Maternity Exam 7

Answer: C Explanation: When the posterior fontanelle is in the upper right quadrant of the maternal pelvis, the fetus is in the right occiput anterior (ROA) position. Choice 1: When the fetus is in left occiput anterior (LOA) position, the posterior fontanelles are in the upper left quadrant of the maternal pelvis. Choice 2: When the fetus is in the left occiput posterior (LOP) position, the posterior fontanelle is in the lower left quadrant of the maternal pelvis. Choice 4: When the fetus is in the right occiput posterior (ROP) position, the posterior fontanelle is in the lower right quadrant of the maternal pelvis

1) During an intrapartum vaginal examination the nurse palpates the following (see image). Based upon this information, which diagram best describes the fetal descent and station?

6) The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? A) Check fetal heart tones. B) Encourage the mother to go for a walk. C) Change bed linens. D) Call the physician.

Answer: A Explanation: A) When the membranes rupture, the nurse notes the color and odor of the amniotic fluid and the time of rupture and immediately auscultates the F H R. B) If there has been a rupture of membranes, the laboring client should not be allowed to walk. C) The bed linens can be changed after assessing the heart rate. D) The physician does not need to be called after rupture of the membranes unless there is a change in the status of the fetus or client.

15) Upon delivery of the newborn, what nursing intervention most promotes parental attachment? A) Placing the newborn under the radiant warmer. B) Placing the newborn on the mother's abdomen. C) Allowing the mother a chance to rest immediately after delivery. D) Taking the newborn to the nursery for the initial assessment.

Answer: B Explanation: A) Removing the baby from the mother does not promote attachment. B) As the baby is placed on the mother's abdomen or chest, she frequently reaches out to touch and stroke her baby. When the newborn is placed in this position, the father or partner also has a very clear, close view and can reach out to touch the baby. C) Removing the baby from the mother does not promote attachment. D) Removing the baby from the mother does not promote attachment.

The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? A) The sterile vaginal exam B) Welcoming the couple C) Auscultation of the fetal heart rate D) Checking for ruptured membranes

Answer: B Explanation: A) The sterile vaginal exam should be performed after maternal vital signs have been assessed. B) It is important to establish rapport and to create an environment in which the family feels free to ask questions. The support and encouragement of the nurse in maintaining a caring environment begins with the initial admission. C) The fetal heart rate should be listened to after the client is made comfortable. D) Assessing for intact or ruptured membranes is a part of the admission assessment after the client is made comfortable.

1) The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? A) Late decelerations B) Early decelerations C) Accelerations D) Fetal dysrhythmia

Answer: C Explanation: A) Late decelerations indicate uteroplacental insufficiency. B) Early decelerations are indicative of head compression. C) A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the F H R. D) Fetal dysrhythmia is associated with complete heart block in the fetus.

1) The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be which of the following? A) Moderate variability B) Early decelerations C) Late decelerations D) Accelerations

Answer: C Explanation: A) Normal F H R variability is in the moderate range. B) Early deceleration is usually considered benign. C) Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign. D) Accelerations are thought to be a sign of fetal well-being.

1) After noting meconium-stained amniotic fluid and fetal heart rate decelerations, the physician diagnoses a depressed fetus. The appropriate nursing action at this time would be to do what? A) Increase the mother's oxygen rate. B) Turn the mother to the left lateral position. C) Prepare the mother for a higher-risk delivery. D) Increase the intravenous infusion rate.

Answer: C Explanation: A) Use of oxygen is not a nursing action that would change the status of the depressed fetus. B) Position change to the left side is not a nursing action that would change the status of the depressed fetus. C) Meconium-stained fluid and heart rate decelerations are indications that delivery is considered higher-risk. D) Increasing the I V rate is not a nursing action that would change the status of the depressed fetus.

6) The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "These questions are asked of all women. It's no big deal." B) "I'd prefer that your partner ask me all the questions, not you." C) "A client's preferences for her birth are important for me to understand." D) "Many women have beliefs about childbearing that affect these choices." E) "I'm gathering information that the nurses will use after the birth."

Answer: C, D Explanation: A) Although this information is asked of all clients, it is purposefully gathered. B) It is not therapeutic communication to tell the partner not to ask questions. C) The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth. D) The nurse incorporates the family's expectations into the plan of care to be culturally appropriate and to facilitate the birth. The information gathered will be used during the labor and birth, not after delivery

1. The midwife performs a vaginal exam and determines that the fetal head is at a -2 station. What does this indicate to the nurse about the birth? A) The birth is imminent. B) The birth is likely to occur in 1-2 hours. C) The birth will occur later in the shift. D) The birth is difficult to predict.

Answer: D Explanation: A) Birth is not imminent at this time. B) Birth will not likely occur in 1-2 hours. C) Birth cannot really be predicted at this time. D) A -2 station means that the fetus is 2 c m above the ischial spines. The ischial spines as a landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. With the fetus's head that high in the pelvis, it is difficult to predict when birth will occur.

1) After several hours of labor, the electronic fetal monitor (E F M) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? A) Breech presentation B) Uteroplacental insufficiency C) Compression of the fetal head D) Umbilical cord compression

Answer: D Explanation: A) Breech presentations by themselves do not cause decelerations. B) Uteroplacental insufficiency causes late decelerations. C) Early decelerations occur with fetal head compression. D) Variable decelerations occur when there is umbilical cord compression.

Answer: C Explanation: C) The greater, or anterior, fontanelle (bregma) is diamond shaped, measures 2 to 3 c m, and is situated at the junction of the sagittal, coronal, and frontal sutures. It permits growth of the brain by remaining unossified for as long as 18 months. Choice 1 is the posterior fontanelle. Choice 2 is the sagittal suture. Choice 4 is the frontal suture.

The nurse is reviewing educational material on newborn care with a patient in the 3rd trimester of pregnancy. Which area on the following diagram should the nurse point out as being the anterior fontanelle? A) A B) B C) C D) D

1) A woman is in labor. The fetus is in vertex position. When the client's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. What should the nurse do immediately? A) Change the client's position in bed. B) Notify the physician that birth is imminent. C) Administer oxygen at 2 liters per minute. D) Begin continuous fetal heart rate monitoring.

Answer: D Explanation: A) Changing the client's position is not indicated. B) Meconium-stained amniotic fluid does not indicate that birth is imminent. C) Oxygen administration is not indicated. D) Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring.

15) Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply? A) "I'm checking the blood vessels in the cord to see whether it has one artery and one vein." B) "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein." C) "I'm checking the blood vessels in the cord to see whether it has two veins and one artery." D) "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins."

Answer: B Explanation: A) A normal umbilical cord does not have one artery and one vein. B) Two arteries and one vein are present in a normal umbilical cord. C) A normal umbilical cord does not have two veins and one artery. D) A normal umbilical cord does not have two arteries and two veins.

