Maternity/OB

-The approximate strength of the contraction. -Described as "mild", "moderate", "strong"

Intensity of the contraction

Which statement explains why the nurse is instructed to collect the index fingerprint of the mother and footprints of the infant after labor? 1. It is a part of a cultural practice. 2. It is performed to identify the infant. 3. It indicates that the mother has an allergic condition. 4. It helps the mother when retrieving the infant from the nursery.

It is performed to identify the infant. P. 151

At which time is eye care to prevent ophthalmia neonatorum given to an infant? 1. 1 hour after birth 2. 12 hours after birth 3. 1 day after birth 4. Immediately after birth

1 hour after birth. --Eye care is given to infants to prevent ophthalmia neonatorum (caused by Neisseria gonorrhoeae). --> Provided 1 hour after birth so that the mother and infant can bond in the first hour. P. 159

Which Apgar score indicates that an infant should undergo active resuscitation? 1. 9 2. 4 3. 5 4. 2

2 --Apgar score is used to evaluate the infant's condition after birth. --Apgar score less than 3 indicates the infant needs active resuscitation. **Apgar score of 8-10 means the infant requires only continued observation & support of adaptation. **Apgar score of 4-7 indicates that the infant needs gentle stimulation such as rubbing of the back. P. 158

Which Apgar rating in the skin color category would the nurse give to an infant whose entire body is pink? 1. 1 2. 0 3. 3 4. 2

2. --Apgar score is used to evaluate the infant's condition after birth. --> Complete pink color of the infant's body= Apgar score of 2. **Apgar score 1 = The infant has a pink body but the extremities are blue. **Apgar score 0 = The infant has a pale blue color. P. 158

Which outcome validates the administration of vitamin K (AquaMephyton) to a newborn? 1. Cord healing 2. Blood clotting 3. Respiratory stability 4. Infection prevention

Blood clotting. --Vitamin K (AquaMephyton) is required by the newborn to assist in blood clotting. --> Vitamin K is lacking in newborns due to a sterile GI tract. --A single dose of vitamin K is given into the vastus lateralis muscle before leaving the delivery room, at age 1 hour. P. 160

Which cultural practice by the father of the baby would the nurse observe when caring for a Chinese newborn? 1. Shaving the head of the newborn. 2. Bringing a silk material called hada. 3. Throwing rice to ward off evil spirits. 4. Whispering praises in the newborn's ear.

Bringing a silk material called hada. --Hada is brought as a sign of greeting and good luck to the child. **Muslim culture: The father shaves the head of the newborn. **Japanese culture: Chanting and throwing rice to ward off evil spirits occurs. **Arabic culture: The father whispers praises in the newborn's ear. P. 123

Which term describes the situation when 3 to 4 cm of the fetal head is visible at the vaginal opening? 1. Crowning 2. Tidaling 3. Caput Succedaneum 4. Coronal presentation

Crowning **Tidaling: relates to fluctuations in the water seal of a chest tube. **Caput succedaneum: is swelling of the scalp in a newborn. **Coronal presentation: one of the most important sutures in a newborn's skull. P. 150

A pregnant patient has opted for a home birth. Which disadvantage of delivering at home would the nurse discuss with the patient? 1. Risk of exposure to different pathogens. 2. Delay in reaching emergency service. 3. Presence of the entire family during labor. 4. Decreased chance of strenuous procedures.

Delay in reaching emergency service. P. 125

Which cultural practice would the nurse observe in a Khmer patient during the immediate postpartum period? 1. Discarding of the colostrum 2. Placing keys under the pillow 3. Eating meat 4. Wearing red clothing

Discarding the colostrum P. 123

-The elapsed time from the beginning of a contraction until the end of the same contraction. -The average number of seconds contractions last, such as 45 to 50 seconds. -If longer than 90 seconds may reduce fetal oxygen supply.

Duration of the contraction

Which presentation involves the full extension of the fetal head? 1. Face 2. Brow 3. Vertex 4. Military

Face. --"Presentation" is a term that indicates the fetal part that enters the pelvis first. --Presentation where the fetal head is fully extended and the face of the fetus enters the pelvis first = face presentation. **Brow presentation: A partial extension of the fetal head. **Vertex presentation: Full flexion of the head. **Military presentation: The fetal head is neither flexed nor extended. P. 129

A newborn with a weak cry, a completely pink body, and minimal flexion of the extremities has a heart rate of ≥ 100 beats per minute 10 minutes after birth. The infant has minimal response to stimulation. Which nursing intervention should the nurse choose in this situation? 1. Perform active resuscitation. 2. Gently rub the back of the infant. 3. Keep the baby on the patient's breast. 4. Provide support for the infant's adaptation.

Gently rub the back of the infant. --The Apgar score would be 6. <-- Apgar score of 4 to 7 indicates that the infant is having slight respiratory depression and needs gentle stimulation on the back of the body. P. 158

Which nursing action has the highest priority for a patient in the second stage of labor? 1. Check the fetal position. 2. Administer pain medication. 3. Help the mother push effectively. 4. Prepare the mother to breast-feed on the delivery table.

Help the mother push effectively. --Second stage of labor is the pushing stage. P. 155

Which condition would the nurse document when there is a deep blue color change in a nitrazine paper test on a pregnant woman? 1. Placenta previa 2. Active phase of labor 3. Urinary incontinence 4. Rupture of membranes

Rupture of membranes. --A blue-green or deep blue color of the nitrazine paper indicates that the fluid is alkaline and mostly amniotic fluid. **A yellow-green color of the strip indicates the fluid is acidic (likely urine). P. 144

Which condition would the nurse assess for in a newborn with blue hands and feet? 1. Low glucose levels 2. Respiratory distress 3. Low body temperature 4. Sluggish peripheral circulation

Sluggish peripheral circulation. --Also known as acrocyanosis (which is normal in infants). **Respiratory distress: causes persistent cyanosis & is seen in areas other than the hands and the feet of the infant. P. 157

A patient in the 36th week of gestation has intense Braxton Hicks contractions along with continuous clear pink, thick vaginal discharge. The patient also has a slight weight loss of about 2 lbs. Which condition would the nurse document regarding this patient? 1. False labor 2. Term pregnancy 3. Uterine prolapse 4. Vaginal infection

Term pregnancy. -Clear pink, thick vaginal discharge (bloody show) is seen during the onset of delivery. P. 132

A patient in the third trimester reports regular, intense contractions. On examination, the nurse finds that the patient's cervix is dilated to 10 cm. What does the nurse infer from this finding? 1. The fetal chin is on the chest. 2. The cervix has completely effaced. 3. The fetal feet are present at the cervix. 4. The fetal head is in the vertex presentation.

The cervix has completely effaced. --Dilation of the cervix to 10 cm indicates complete cervical dilation/effacement. P. 155

At which point during the labor process would the health care provider know that the second stage of labor has begun? 1. The fetus is at +1 station. 2. The placenta is delivered. 3. The woman feels the urge to push. 4. The cervix is fully dilated at 10 cm.

The cervix is fully dilated at 10 cm. --Stage 2 is full dilation of the cervix until birth of the fetus. **Delivery of the placenta is stage 3. P. 155

The nurse is caring for a woman at 36 weeks of gestation who has frequent intense contractions while walking, along with bloody show and discomfort in the lower abdomen. Which statement represents correct documentation by the nurse? 1. The patient is experiencing labor pain. 2. The fetus is in the footling breech position. 3. The fetus is in the complete breech position. 4. The patient is having Braxton Hicks contractions.

The patient is experiencing labor pain. **Footling breech position: Fetal feet at the cervix. **Complete breech position: Flexion of the head and other extremities. **Braxton Hicks contractions: Irregular contractions of the uterus, which stop or decrease on ambulation. P. 132

The nurse is assisting the primary health care provider during an amniotomy and finds that the patient's amniotic fluid contains white flecks. Which condition explains this finding in the patient? 1. Infection in the patient. 2. Vernix in the amniotic fluid. 3. Meconium in the amniotic fluid. 4. Compression of the umbilical cord.

Vernix in the amniotic fluid. --Clear amniotic fluid w/ white flecks is a normal finding. --Vernix is a skin protectant on the fetus. **Yellow-colored amniotic fluid and an offensive odor indicate infection in the patient. **Green-stained fluid indicates the fetus has passed meconium. **Compression of the umbilical cord causes decreased respiratory status in the fetus. P. 144

A patient in labor has had a rupture of the amniotic sac and also has an elevation in body temperature. The nurse is concerned about infection. Which assessment finding regarding the amniotic fluid would confirm this? 1. Green-colored fluid 2. Yellow-colored fluid 3. Sweet smelling fluid 4. Clear fluid with flecks

Yellow-colored fluid --Yellow or cloudy amniotic fluid with an offensive odor indicates the presence of infection. **Green amniotic fluid indicates that the fetus has passed the first stool (meconium). **Normal amniotic fluid has a sweet smell and clear fluid with flecks of white vernix. P. 144

Which cultural practice would the nurse observe in a Hindu patient on the obstetrics unit? Select all that apply. 1. A preference to bottle-feed the infant. 2. Passive and obedient behavior during delivery. 3. Showering immediately postpartum. 4. Remaining secluded for 40 days postpartum. 5. Assertion about not wanting pain relief.

2 & 4 -Passive and obedient behavior during delivery. -Remaining secluded for 40 days postpartum. P. 124

Which nursing interventions would prevent maternal exhaustion and inhibition of labor? Select all that apply. 1. Ambulating the patient at regular intervals. 2. Providing emotional support to the patient. 3. Asking the patient not to void prior to labor. 4. Elevating the patient's bed to an angle of 45* 5. Preventing the patient from premature pushing.

2 & 5 -Providing emotional support to the patient. -Preventing the patient from premature pushing. P. 128

Which duration of time is consistent with the active phase of labor? 1. 2 to 6 hours 2. 4 to 6 hours 3. 5 to 30 minutes 4. 30 minutes to 2 hours

2 to 6 hours. --Active phase is the second phase of the first stage of labor. **Latent phase is a duration of 4 to 6 hours. **Second stage of labor typically lasts for 30 minutes to 2 hours. **Third phase of labor lasts 5-30 minutes and ends with the expulsion of the placenta. P. 155

The nursing instructor is teaching the student nurse about assisting with an emergency birth. In which order would the nursing instructor teach the procedure? 1. Support the infant's head and body as they emerge. 2. Obtain a precip tray and put on gloves and a cover gown. 3. Wipe the secretions from the infant's face and cut the umbilical cord. 4. Observe for placental detachment and bleeding and document the events. 5. Wrap the infant in blankets and place the infant in skin-to-skin contact with the mother.

2, 1, 3, 5, 4 -Obtain a precip tray and put on gloves and a cover gown. -Support the infant's head and body as they emerge. -Wipe the secretions from the infant's face and cut the umbilical cord. -Wrap the infant in blankets and place the infant in skin-to-skin contact with the mother. -Observe for placental detachment and bleeding and document the events. P. 135-136

Which nursing interventions help to maintain a neutral thermal environment for the newborn? Select all that apply. 1. Leave the infant uncovered in the open air. 2. Dry the infant with a warm towel. 3. Place the infant in a radiant warmer. 4. Place a hat on the head of the infant. 5. Avoid skin-to-skin contact between the infant and mother.

2, 3, 4 -Dry the infant with a warm towel (prevents heat loss caused by evaporation of the amniotic fluid on the skin). -Place the infant in a radiant warmer (supplies heat to the infant). -Place a hat on the head of the infant (to avoid heat loss). P. 157

During labor, a patient starts pushing before the complete dilation of the cervix. For which conditions is the patient at risk as a result of this behavior? Select all that apply. 1. Perineal laceration 2. Fetal distress 3. Fetal hypoxia 4. Speeding of labor 5. Maternal exhaustion

3 & 5 -Fetal hypoxia -Maternal exhaustion P. 149

Which assessment finding would the nurse observe in a patient with a postpartum vaginal laceration? 1. Small clots in the vaginal bleeding 2. Dark red vaginal bleeding 3. Pale brown vaginal bleeding 4. A continuous trickle of bright red vaginal bleeding

A continuous trickle of bright red vaginal bleeding. --An unexpected finding that indicates there are lacerations in the vagina, uterus, or cervix. **Vaginal blood containing small clots is normal postpartum. **Vaginal bleeding that is dark in color postpartum is called: lochia rubra (and is expected). --> Pale brown vaginal bleeding indicates lochia rubra subsiding. P. 152

The fetal heart rate in a pregnant patient varies by 15 beats/min below the baseline, and the effect lasts even after the contraction ends. Which intervention should the nurse provide first to the patient in this condition? 1. Administer a tocolytic agent to the patient. 2. Assist the patient into the left side-lying position. 3. Administer oxygen at 8 to 10 L/min through a face mask. 4. Stop the infusion of oxytocin (Pitocin) in the patient.

Administer oxygen at 8 to 10 L/min through a face mask. --a fetal heart rate of 15 beats/min below the baseline that lasts even after the contraction ends = fetus has late decelerations. --Maternal oxygenation is provided to reduce the risk of fetal hypoxia due to late deceleration. **Tocolytic agents are administered to suppress premature labor. **left side-lying position is done to prevent supine hypotension. **Stopping oxytocin (Pitocin) decreases the contractions. P. 140-142

In which type of presentation is the fetal head partly extended? 1. Face 2. Brow 3. Vertex 4. Military

Brow. --Brow presentation the fetal head is partly extended as a result of the bending of the fetal neck and head. --> Which results from poor flexion of the head, which tends to convert to either a face or a vertex presentation. **Face presentation: the head is fully extended. **Vertex presentation: the fetal head is fully flexed. **Military presentation: the fetal head is neither flexed nor extended. P. 129

Which clinical manifestation does the nurse expect to observe in a patient during the active phase of labor? 1. Cervix dilation of 4-7 cm. 2. Intact amniotic membranes 3. Occurrence of firm contractions 4. Occurrence of contractions for 60-90 seconds

Cervix dilation of 4-7 cm. **Latent phase: Amniotic membranes are intact. **Transition phase: Firm contractions occur for a duration of 60-90 seconds. P. 155

Which clinical finding is associated with a risk of fetal tachycardia? 1. Absence of uterine contractions in the first trimester. 2. Maternal temperature of 98* F in the second trimester. 3. Uterine contractions lasting for 75 seconds in the third trimester. 4. Fetal heart rate of 165 beats/min lasting for 10 min in the third trimester.

Fetal heart rate of 165 beats/min lasting for 10 min in the third trimester. --Fetal tachycardia is a baseline fetal heart rate of 160 beats/min or greater lasting for 10 minutes. P. 140

On electronic fetal monitoring, the fetal heart rate decelerates by 15 beats per minute below baseline, lasting for 1 minute. There are also altering V-shaped and W-shaped curves on the monitor. Which condition do these findings indicate? 1. Fetal hypoxia 2. Cord prolapse 3. Fetal tachysystole 4. Fetal respiratory acidosis

Fetal respiratory acidosis --Variable decelerations is a condition where the fetal heart rate decreases by up to 15 beats/min below baseline. Lasting 15 seconds to 2 minutes, and ends with U-, V-, or W-shaped curves on the monitor. --> This occurs due to compression of the umbilical cord around the fetal neck and results in Fetal respiratory acidosis. P. 142

A patient in the third trimester of pregnancy reports a sudden outflow of green-colored fluid from the vagina. Which condition may be present? 1. Fetal vitamin K deficiency. 2. Vaginal infection in the mother. 3. The mother is currently on antibiotic therapy. 4. Fetal respiratory depression.

Fetal respiratory depression. --A sudden outflow of fluid from the vagina during the third trimester indicates a rupture of the amniotic membranes. --> Green coloration of the amniotic fluid indicates that the fetus has eliminated the first stool before birth. --> Leading to the complication of respiratory depression in the fetus. **Intestinal flora are absent in infants, therefore vitamin K (aquaMEPHYTON) is injected 1 hour after birth. P. 144

Which type of contractions would the nurse document in a patient whose fundus is not easily indented with the fingertips and is similar in feel to the forehead? 1. Mild 2. Firm 3. Moderate 4. Decrement phase

Firm P. 127

-Fundus cannot be readily indented with the fingertips. -The fundus of the uterus feels similar to the forehead.

Firm Contractions

Which description of the fundus during the fourth stage of labor would the nurse document in a patient with no postpartum complications? 1. Firm and at the umbilicus 2. Soft and deviated to the left 3. Firm and deviated to the right 4. Soft to touch but firm with massage

Firm and at the umbilicus. --Fourth stage (recovery of labor) the uterus is normally found firmly contracted at or below the umbilicus level. **Deviation to the right = a full bladder **A boggy/soft uterus = potential complication P. 156

Which characteristic of the newborn is evaluated first within 5 minutes of birth? 1. Skin color 2. Heart rate 3. Respiration 4. Reflex action

Heart rate. --Heart rate and respiratory rate should be measured within 5 minutes of the birth --> The heart rate is the first parameter that needs to be measured in the infant. P. 158

At which time would a nitrazine test be performed? 1. If the fetal heart rate is showing late decelerations. 2. If the fetal heart rate has a sinusoidal pattern. 3. If it is unclear whether the membranes have ruptured. 4. If the membranes are artificially ruptured.

If it is unclear whether the membranes have ruptured. --Nitrazine test is performed to determine whether amniotic fluid is present in the vaginal outflow. **If fetal HR has late decelerations, then oxygen therapy may be required. --> They occur as a result of a reduced oxygen supply. **Sinusoidal pattern: A pattern of FHR that occurs as a result of fetal response to the mother's medication. **Amniotomy: Artificially rupturing membranes. P. 144

-The amount of time the uterus relaxes between contractions. -When blood flow from the mother into the placenta gradually decreases during contractions and resumes. -If shorter than 60 seconds may reduce fetal oxygen supply.

Interval between contractions

The health care provider prescribes vitamin K (AquaMEPHYTON) to an infant 1 hour after birth. Which condition in the newborn is being managed? 1. Malnourishment 2. Lack of intestinal flora 3. Inability to digest vitamin K 4. Risk of thrombus formation

Lack of intestinal flora. P. 160

The nurse is assisting a patient during labor and finds that the fetal head is in the left quadrant of the patient's pelvis facing the left thigh, and it is undergoing restitution. Which description of fetal position would the nurse document in the patient's medical record? 1. Left occiput anterior position and the head born in flexion 2. Left occiput posterior position and the head born in flexion 3. Left occiput anterior position and the head born in extension 4. Left occiput posterior position and the head born in extension

Left occiput anterior position and the head born in extension. --Presence of the fetal head in the left quadrant of the patient's pelvis facing the left thigh = left occiput anterior position. --Restitution: The phenomenon involving the realignment of the head according to the shoulders when born in extension. P. 130

The ultrasound scan of a patient shows that the fetus is parallel to the mother's spine and the fetal head is fully flexed in the transverse position towards the left side. Which position would the nurse document based on this scan? 1. Transverse lie; breech presentation LST 2. Transverse lie; vertex presentation LOA 3. Longitudinal lie; breech presentation LSA 4. Longitudinal lie; vertex presentation LOT

Longitudinal lie; vertex presentation LOT. --Fetus is parallel to the mother's spine (longitudinal lie), vertex position represents occiput, Transverse position toward the left is presented as LOT. **If the fetus is at right angles to the mother's body with the feet flexed facing anteriorly, it would be presented as: Transverse lie; breech presentation LST. **If the fetus is at a right angle with the vertex anterior, it would present as: Transverse lie; vertex presentation LOA. **If the fetus is parallel to the body with legs flexed towards the left, it would be present as: longitudinal lie; breech presentation LSA. P. 129-130

Which condition increases the risk of fetal tachycardia? 1. Fetal hypoxia 2. Cord prolapse 3. Maternal dehydration 4. Uteroplacental insufficiency

Maternal dehydration. --FHR greater than 160 beats/min and lasts 2 to 10 minutes or longer = fetal tachycardia. **Fetal hypoxia causes absent variability. **Marked variability is caused by cord prolapse. **Uteroplacental insufficiency causes absent variability. P. 140

-Fundus is easily indented with the fingertips -The fundus of the uterus feels similar to the tip of the nose

Mild Contractions

-Fundus can be indented with the fingertips but with more difficulty. -The fundus of the uterus feels similar to the chin.

Moderate Contractions

In a patient whose uterus feels similar to the chin, which condition would the labor nurse associate with uterine contractions that last for more than 90 seconds every 2 minutes? 1. Mild contraction and risk of fetal distress. 2. Firm contraction and risk of fetal hypoxia. 3. Very firm contraction and risk of fetal distress. 4. Moderate contraction and risk of fetal hypoxia.

Moderate contraction and risk of fetal hypoxia. --Contractions that last longer than 90 secs and are at intervals of every 2 minutes would reduce the oxygen supply to the fetus. --> Resulting in fetal hypoxia. --Fundus of the uterus feeling similar to the chin, the patient is having moderate contractions. P. 127

The nurse caring for a patient during labor observes that the presenting part of the fetus has not reached 0 station as labor begins. Which conclusion about the patient would the nurse infer from this assessment? 1. Nulliparous status and will undergo vaginal delivery. 2. Nulliparous status and will undergo cesarean delivery. 3. Multiparous status with previous vaginal delivery. 4. Multiparous status and previous cesarean delivery.

Multiparous status with previous vaginal delivery. --Presenting part of the fetus is seen at 0 station (the level of the ischial spines on the woman's pelvis) during engagement. --Engagement: the process of fetal descent into the mother's pelvis. --A multiparous patient who had a previous vaginal delivery will have a decrease in the angle between the symphysis pubis and the fetal head (angle of progression). P. 132, 150

Which position would the nurse document for a fetus in a breech presentation in the mother's right posterior pelvis? 1. Right sacrum posterior 2. Right sacrum anterior 3. Left sacrum posterior 4. Left sacrum anterior

Right sacrum posterior. --First word refers to which side of the mother's pelvis the presenting part is facing, the second is the fetal reference point (occiput for vertex presentations, mentum for face, and sacrum for breech), and the third references the front or back of the mother's pelvis (if fetus is neither anterior or posterior, then it is transverse). P. 129

While assisting a patient in labor, the nurse finds that the patient has passed stool and has a bulging perineum. The patient states, "The baby is coming." Which stage of labor does this describe? 1. Active phase 2. Latent phase 3. Second stage 4. Transition phase

Second stage. --Stage 2 involves: expulsion of the fetus. **Stage 1 involves: dilation and effacement of the cervix. ---> Stage 1 includes three phases: Latent phase (increased urine frequency & increased thirst), the active phase (facial flushing and fears of losing control), transition phase (restlessness, tremors of the legs, & irritable behavior occur). P. 155

The nurse is assisting the health care provider to determine fetal presentation by Leopold's maneuver. Which area would the nurse expect the provider to palpate to confirm the presentation of the fetus? 1. Uterine fundus of the patient. 2. Suprapubic area of the patient. 3. Hard, smooth contour of the fetus. 4. Maternal abdomen toward the feet.

Suprapubic area of the patient. --Leopold's maneuver: A technique used to determine the fetal position and presentation. **Palpation of the uterine fundus gives an idea of fetal presence. **Palpating a hard, smooth contour helps locate the back of the fetus. **Palpating the maternal abdomen toward the feet or the symphysis pubis can determine the attitude of the fetal head. P. 136-137

The nurse is caring for a patient in labor who has been administered meperidine hydrochloride (Demerol). Which heart rate pattern would the nurse assess for on the electronic fetal heart rate monitor? 1. U-shaped 2. V-shaped 3. W-shaped 4. Undulating

Undulating. --Undulating pattern is a specific fetal heart rate pattern that has a smooth, wavelike appearance. --> This is caused by the fetal response to meds (meperidine hydrochloride/Demerol) given to the mother during labor. --> Also observed due to fetal anemia. **U-, V-, and W-shaped patterns are due to variable decelerations in the FHR. <-- Indicate compression of the umbilical cord, resulting in respiratory acidosis. P. 142-143

Which condition in the laboring mother may lead to impaired fetal circulation and hypoxia and is evidenced by reddening of the patient's face, an increase in blood pressure, and slowing of the pulse rate? 1. Forceful pushing 2. Spontaneous pushing 3. Increased venous return 4. Decreased intrathoracic pressure

Forceful pushing. --Called Valsalva's maneuver, may cause impaired fetal circulation and fetal hypoxia. P. 146

-The elapsed time from the beginning of the next contraction. -Described in minutes and fractions of minutes (4 1/2 minutes for example). -Occurring more often than every 2 minutes may reduce fetal oxygen supply.

Frequency of contractions

A patient who has had a cesarean section in her previous pregnancy fears having another cesarean. Which response by the nurse would be helpful to relieve the patient's anxiety? 1. "Cesarean section will not be required this time." 2. "Feeling tense may lead to other complications." 3. "Being worried may increase the need for cesarean." 4. "Remaining calm will help you deliver with fewer risks."

"Remaining calm will help you deliver with fewer risks." P. 148

The nurse is repeating instructions to a patient about the conditions that need immediate medical attention. Which statement made by the patient indicates the need for further education? 1. "I should report to the hospital if I have intense contractions." 2. "I should report to the hospital if I find clear vaginal secretions." 3. "I should report to the hospital if I feel decreased fetal movements." 4. "I should report to the hospital if I have a sudden outflow from the vagina."

"I should report to the hospital if I find clear vaginal secretions." P. 134

Which patient signs indicate impending birth? Select all that apply. 1. Grunting sounds by the patient. 2. Rupture of the amniotic membrane. 3. Bulging of the patient's perineum. 4. Variable decelerations of the fetal heart rate. 5. Intense irregular Braxton Hicks contractions.

1 & 3 -Grunting sounds by the patient. -Bulging of the patient's perineum (as a result of the descent of the fetus). P. 135

Which hematological changes occur during labor and delivery? Select all that apply. 1. Loss of blood 2. Decreased fibrinogen 3. Increased blood volume 4. Decreased clotting factor 5. