to be present for the examination." 2 "What's the problem with your mother being present?" 3 "I'm sure that your mother wants to be with you for support." Correct4 Tell the mother, "I'm sorry, but I need to ask you to stay in the waiting area."

In many jurisdictions, a minor who is self-supporting and living away from home, providing military service, married, pregnant, or a parent, is considered an emancipated minor. The emancipated minor assumes most responsibilities before the age of 18 years. An emancipated minor is entitled to confidentiality in dealings with health care providers. Therefore, it is appropriate to ask the client's mother to step out of the room, and none of the other responses are appropriate.

A client is prescribed uterine stimulants to augment labor. Which condition would need to be ruled out before initiating therapy? 1 Liver disease 2 Pituitary tumors Correct3 Pelvic inflammatory disease 4 Presence of an intrauterine device

Labor-inducing drugs are contraindicated in women who have pelvic inflammatory disease. If the mother has an infection, labor may not progress as usual. Ovarian stimulants are contraindicated in women who have liver disease because the stimulants can cause ovarian hyperstimulation and potentially cause abnormalities in liver function. Ovarian stimulants also are contraindicated in women with pituitary tumors because they are also associated with ovarian hyperstimulation. Abortifacient drugs are contraindicated in women who have intrauterine devices because these drugs can alter the placement of the device or expel it completely.

Immediately after the third stage of labor, the nurse administers a prescribed oxytocin infusion. Which is the purpose of this medication? Correct1 To help the uterus contract 2 To lessen uterine discomfort 3 To aid in the separation of the placenta 4 To stimulate breast milk production

Oxytocin given after the third stage of labor will stimulate the uterus to contract and remain contracted. Oxytocin does not have an analgesic effect. It is administered after the placenta is expelled (third stage of labor). Prolactin, not oxytocin, stimulates milk production.

Which complication would the nurse anticipate when a client who is 36 weeks' pregnant presents with swelling of the face, blurred vision, and epigastric discomfort? Correct1 Preeclampsia 2 Placenta previa 3 Gestational diabetes 4 Hyperemesis gravidarum

Swelling of the face, blurred vision, and epigastric discomfort are classic signs of preeclampsia. Placenta previa, gestational diabetes, and hyperemesis gravidarum do not present with swelling of the face, blurred vision, and epigastric discomfort.

Which intervention would the nurse perform before the administration of Rho(D) immune globulin to a postpartum client? 1 Start a primary intravenous (IV) line so that the drug may be administered via IV piggyback. Correct2 Ensure that the client is Rh negative and the neonate is Rh positive. 3 Obtain a syringe and needle appropriate for the subcutaneous injection. 4 Determine that the client has not eaten since midnight of the previous night.

Rho(D) immune globulin is given to Rh-negative mothers not previously sensitized who have Rh-positive neonates; it prevents Rh incompatibility in the next pregnancy. Rho(D) immune globulin is administered intramuscularly, not intravenously or subcutaneously. There is no need for the client to fast; the client may eat and drink before receiving this medication.

A client and her partner are working together to achieve an unmedicated birth. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. Which action would the nurse instruct the partner to do that will alleviate the client's discomfort during contractions? Correct1 Deep-breathe slowly. 2 Perform pelvic rocking. 3 Use the panting technique. 4 Begin patterned, paced breathing.

Slow, deep breathing expands the spaces between the ribs and raises the abdominal muscles, giving the uterus room to expand and preventing painful pressure of the uterus against the abdominal wall. Pelvic rocking is used to relieve pressure from back labor. Panting is used to halt or delay the expulsion of the infant's head before complete dilation has occurred. Patterned, paced breathing is used during the transition phase of the first stage; the client has not yet reached this phase.

Frequent handwashing by nursing staff prevents mastitis that is caused by which microorganism? 1 Escherichia coli 2 Group B Streptococcus Correct3 Staphylococcus aureus 4 Chlamydia trachomatis

Staphylococcus aureus is a resident organism of the skin and is the causative agent of 95% of infections that result in maternal mastitis. Escherichia coli is found in the lower intestinal tract; it is not associated with mastitis. Group B Streptococcus rarely causes mastitis. Chlamydia trachomatis can cause neonatal pneumonia and conjunctivitis, not mastitis.

While a client is being interviewed at her first prenatal visit, she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would the nurse record this information? Correct1 G5 T1 P1 A2 L2 2 G4 T1 P1 A2 L2 3 G4 T2 P0 A0 L2 4 G5 T2 P1 A1 L2

The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that is over 38 weeks). The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions. Counting the pregnancies in the question gives you G5; that eliminates the G4 choices. The other G5 choice does not correctly assess a preterm pregnancy; the client has had only one term pregnancy, not two.

A client expected to use the Lamaze technique throughout labor but has an emergency cesarean birth. A day later, the woman is found crying and tells the nurse that she is extremely disappointed that a cesarean birth was necessary. She asks the nurse, "Why did this happen to me?" Which would be the response of the nurse? 1 The client's feelings will pass once she has bonded with her newborn. 2 The client is probably suffering from postpartum depression and needs special care. 3 An emergency cesarean birth affects a woman's self-concept and will lead to postpartum blues. Correct4 An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience.

The client's response is appropriate to the situation; she is in the "Why me?" stage of the grieving process as she grieves the loss of her anticipated birth experience. The client's feelings are unrelated to bonding. The client's statement is not indicative of depression. Self-concept is not specifically affected and is not necessarily related to postpartum blues.

A newly pregnant woman is ambivalent about her pregnancy because she had planned to go back to work when her youngest child started school next year. Which developmental task of pregnancy would the woman accomplish in the first trimester? 1 Recognize her ambivalence Correct2 Accept that she is pregnant 3 Prepare for the birth of the baby 4 Recognize the fetus as an individual separate from the mother

The developmental task of the first trimester is accepting the reality of the pregnancy. Ambivalence is a normal emotion associated with early pregnancy, not a developmental task. Preparing for the birth is a developmental task of the third trimester. Recognizing the fetus as a separate individual from the mother is a developmental task of the second trimester.

A client is admitted to the birthing center in active labor. She is 100% effaced, dilated 3 cm, and at +1 station. The client is in which stage of labor? Correct1 First 2 Latent 3 Second 4 Transition

The first stage of labor lasts from its onset until the cervix is fully dilated at 10 cm. There are three phases to the first stage of labor. Latent is the first phase of the first stage of labor. The second stage of labor lasts from complete dilation to birth. Transition is the third phase of the first stage of labor.

Which nursing advice would be provided to a pregnant woman in her first trimester? 1 "Cut down on drugs, alcohol, and cigarettes." Correct2 "Avoid drugs and don't smoke or drink alcohol." 3 "Avoid smoking, limit alcohol consumption, and don't take aspirin." 4 "Take only prescription drugs, especially in the second and third trimesters."

The first trimester is the period when all major embryonic organs are forming; drugs, alcohol, and tobacco may cause major defects. Cutting down on these substances is insufficient; they are teratogens and should be eliminated. Even 1 oz of an alcoholic drink is considered harmful; baby aspirin may be prescribed to some women who are considered at risk for pregnancy-induced hypertension but not during the first trimester. Medications, unless absolutely necessary, should be avoided throughout pregnancy; however, this is most significant in the first trimester.

Which nursing intervention is the highest priority for a pregnant client experiencing dystocia? Correct1 Monitoring fetal heart rate Incorrect2 Providing comfort measures 3 Changing the client's position frequently 4 Keeping client's partner informed about the progress of the labor

The highest priority nursing intervention for a pregnant client with dystocia is monitoring the fetal heart rate, as changes may reflect fetal distress. Comfort measures, changing the client's position, and keeping the client's partner informed are not the highest priorities, as these interventions do not permit the nurse to monitor for fetal distress.

Which action would be the nurse's priority when caring for a client who is 1 hour postpartum and has a boggy uterus that is midline and 1 cm below the umbilicus, as well as profuse lochia and two 4-cm clots? Correct1 Massage the fundus. 2 Notify the health care provider. 3 Place client on bedpan to empty bladder. 4 Administer Methergine 0.2 mg IM, which has been ordered as needed.

The nurse should initially massage the fundus until firm, as a boggy uterus indicates uterine atony (which would be confirmed by profuse lochia and the passage of clots larger than 1 cm). Once fundal massage has been started, the health care provider should be notified. Administering Methergine may also be necessary if the fundus does not become or remain firm with massage. There is no indication the client has a distended bladder, as the fundus is midline and below the umbilicus.

Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? Correct1 Pica 2 Caffeine intake 3 Alcohol abuse 4 Artificial sweetener use

The practice of pica, especially the ingestion of heavy metals, must be considered when pregnant women are found to be anemic. Caffeine, alcohol, and artificial sweeteners are not directly linked to anemia in pregnant women.

Which role is the nurse's priority when a pregnant client's state is deteriorating and the possible clinical decisions to be made could adversely affect the client, the fetus, or both? Correct1 Advocate 2 Collaborator 3 Case manager 4 Care coordinator

The priority role of the nurse is to advocate for both the client and fetus when there is risk, particularly when there is an ethical dilemma regarding care. As an advocate, the nurse would seek out resources, such as the facility's ethicist or the ethics committee, for advice on the ethics of clinical decisions. In the role of collaborator, the nurse would promote relationships within the health care team. The nurse may play the role of case manager for a pregnant client, but it would not be the priority in an emergent situation where there is an ethical dilemma. Coordinating care is an important aspect of the nursing role, but it is not the priority when the health of the client and fetus is in jeopardy.

A client at 32 weeks of gestation is admitted in active labor. Her cervix is 100% effaced and dilated to 4 cm. Intramuscular betamethasone 12 mg is prescribed. Which explanation by the nurse is appropriate about this medication? 1 It increases cervical dilation. Correct2 It accelerates fetal lung maturity. 3 It reduces the risk for a precipitous birth. 4 It minimizes the potential for maternal hypertension.

The steroid betamethasone crosses the placenta and promotes lung maturity in the fetus. Steroids do not increase cervical dilation, reduce the risk for precipitous birth, or minimize the potential for maternal hypertension.

A 10-week-pregnant client comes to the clinic for her second prenatal visit. She asks why she feels the need to urinate so often. Which is the appropriate response of the nurse? 1 It is caused by the descent of the baby's head into the uterus. Correct2 It is influenced by the enlarging uterus, which is still within the pelvis. 3 It is caused by maternal renal filtration of waste products excreted by the growing fetus. 4 It is mostly a psychological phenomenon that results from the knowledge that one is pregnant.

The uterus remains within the pelvis until the second trimester, placing pressure on the bladder. The fetus is in the uterus during the first trimester, but head descent occurs in preparation for delivery in the third trimester; fetal waste products are minimal at this time and do not influence urinary frequency. Frequency is a physiologic, not a psychological, sign of early and late pregnancy.

The nurse is assessing a 41-week primigravida who was admitted in early labor after her membranes ruptured. Her contractions are irregular, and her cervix is dilated 3 cm. The fetal head is at 0 station, and the fetal heart rate tracing is reactive. Which suggestion by the nurse may help the client stimulate labor? 1 Encourage her to watch television. Correct2 Take a walk around the unit with her. 3 Ask her to maintain a left lateral position. 4 Promote the patterned, paced breathing technique.

Walking may increase the frequency and intensity of the contractions. Although watching television may be a relaxing activity, it would not help stimulate labor. At this time, there is no indication that the client should assume the left lateral position. During early labor, slow chest or abdominal breathing helps the client relax; the patterned, paced breathing technique is more appropriate for the transition phase of labor.