15) The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score? A) 7 B) 8 C) 9 D) 10

Answer: B Explanation: A) The Apgar score would be higher; only the skin color needs to be subtracted from the score. B) The strong cry earns 2 points. The crying with foot sole stimulation earns 2 points. The limb flexion and resistance earn 2 points each. Bluish color earns 0 points. The Apgar score is 8. C) The Apgar score would be lower than 9 because of the skin color. D) Ten is a perfect score. The nurse needs to subtract for skin color.

15) Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently? A) A full bladder impedes oxygen flow to the fetus. B) Frequent voiding prevents bruising of the bladder. C) Frequent voiding encourages sphincter control. D) A full bladder can impede fetal descent.

Answer: D Explanation: A) Oxygen flow to the fetus is not impacted by a full bladder. B) Frequent voiding has nothing to do with bruising of the bladder. C) Frequent voiding has nothing to do with sphincter control. D) The woman should be encouraged to void because a full bladder can interfere with fetal descent. If the woman is unable to void, catheterization may be necessary.

15) A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? A) A soaked perineal pad since the last 15-minute check B) An edematous perineum C) The client experiencing tremors D) A fundus located at the umbilicus

answer: A Explanation: A) If the perineal pad becomes soaked in a 15-minute period, or if blood pools under the buttocks, continuous observation is necessary. As long as the woman remains in bed during the first hour, bleeding should not exceed saturation of one pad. B) An edematous perineum is a normal postpartal finding. C) Tremors are a normal postpartal finding. D) A fundus located at the umbilicus is a normal postpartal finding.

Answer: C Explanation: C) Episodic accelerations are not associated with contractions and tend to be more peaked and abrupt. They are often associated with fetal movement, stimulation, or an environmental stimulus. Episodic accelerations are reassuring F H R patterns, whether or not they are accompanied by fetal movement. Early decelerations are a visually apparent, usually symmetrical, gradual decrease and return of the F H R associated with a uterine contraction. Periodic accelerations are associated with uterine contractions. When they occur on a repetitive basis, they may be smooth in configuration, multiphasic, and may precede variable decelerations. In variable decelerations with overshoot, the timing of the decelerations is variable, and most have a sharp decline. Rebound accelerations (overshoot) occur after most of the decelerations.

1) A laboring patient being monitored has the following rhythm strip: How should the nurse interpret this finding? A) Early decelerations B) Periodic accelerations C) Episodic accelerations D) Variable decelerations with overshoot

1. A pregnant patient's fetus is in the left-occiput-transverse position. Which diagram should the nurse use to explain this position to the patient?

Answer: A Explanation: A) Choice 1 is the L O T or left-occiput-transverse position. Choice 2 is the L O P or left-occiput-posterior position. Choice 3 is the R O T or right-occiput-transverse position. Choice 4 is the L O A or left-occiput-anterior position.

1) While caring for a client in labor, the nurse notes the following persistent rhythm on the fetal heart rate monitor: Which action should the nurse take first? A) Notify the provider. B) Prepare for expedient delivery. C) Reposition the client. D) Discontinue oxytocin therapy.

Answer: A Explanation: A) The fetal heart rate monitor demonstrates a persistent sinusoidal pattern. The provider should be notified immediately. B) Expeditious birth of the baby is a priority after the healthcare provider is notified. C) Repositioning the client is not the immediate action that should be taken to address a persistent sinusoidal pattern. D) Discontinuing oxytocin therapy is not the immediate action that should be taken to address a persistent sinusoidal pattern.

1) The nurse is caring for a client undergoing fetal heart rate monitoring, and the F H R is greater than 162 beats/min for 12 minutes. For what cause(s) should the nurse anticipate treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal anxiety B) Fetal asphyxia C) Prematurity D) Fetal anemia E) Maternal hypotension

Answer: A, B, C, D Explanation: A) Maternal anxiety may result in fetal tachycardia. B) Fetal asphyxia may result in fetal tachycardia. C) Prematurity may result in fetal tachycardia. D) Fetal anemia may result in fetal tachycardia. E) Maternal hypotension may result in fetal bradycardia, not fetal tachycardia.

1) The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention? A) Early decelerations with each contraction B) Variable decelerations that recover to the baseline C) Late decelerations with minimal variability D) Accelerations

Answer: C Explanation: A) Early decelerations are usually benign. B) Variable decelerations indicate cord compression, but those that recover to the baseline indicate that the fetus is tolerating the decelerations. C) Late decelerations are considered a nonreassuring fetal heart rate (F H R) pattern, and therefore require immediate intervention. Accelerations of the fetal heart rate indicate good oxygen reserve

1. A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 c m dilated. The nurse knows that the client is in which phase of labor? A) Active B) Latent C) Transition D) Fourth

Answer: C Explanation: A) In the active phase, the woman dilates from 4 to 7 centimeters. B) The latent phase is the beginning of labor contractions and the cervix may be dilated 0 to 3 centimeters. C) The transition phase begins with 8 c m to 10 c m of dilation, and contractions become more frequent, are longer in duration, and increase in intensity. D) There is no fourth phase. The fourth stage occurs after delivery of the placenta.

1. The fetus of a patient in labor is determined to be in the brow presentation. Which diagram should the nurse provide to the patient to explain this position?

Answer: C Explanation: C) In the brow presentation, the fetal head is in partial (halfway) extension. The occipitomental diameter, which is the largest diameter of the fetal head, presents to the pelvis. Choice 1 is the vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis. Choice 2 is the Sinciput (median vertex) prese ntation (also called military presentation) with no flexion or extension. The occipitofrontal diameter presents to the pelvis. Choice 4 is the face presentation. The fetal head is in complete extension, and the submentobregmatic diameter presents to the pelvis.

Answer: D Explanation: D) The head has completed internal rotation. The cervix is fully dilated. In Choice 1, the fetus is at station 0 with the head engaged at the spine and a significant amount of cervix that has not yet dilated. In Choice 2, the fetus is engaged at station +2 as the cervix is thinner and more of the fetal head can be palpated. In Choice 3. the fetus is engaged at station +4 with the posterior fontanelle towards the maternal left pelvis.

1) The fetus of a laboring patient is in the following position: What should the nurse expect when conducting the intrapartum vaginal examination?

Answer: C Explanation: C) The heart tones for the right occiput anterior position would be in the maternal lower right quadrant next to the symphysis pubis. Choice 1 is the location to auscultate sounds if the fetus is in the left occiput posterior position. Choice 2 is the location to auscultate sounds if the fetus is in the left occiput anterior position. Choice 4 is the location to auscultate sounds if the fetus is in the right occiput posterior position.

1) The fetus of a pregnant patient is in the right occiput anterior (R O A) position. Where should the nurse auscultate the fetal heart sounds? A) A B) B C) C D) D

Answer: B Explanation: B) If the placenta separates from the outer margins inward, it will roll up and present sideways with the maternal surface delivering first. This is known as the Duncan mechanism of placental delivery and is commonly called dirty Duncan because the placental surface is rough. If the placenta separates from the inside to the outer margins, it is expelled with the fetal (shiny) side presenting. This is known as the Schultze mechanism of placental delivery or, more commonly, shiny Schultze. This diagram does not demonstrate complete or incomplete mechanisms of placental delivery.

1. The nurse is assisting in the delivery of a pregnant patient's placenta post-delivery. The placenta appears as follows. What term should the nurse use to document this placental delivery? A) Schultz mechanism of delivery B) Duncan mechanism of delivery C) Complete mechanism of delivery D) Incomplete mechanism of delivery

6) The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching? A) "The fetus's heart rate will vary between 110 and 160." B) "The heart rate is monitored to see whether the fetus is tolerating labor." C) "By listening to the heart, we can tell the gender of the fetus." D) "After listening to the heart rate, you will contact the midwife."

A) Answer: C Explanation: A) A normal fetal heart rate is 110-160. B) The fetal heart rate (F H R) is auscultated every 30 minutes. It should remain between 110 and 160 beats per minute (beats/m i n) without the presence of decelerations. C) Fetal heart rate is not a predictor of gender. D) Once the admission is complete, the nurse will contact the client's provider with the assessment findings.

1) The nurse auscultates the F H R and determines a rate of 112 beats/min. Which action is appropriate? A) Inform the maternal client that the rate is normal. B) Reassess the F H R in 5 minutes because the rate is low. C) Report the F H R to the doctor immediately. D) Turn the maternal client on her side and administer oxygen.

Answer: A Explanation: A) A fetal heart rate of 112 beats/min. falls within the normal range of 110-160 beats/min., so there is no need to inform the doctor. B) There is no need to reassess later. C) There is no need to inform the doctor. There is no need to reposition the client

1. How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? A) Breech, transverse B) Breech, longitudinal C) Breech, frank D) Vertex, transverse

Answer: A Explanation: A) A shoulder presentation is one type of breech presentation, and is also called a transverse lie. B) A shoulder presentation is not a longitudinal lie. C) In a frank breech, the buttocks are the presenting part. D) A shoulder presentation is not vertex.

1. A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilation 6 c m; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? A) Cervical dilation 6 c m B) Mild contraction intensity C) Contraction frequency every 5 minutes D) Contraction duration 30-40 seconds

Answer: A Explanation: A) Cervical dilation of 6 c m indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 c m and contractions and pain intensify. B) Mild contractions are consistent with most of the scenario. C) This contraction frequency is consistent with most of the scenario. D) This contraction duration is consistent with most of the scenario.

1) The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? A) Woman at 7 c m, fetal heart tones auscultated every 90 minutes B) Woman at 10 c m and pushing, external fetal monitor applied C) Woman with meconium-stained fluid, internal fetal scalp electrode in use D) Woman in preterm labor, external monitor in place

Answer: A Explanation: A) During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough. B) External monitoring can be done instead of auscultation of the fetal heart tones during labor. C) Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. D) External monitoring during preterm labor will assess both contractions and fetal status.

1) The nurse is caring for a client with fetal heart rate monitoring, and the fetus is discovered to have tachycardia. Which complication should the nurse anticipate in the fetus? A) Infection B) Umbilical cord compression C) Vagus nerve stimulation D) Hypoxemia

Answer: A Explanation: A) Infection is one of the most common causes of fetal tachycardia. B) Umbilical cord compression may result in bradycardia, not tachycardia. C) Vagus nerve stimulation may result in bradycardia, not tachycardia. D) Hypoxemia may result in bradycardia, not tachycardia.

28) The nurse has completed an initial physical assessment for a client admitted to the birthing unit. Which action should the nurse take next? A) Obtain the client's social history B) Document the physical assessment findings C) Report findings to the physician D) Perform interventions for pain management

Answer: A Explanation: A) Once initial physical assessments are performed, the nurse can then take a detailed social history that provides a comprehensive view of both the woman's social habits and psychologic factors that may affect her birth experience. B) Documenting the physical assessment findings may be performed after the initial physical assessment is performed and social history is obtained. C) It may not be necessary to report findings to the physician in the absence of other complicating factors. D) Interventions for pain management may not be needed at this time. Additionally, effective pain management may depend on the client's social history.

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done? A) To contract the uterus and minimize bleeding B) To decrease breast milk production C) To decrease maternal blood pressure To increase maternal blood pressure

Answer: A Explanation: A) Oxytocin is given to contract the uterus and minimize bleeding. B) Oxytocin does not have an effect on breast milk production. C) Oxytocin does not have an effect on maternal blood pressure. D) Oxytocin does not have an effect on maternal blood pressure.

1) The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first? A) Perform Leopold maneuvers to determine fetal position. B) Count the fetal heart rate between, during, and for 30 seconds following a uterine contraction (U C). C) Dry the maternal abdomen before using the Doppler. D) The diaphragm should be cooled before using the Doppler.

Answer: A Explanation: A) Performing Leopold maneuvers is the first step. B) This is how to auscultate the fetal heart rate, but it is not the first step in assessment. C) Prior to using the Doppler device, a water-based gel is applied to the skin. D) The diaphragm should be warmed before using the Doppler.

1) The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? A) Document the fetal heart rate. B) Apply oxygen via mask at 10 liters. C) Prepare for imminent delivery. D) Assist the client into Fowler's position.

Answer: A Explanation: A) The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. B) No oxygen is necessary. C) There is no indication that delivery will be occurring soon. D) There is no need to put the client in Fowler's position.

1. To identify the duration of a contraction, the nurse would do which of the following? A) Start timing from the beginning of one contraction to the completion of the same contraction. B) Time between the beginning of one contraction and the beginning of the next contraction. C) Palpate for the strength of the contraction at its peak. D) Time from the beginning of the contraction to the peak of the same contraction.

Answer: A Explanation: A) The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction. B) Duration is not measured this way. C) Duration is not measured this way. D) Duration is not measured this way.

1) The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? A) Assist the client to change position. B) Apply oxygen to the client at 2 liters per nasal cannula. C) Notify the operating room of the need for a cesarean birth. D) Determine the color of the leaking amniotic fluid.

Answer: A Explanation: A) The fetus is exhibiting variable decelerations, which are caused by cord compression. Sometimes late or variable decelerations are due to the supine position of the laboring woman. In this case, the decrease in uterine blood flow to the fetus may be alleviated by raising the woman's upper trunk or turning her to the side to displace pressure of the gravid uterus on the inferior vena cava. B) A nasal cannula is rarely used in labor and birth. C) There is no indication that a cesarean delivery is needed. D) There is no indication that the amniotic fluid is meconium-stained or bloody.

1) The nurse is assessing the baseline fetal heart rate for a client in labor. What action should the nurse take first? A) Measure the fetal heart rate for 10 minutes B) Round the heart rate to increments of 5 beats/minute C) Exclude periods of marked variation D) Calculate the mean (average) heart rate

Answer: A Explanation: A) The first action the nurse should take is measuring the fetal heart rate for 10 minutes. B) The nurse should round the fetal heart rate to increments of 5 beats/minute after taking a 10-minute measurement of the fetal heart rate. C) The nurse should exclude periods of marked variation after taking a 10-minute measurement of the fetal heart rate. D) The nurse should calculate the mean (average) heart rate after taking a 10-minute measurement of the fetal heart rate.

1) The nurse is reviewing the F H R monitor for a client in labor. The rhythm strip yields the following result: How should the nurse interpret this pattern? A) Moderate variability B) Minimal variability C) Absent variability D) Marked variability

Answer: A Explanation: A) The pattern demonstrates Moderate F H R variability (normal) with an amplitude range of 6 to 25 beats/minute. B) Minimal variability refers to a F H R with an amplitude range detectable but 5 beats/minute or less. C) Absent variability refers to a pattern with no detectable amplitude range. D) Marked variability refers to a pattern with an amplitude range greater than 25 beats/minute.

15) The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? A) Hyperventilation B) Seizure auras C) Imminent birth D) Anxiety

Answer: A Explanation: A) These symptoms all are consistent with hyperventilation. B) Seizure auras do not have these symptoms. C) Imminent birth does not have these symptoms. Anxiety does not have these symptoms

1) While caring for a client in labor, the nurse notes the following F H R pattern: Which action should the nurse perform? A) Continue to monitor the client B) Fetal scalp stimulation C) Palpate contraction strength D) Discontinue oxytocin

Answer: A Explanation: A) This is a benign finding; there is no slowing of fetal heart rate with contractions. B) Fetal scalp stimulation is not indicated based on this finding. C) Contraction strength assessment is not indicated based on this finding. D) Discontinuing oxytocin should not be performed based on this finding.

6) By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? A) Recognizing the client as an active participant in her own care. B) Attempting to correct any misinformation the client might have received. C) Acting as an advocate for the client. D) Establishing rapport with the client.

Answer: A Explanation: A) Understanding the couple's expectations and plans helps the nurse provide optimal nursing care and facilitate the best possible birth experience. B) Any misinformation the family has can be corrected, but that is not the primary focus. C) The nurse might use the information about plans and expectations to act as an advocate for the client as the labor progresses, but this is not the primary rationale for inquiring about them. D) Rapport and a therapeutic relationship are important for all nurse-client interactions, but are not best addressed by asking about plans and expectations for the birth.

15) Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? A) Massage the fundus until firm B) Express retained clots C) Increase the intravenous solution D) Call the physician

Answer: A Explanation: A) When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm. B) Expressing retained clots is not the nurse's first action. C) Increasing the intravenous solution is not a priority in this case. D) The physician does not need to be notified unless either the uterus does not respond to massage or the bleeding does not decrease.

1. The client has asked the nurse why her cervix has only changed from 1 to 2 c m in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client? A) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." B) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."

Answer: A Explanation: A) With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls. B) As the fetal head descends to the pelvic floor, the pressure of the presenting part causes the perineal structure, which was once 5 c m in thickness, to change to a structure less than 1 c m thick. The perineal body's thinning primarily occurs during later stages of labor; it is not expected now. C) This reply is not therapeutic. The nurse must always be therapeutic in all communication. D) The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.

1) The nurse is caring for a client who has experienced premature rupture of membranes. For which maternal implication(s) should the nurse monitor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Infection B) Preterm labor C) Dyspnea D) Discomfort E) E) Uterine distention

Answer: A, B Explanation: A) Premature rupture of membranes places the client at an increased risk for infection. B) Premature rupture of membranes places the client at an increased risk for preterm labor. C) Hydramnios, not premature rupture of membranes, increases dyspnea. D) Hydramnios, not premature rupture of membranes, increases discomfort. E) Multiple gestation, not premature rupture of membranes, increases uterine distention.

1) The nurse is assessing the comfort of the parents during the third stage of labor. Which finding(s) indicate that the parents feel comfortable during this stage? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Talking to the newborn B) Verbally expressing feelings of pride C) Requesting to dim the lights D) Preferring limited contact with the newborn initially E) Immediately placing phone calls

Answer: A, B Explanation: A) Talking to the newborn and verbally expressing feelings of pride are indications that the parents feel comfortable in the environment. B) Talking to the newborn and verbally expressing feelings of pride are indications that the parents feel comfortable in the environment. C) Requesting to dim the lights does not necessarily indicate whether or not the parents feel comfortable in the environment. D) The parents may prefer to limit contact with the newborn initially, and it is important for the nurse to support the wishes of the parent. However, this does not necessarily indicate whether or not the parents feel comfortable in the environment. E) Immediately placing phone calls after the newborn is delivered does not necessarily indicate whether or not the parents feel comfortable in the environment.

1. The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Maternal exhaustion B) Cervical edema C) Tearing and bruising of the cervix D) Enhanced perineal thinning E) Having to perform an episiotomy

Answer: A, B, C Explanation: A) If the cervix is not completely dilated, maternal exhaustion can occur. B) If the cervix is not completely dilated, cervical edema can occur. C) If the cervix is not completely dilated, tearing and bruising of the cervix can occur. D) Cervical dilation has nothing to do with perineal thinning. E) Not bearing down until the cervix is completely dilated has nothing to do with needing an episiotomy.

15) The nurse is reviewing the contents of the birthing unit's emergency pack for use in case of a precipitous birth. Which item(s) should the nurse ensure is (are) included in the pack? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Sterile drape B) Bulb syringe C) Two sterile clamps D) Sterile gloves E) Forceps

Answer: A, B, C, D Explanation: A) A small drape is included that can be placed under the woman's buttocks to provide a sterile field. B) A bulb syringe is needed to clear mucus from the newborn's mouth. C) Two sterile clamps (Kelly or Rochester) are needed to clamp the umbilical cord before applying a cord clamp. D) Sterile gloves are a basic element of a typical birthing unit emergency pack. E) Forceps are not required during a precipitous birth.

1. Childbirth preparation offers several advantages including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) It helps a pregnant woman and her support person understand the choices in the birth setting. B) It promotes awareness of available options. C) It provides tools for a pregnant woman and her support person to use during labor and birth. D) Women who receive continuous support during labor require more analgesia, and have more cesarean and instrument births. E) Each method has been shown to shorten labor.

Answer: A, B, C, E Explanation: A) Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. B) Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. C) Childbirth preparation offers several advantages. It helps a pregnant woman and her support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. D) This is not true. Women who receive continuous support during labor require less analgesia, and have fewer cesarean and instrument births. Childbirth preparation offers several advantages. Each method has been shown to shorten labor

1) Upon assessing the F H R tracing, the nurse determines that there is fetal tachycardia. The fetal tachycardia would be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Early fetal hypoxia B) Prolonged fetal stimulation C) Fetal anemia D) Fetal sleep cycle E) Infection

Answer: A, B, C, E Explanation: A) Early fetal hypoxia can cause fetal tachycardia. B) Prolonged fetal stimulation can cause fetal tachycardia. C) Fetal anemia can cause fetal tachycardia. D) The fetal sleep cycle does not cause fetal tachycardia. E) Infection can cause fetal tachycardia.

1. Premonitory signs of labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Braxton Hicks contractions B) Cervical softening and effacement C) Weight gain D) Rupture of membranes E) Sudden loss of energy

Answer: A, B, D Explanation: A) A premonitory sign of labor includes Braxton Hicks contractions. B) A premonitory sign of labor includes cervical softening and effacement. C) A premonitory sign of labor includes weight loss, not weight gain. D) A premonitory sign of labor includes rupture of membranes. E) A premonitory sign of labor includes a sudden burst of energy, not a loss of energy.

6) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Fetal heart rate of 130 with average variability B) Blood pressure of 130/80 C) Maternal pulse of 160 D) Protein of +1 in urine E) Odorless, clear fluid on underwear

Answer: A, B, E Explanation: A) Fetal heart rate (F H R) of 110-160 with average variability is a normal indication. B) Maternal vital sign of blood pressure below 140/90 is a normal indication. C) A pulse of 60-100 is a normal indication. D) Proteinuria of +1 or more could be a sign of preeclampsia. E) Fluid clear and without odor if membranes ruptured is a normal indication.

1) Fetal factors that possibly indicate electronic fetal monitoring include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Meconium passage B) Multiple gestation C) Preeclampsia D) Grand multiparity E) Decreased fetal movement

Answer: A, B, E Explanation: A) Meconium passage is an indicator for electronic fetal monitoring. B) Multiple gestation is an indicator for electronic fetal monitoring. C) Preeclampsia is a maternal indicator for electronic fetal monitoring. D) Grand multiparity is a maternal indicator for electronic fetal monitoring. E) Decreased fetal movement is an indicator for electronic fetal monitoring.

1) Before performing Leopold maneuvers, what would the nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Have the client empty her bladder. B) Place the client in Trendelenburg position. C) Have the client lie on her back with her feet on the bed and knees bent. D) Turn the client to her left side. E) This is not the optimal position for the client when performing Leopold maneuvers.

Answer: A, C Explanation: A) The woman should have recently emptied her bladder before performing Leopold maneuvers. B) Placing the client in Trendelenburg position is not consistent with accurately performing Leopold maneuvers. C) The woman should lie on her back with her abdomen uncovered. To aid in relaxation of the abdominal wall, the shoulders should be raised slightly on a pillow and the knees drawn up a little. D) Placing the client on her left side is not consistent with accurately performing Leopold maneuvers.

1) The nurse is caring for a client and her spouse during the third stage of labor. Which action(s) support initial parental-newborn attachment at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Minimizing assessments B) Delaying ophthalmic antibiotics for 2 hours C) Dimming the room lights D) Talking quietly E) Providing privacy

Answer: A, C, D, E Explanation: A) Minimizing assessments enhances parental newborn attachment during this time. B) Ophthalmic antibiotics may be delayed during the first hour, but not up to 2 hours. C) Dimming the room lights enhances parental-newborn attachment during this time. D) Talking quietly enhances parental-newborn attachment during this time. E) Providing privacy enhances parental-newborn attachment during this time.

1. A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Android B) Anthropoid C) Gynecoid D) Platypelloid E) Lambdoidal suture

Answer: A, D Explanation: A) In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. B) The anthropoid pelvis type is considered favorable for vaginal childbirth. C) The gynecoid pelvis type is considered favorable for vaginal childbirth. D) In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely. E) This is not a pelvis type.

1. The nurse is teaching a prenatal class about false labor. The nurse should teach clients that false labor will most likely include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) Contractions are at regular intervals

Answer: A, D Explanation: A) True labor contractions intensify while walking. B) True labor results in increased intensity and frequency of contractions. C) True labor results in progressive dilation. D) The discomfort of true labor contractions usually starts in the back and radiates around to the abdomen. E) With false labor, contractions are irregular.

1. A client who is having false labor most likely would have which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) contractions lessen with rest and warm tub baths.

Answer: A, D, E Explanation: A) True labor contractions intensify while walking. B) The contractions of true labor produce progressive dilation and effacement of the cervix. They occur regularly and increase in frequency, duration, and intensity. C) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. D) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. E) In true labor, contractions do not lessen with rest and warm tub baths.

1. The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? A) Client at 5 c m requesting labor epidural analgesia B) Client whose cervix remains at 6 c m for 4 hours C) Client who has developed nausea and vomiting D) Client requesting her partner to stay with her

Answer: B Explanation: A) Contacting the supervisor is required when an abnormal situation is present. Requests for medication are not abnormal. B) Average cervical change in the active phase of the first stage of labor is 1.2 c m/hour; thus, this client's lack of cervical change is unexpected, and should be reported to the supervisor. C) Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation is present. Clients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present

1. A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? A) Active B) Transition C) Latent D) Second

Answer: B Explanation: A) During the active phase, the cervix dilates from about 4 to 7 c m. When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. B) During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety. C) The latent phase is characterized by mild contractions lasting 20 to 40 seconds with a frequency of 3 to 30 minutes. In the latent stage, the woman may be relieved that labor has finally started. D) The second stage is the pushing stage, and the woman might feel relieved that the birth is near and she can push. There is no second phase of labor.

1. A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? A) Engagement B) Lightening C) Molding D) Braxton Hicks contractions

Answer: B Explanation: A) Engagement of the presenting part occurs when the largest diameter of the fetal presenting part reaches or passes through the pelvic inlet. B) Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet. C) The fetal cranial bones overlap under pressure of the powers of labor and the demands of the unyielding pelvis. This overlapping is called molding. D) Braxton Hicks contractions occur before the onset of labor.

1. Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? A) Place the client in McRoberts position. B) Watch for the emergence of the placenta. C) Prepare for the delivery of an undiagnosed twin. D) Place the client in a supine position.

Answer: B Explanation: A) Exercises aimed at adducting the legs into an extended McRoberts position, which is performed by flexing the mother's thighs toward her shoulders while she is lying on her back, help enable the woman to stretch her hamstring muscles, a task usually required during the second stage of labor. B) Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina. C) The first placenta usually does not deliver before the birth of the second twin. D) Blood pressure may drop precipitously when the pregnant woman lies in a supine position and experiences aortocaval compression.

1. Which client requires immediate intervention by the labor and delivery nurse? A) Client at 8 c m, systolic blood pressure has increased 35 m m H g B) Client who delivered 1 hour ago with W B C of 50,000/m m3 C) Client at 5 c m with a respiratory rate of 22 between contractions D) Client in active labor with polyuria

Answer: B Explanation: A) In the first stage, systolic pressure may increase by 35 m m H g, and there may be further increases in the second stage during pushing efforts. B) The white blood cell (W B C) count increases to between 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification. C) Oxygen demand and consumption increase at the onset of labor because of the presence of uterine contractions. This client requires no further intervention. D) Polyuria is common during labor. This results from the increase in cardiac output, which causes an increase in the glomerular filtration rate and renal plasma flow, and requires no further intervention.

1. The client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? A) "Unless you have pain with urination, we don't need to worry about it." B) "These symptoms usually mean the baby's head has descended further." C) "Come in for an appointment today and we'll check everything out." D) "This might indicate that the baby is no longer in a head-down position."

Answer: B Explanation: A) Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection. B) This is the best response because it most directly addresses what the client has reported. C) There is no need for an additional appointment. D) The fetus's changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis.

6) The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 c m and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? A) Encourage the husband to remain in the room. B) Keep the client on bed rest at this time. C) Apply an internal fetal scalp electrode. D) Obtain a clean-catch urine specimen.

Answer: B Explanation: A) It is unknown from the given information whether it is culturally appropriate for the client's husband to remain in the room for the labor and birth. B) Because the membranes are ruptured and the head is high in the pelvis at a -2 station, the client should be maintained on bed rest to prevent cord prolapse. C) An internal fetal scalp electrode is placed when there are signs of fetal intolerance of labor. This client has normal fetal heart tones and clear amniotic fluid; no signs of fetal intolerance of labor are present. D) A clean-catch urine specimen is usually obtained upon admission, but amniotic fluid contamination might falsely increase the reading of protein present.

1) The laboring client is at 7 c m, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? A) Fear/Anxiety related to discomfort of labor and unknown labor outcome B) Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent C) Coping: Family, Compromised, related to labor process D) Knowledge, Deficient, related to lack of information about normal labor process and comfort measures

Answer: B Explanation: A) The client is not exhibiting fear or anxiety, but acute pain; therefore, this diagnosis does not fit. B) The client is exhibiting signs of acute pain, which is both common and expected in the transitional phase of labor. C) There is no evidence regarding the family's coping, only the client's coping with the pain. The client used breathing and relaxation techniques earlier in labor, demonstrating knowledge of these techniques

1) The nurse is admitting a client to the birthing unit. What question should the nurse ask to gain a better understanding of the client's psychosocial status? A) "How did you decide to have your baby at this hospital?" B) "Who will be your labor support person?" C) "Have you chosen names for your baby yet?" D) "What feeding method will you use for your baby?"

Answer: B Explanation: A) The reason the client is delivering at this facility is not an indication of psychosocial status. B) The expectant mother's partner or support person is an important member of the birthing team, and assessments of the couple's coping, interactions, and teamwork are integral to the nurse's knowledge base. The nurse's physical presence with the laboring woman provides the best opportunity for ongoing assessment. C) Naming the infant is influenced by culture, and is not an indicator of psychosocial status. The chosen feeding method is not an indicator of psychosocial status

1. A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 c m, 100% effaced, and -2 station. What best describes this labor? A) Second phase B) Latent phase C) Active phase D) Transition phase

Answer: B Explanation: A) There is no phase of labor that is identified as the second phase. B) In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions. C) When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. During this phase the cervix dilates from about 4 to 7 c m. D) When the woman enters the transition phase, she may demonstrate significant anxiety. She becomes acutely aware of the increasing force and intensity of the contractions. She may become restless, frequently changing position.

1) A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching? A) "The most important part of fetal heart monitoring is the absence of variable decelerations." B) "The most important part of fetal heart monitoring is the presence of variability." C) "The most important part of fetal heart monitoring is the fetal heart rate baseline." D) "The most important part of fetal heart monitoring is the depth of decelerations."

Answer: B Explanation: A) Variable decelerations indicate cord compression. B) Baseline variability is a reliable indicator of fetal cardiac and neurologic function, and overall well-being. The opposing "push-pull" balancing between the sympathetic nervous system and the parasympathetic nervous system directly affects the F H R. C) The fetal heart rate baseline does not indicate central nervous system function. D) The depth of decelerations does not indicate central nervous system function.

1) The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? A) "I stimulated the top of the fetus's head to wake him up a little." B) "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." C) "I stimulated the top of the fetus's head to calm the fetus down before birth." D) "I stimulated the top of the fetus's head to find out whether he is in distress."

Answer: B Explanation: A) Waking the fetus is not the goal or outcome of fetal scalp stimulation. B) Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being. C) Calming the fetus is not the goal or outcome of fetal scalp stimulation. D) The nurse wants to assess what the fetus does with stimulation.

1) The nurse is performing Leopold maneuvers with a patient in the 3rd trimester of pregnancy. Which maneuver should the nurse perform first?

Answer: B Explanation: B) For the first maneuver, while facing the woman, the nurse palpates the upper abdomen with both hands. Choice 1 is the second maneuver, where the nurse tries to determine the location of the fetal back and notes whether it is on the right or left side of the maternal abdomen. Choice 3 is the third maneuver, where the nurse determines what fetal part is lying above the inlet by gently grasping the lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the right hand. Choice 4 is the fourth maneuver, where the nurse faces the woman's feet and attempts to locate the cephalic prominence or brow. Location of this landmark assists in assessing the descent of the presenting part into the pelvis. The fingers of both hands are moved gently down the sides of the uterus toward the pubis.

1) The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? A) Blood pressure 120/88 B) Father a carrier of sickle-cell trait C) Dark red vaginal bleeding D) History of domestic abuse

Answer: C Explanation: A) Although the diastolic reading is slightly elevated, this blood pressure reading is not the top priority. B) The infant also might have sickle-cell trait, but it is not life-threatening at this time. C) Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus. D) This client is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the client.

1. The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? A) True labor contractions begin in the back and sweep toward the front. B) False labor often feels like abdominal tightening, or "balling up." C) True labor can be diagnosed only if cervical change occurs. D) False labor contractions do not increase in intensity or duration.

Answer: C Explanation: A) Although this is a true statement, it is not the most important indication of true labor. B) Although this is a true statement, it is not the most important fact about false and true labor. C) Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilation. D) Although this is a true statement, it is not the most important fact about true and false labor.

1) The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? A) The client is assisted into supine position, and the position of the fetus is assessed. B) The upper portion of the uterus is palpated, then the middle section. C) After determining where the back is located, the cervix is assessed. D) Following voiding, the client's abdomen is palpated from top to bottom.

Answer: C Explanation: A) Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation. B) This is the correct order of the first and second Leopold maneuvers. C) The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers. D) The client is instructed to void prior to beginning Leopold maneuvers to enhance comfort. Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix.

1) Persistent early decelerations are noted. What would the nurse's first action be? A) Turn the mother on her left side and give oxygen. B) Check for prolapsed cord. C) Do nothing. This is a benign pattern. D) Prepare for immediate forceps or cesarean delivery.

Answer: C Explanation: A) Early decelerations do not require any intervention. B) Early decelerations do not indicate a prolapsed cord. C) Early decelerations are considered benign, and do not require any intervention. D) Early decelerations do not warrant an immediate delivery.

1. The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? A) Increased pulse B) Elevated blood pressure C) Muscle tension D) Increased respirations

Answer: C Explanation: A) Increased pulse is a manifestation of pain, but does not impede labor. B) Elevated blood pressure is a manifestation of pain, but does not impede labor. C) It is important for the woman to relax each part of her body. Be alert for signs of muscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process. D) Increased respiration is a manifestation of pain, but does not impede labor.

6) An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be which of the following? A) Insist that he leave the room for at least the next hour. B) Tell him he is not being as effective as he was, and that he needs to let someone else take over. C) Offer to remain with his partner while he takes a break. D) Suggest that the client's mother might be of more help.

Answer: C Explanation: A) Insisting that the father leave does not reassure him about the care the woman will receive in his absence. B) Telling him that he is ineffective does not reassure him about the care the woman will receive in his absence. C) Support persons frequently are reluctant to leave the laboring woman to take care of their own needs. The laboring woman often fears being alone during labor. Even though there is a support person available, the woman's anxiety may be decreased when the nurse remains with her while he takes a break. D) Suggesting that the client's mother take his place does not reassure him about the care the woman will receive in his absence.

15) A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action? A) Determine who might be the father of the baby for paternity testing. B) Ask the client what kind of birthing experience she would like to have. C) Assess blood pressure and check for proteinuria. D) Obtain a Social Services referral to discuss adoption.

Answer: C Explanation: A) Paternity testing is a lower priority than the physiologic well-being of the client and fetus. B) A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences. C) Preeclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority. D) It would be inappropriate to discuss adoption or parenting during labor, especially with an adolescent who did not know she was pregnant prior to the onset of labor. The nurse should wait until after the birth to have this discussion.

1. The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? A) Right-acromion-dorsal-anterior B) Right-sacrum-transverse C) Occiput anterior D) Posterior position

Answer: C Explanation: A) Right-acromion-dorsal-anterior denotes a fetal position in a shoulder presentation, which would be a difficult delivery. B) Right-sacrum-transverse indicates a breech delivery, which would be a difficult delivery. C) The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally. D) The fetal head presents a larger diameter in a posterior position than in an anterior position. A posterior position increases the pressure on the maternal sacral nerves, causing the laboring woman to experience backache and pelvic pressure.

15) A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful? A) Talk to the client the entire time. B) Turn on the television to distract the client. C) Stand next to the bed with hands on the railing next to the client. D) Sit silently in the room away from the bed.

Answer: C Explanation: A) Talking might irritate the client. B) Turning on the television might irritate the client. C) Standing next to the bed is supportive without being irritating. The laboring woman fears being alone during labor. The woman's anxiety may be decreased when the nurse remains with her. D) Sitting silently away from the client can lead to her feeling abandoned.

15) At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score? A) 7 B) 8 C) 9 D) 10

Answer: C Explanation: A) The Apgar score would be higher than 7. B) The Apgar score would be higher than 8. C) Two points each are scored in each of the categories of heart rate, respiratory effort, muscle tone, and reflex irritability. One point is scored in the category of skin color. The total Apgar would be 9. D) The infant has cyanotic limbs, so the Apgar score cannot be perfect.

1) The nurse has just palpated contractions and compares the consistency to that of the forehead in order to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? A) Mild B) Moderate C) Strong D) Weak

Answer: C Explanation: A) The consistency of mild contractions is similar to that of the nose. B) The consistency of moderate contractions is similar to that of the chin. C) The consistency of strong contractions is similar to that of the forehead. D) Weak contractions are not identified.

1) The laboring client with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? A) "The monitor is necessary so we can see how your labor is progressing." B) "The monitor will prevent complications from the meconium in your fluid." C) "The monitor helps us to see how the baby is tolerating labor." D) "The monitor can be removed, and oxygen given instead."

Answer: C Explanation: A) The fetal monitor does not help visualize labor progress. B) The fetal monitor does not prevent complications such as meconium aspiration syndrome. C) Electronic fetal monitoring (E F M) provides a continuous tracing of the fetal heart rate (F H R), allowing characteristics of the F H R to be observed and evaluated. D) Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate.

28) A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do? A) Go to the nurse's station and immediately call the physician. B) Run to the delivery room for an emergency birth pack. C) Stay with the client and ask auxiliary personnel for assistance. D) Hold back the infant's head forcibly until the physician arrives for the delivery.

Answer: C Explanation: A) The nurse can direct auxiliary personnel to contact the physician. B) The nurse can direct auxiliary personnel to retrieve the emergency birth pack. C) If birth is imminent, the nurse must not leave the client alone. D) With one hand, the nurse should apply gentle pressure against the fetal head to maintain flexion and prevent it from popping out rapidly. The nurse does not hold the head back forcibly.

1. The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? A) "In normal labor, as the uterine contractions become stronger, they usually also become less frequent." B) "In normal labor, as the uterine contractions become stronger, they usually also become less painful." C) "In normal labor, as the uterine contractions become stronger, they usually also become longer in duration." D) "In normal labor, as the uterine contractions become stronger, they usually also become shorter in duration."

Answer: C Explanation: A) The uterine contractions of labor become more frequent as labor progresses. B) The uterine contractions of labor become more painful over time. C) During the active and transition phases, contractions become more frequent, are longer in duration, and increase in intensity. D) The uterine contractions of labor do not become shorter in duration as labor progresses.

1. The client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? A) "You shouldn't work so much at this point in pregnancy." B) "What you are describing is not commonly experienced in the last weeks." C) "Your body may be telling you it is going into labor soon." D) "If the bladder pressure continues, come in to the clinic tomorrow."

Answer: C Explanation: A) There is no indication that the client should decrease her work schedule. B) Lightening is a common and expected finding. C) One of the premonitory signs of labor is lightening: The fetus begins to settle into the pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing. D) Lightening does not indicate pathology, and therefore there is no need for the client to come to the clinic if the symptoms continue.

1) A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 c m dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? A) Latent phase B) Active phase C) Transition phase D) Fourth stage

Answer: C Explanation: A) This is not the latent phase; in the latent phase of labor, contractions are every 10-20 minutes, 15-20 seconds' duration progressing to every 5-7 minutes, and 30-40 seconds' duration. Dilatation is 1-3 c m. B) This is not the active phase; in the active phase of labor, contractions are every 2-3 minutes with a dilatation of 4-7 c m. C) The transition phase begins with 8 c m of dilatation, and is characterized by contractions that are closer and more intense. D) The fourth stage occurs after delivery of the placenta.

1. The cervix of a laboring patient is measured as being 50% effaced. Which diagram should the nurse use to explain this finding to the patient?

Answer: C Explanation: C) The cervix is about one half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on the cervix. Choice 1 is the beginning of labor, where there is no cervical effacement or dilation. The fetal head is cushioned by amniotic fluid. Choice 2 is the beginning of cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. Choice 4 is complete effacement and dilation.

1. The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Woman at 7 c m, fetus in general flexion B) Woman at 3 c m, fetus in longitudinal lie C) Woman at 4 c m, fetus with transverse lie D) Woman at 6 c m, fetus at -2 station, mild contractions E) Woman at 5 c m, fetal presenting part is right shoulder

Answer: C, D, E Explanation: A) Fetal attitude refers to the relation of the fetal body parts to one another and describes the posture the fetus assumes as it conforms to the shape of the uterine cavity. The normal attitude of the fetus is termed general flexion, where the head is flexed so that the chin is on the chest with the arms crossed over the chest, and the legs are flexed at the knees with the thighs on the abdomen. B) Fetal lie refers to the relationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, or cephalocaudal, axis of the mother. The fetus may assume either a longitudinal (vertical) or a transverse (horizontal) lie; a longitudinal lie is normal. C) A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. D) Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. E) When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part.

28) An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Skin color: Body blue with pinkish extremities B) Umbilical cord: two veins and one artery C) Respiration rate of 30-60 irregular D) Temperature of above 36.5°C (97.8°F) E) Sole creases that involve the heel

Answer: C, D, E Explanation: A) This is not correct. Skin color would be body pink with bluish extremities. B) This is not correct. The umbilical cord would have two arteries and one vein. C) Normal findings would include a respiration rate of 30-60 irregular. D) Normal findings would include temperature of above 36.5°C (97.8°F). E) Normal findings would include sole creases that involve the heel.

1. During the fourth stage of labor, the client's assessment includes a B P of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? A) Turn the client onto her left side. B) Place the bed in Trendelenburg position. C) Massage the fundus. D) Continue to monitor.

Answer: D Explanation: A) A left lateral position is not necessary with a B P of 110/60 and a pulse of 90. B) The Trendelenburg position is not necessary with a B P of 110/60 and a pulse of 90. C) The uterus should be midline and firm; massage is not necessary. D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia.

27) As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? A) Cultural background B) Plans for keeping the infant C) Support persons D) Developmental level

Answer: D Explanation: A) Cultural background is important to planning anyone's care. B) It is important to first determine the client's developmental level when planning nursing care for the mother who is keeping her infant. C) Support persons are important to planning anyone's care. D) Because her cognitive development is incomplete, the younger adolescent may have fewer problem-solving capabilities. The very young woman needs someone to rely on at all times during labor. She may be more childlike and dependent than older teens.

6) The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client? A) Encourage the client to vocalize during contractions. B) Perform vaginal exams only between contractions. C) Provide a C D of soft music with sounds of nature. D) Offer to teach the partner how to massage tense muscles.

Answer: D Explanation: A) Some clients want to vocalize during labor, and some vocalize only when they perceive that they are losing control. The client should determine whether vocalization is desirable for her. B) Vaginal exams are performed between contractions for all laboring clients in order to decrease discomfort. C) The nurse should ask the client what type of music she would like to listen to instead of making assumptions. D) Massage is helpful for many clients, especially during latent and active labor. Massage can increase relaxation and therefore decrease tension and pain.

1. The charge nurse has received the shift change report. Which client requires immediate intervention? A) Woman at 6 c m undergoing induction of labor, strong contractions every 3 minutes B) Woman at 4 c m whose fetus is in a longitudinal lie with a cephalic presentation C) Woman at 10 c m and fetus at +2 station experiencing a strong expulsion urge D) Woman at 3 c m screaming in fear because her mother died during childbirth

Answer: D Explanation: A) Strong contractions every 3 minutes constitute an adequate labor pattern during induction of labor. This client is experiencing no complications. B) Longitudinal lie with cephalic presentation is a head-down position. This is expected. C) 10 c m is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected. D) This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority.

1. When comparing the anterior and posterior fontanelles of a newborn, the nurse knows that both are what? A) Both are approximately the same size. B) Both close within 12 months of birth. C) Both are used in labor to identify station. D) Both allow for assessing the status of the newborn after birth.

Answer: D Explanation: A) The anterior fontanelle measures approximately 2-3 c m. The posterior fontanelle is much smaller. B) The anterior fontanelle closes around the 18th month. The posterior fontanelle closes between 8 and 12 weeks after birth. C) In labor, the presenting part, not the fontanelles, is used to identify station. D) The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth.

1. The nurse is caring for a laboring client. A cervical exam indicates 8 c m dilation. The client is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? A) Leave the client alone so she can rest. B) Ask the family to take a coffee-and-snack break. C) Encourage the client to have an epidural for pain. D) Reassure the client that she will not be left alone.

Answer: D Explanation: A) The client is in the transitional phase of the first stage of labor, and will not want to be alone. B) The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone. C) The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief. D) Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time.

1) The nurse is assessing the emotional state of a client following the delivery of her newborn. Which response by the client requires further follow up by the nurse? A) Excitability B) Crying C) Quiet D) Withdrawn

Answer: D Explanation: A) The emotional response to birth varies, and excitability is considered a normal finding. B) The emotional response to birth varies, and crying is considered a normal finding. C) The emotional response to birth varies, and being quiet is considered a normal finding. D) Being withdrawn is not considered a normal emotional response to delivery of a newborn, and requires further follow up by the nurse.

1. While caring for a client in labor, the nurse notices during a vaginal exam that the fetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be? A) Flexion, extension, restitution, external rotation, and expulsion B) Expulsion, external rotation, and restitution C) Restitution, flexion, external rotation, and expulsion D) Extension, restitution, external rotation, and expulsion

Answer: D Explanation: A) The next set of cardinal movements would not begin with flexion. B) This is not the correct order of fetal position changes. C) This is not the correct order of fetal position changes. D) The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.

1. The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? A) Weak B) Mild C) Moderate D) Strong

Answer: D Explanation: A) Weak contractions are not identified. B) If the uterine wall can be indented easily, the contraction is considered mild. C) Moderate intensity falls between these two ranges. When intensity is measured with an intrauterine catheter, the normal resting tonus (between contractions) is about 10 to 12 m m H g of pressure. During acme the intensity ranges from 25 to 40 m m H g in early labor, 50 to 70 m m H g in active labor, 80 to 100 m m H g during transition, and greater than 100 m m H g while the woman is pushing in the second stage. D) Strong intensity exists when the uterine wall cannot be indented.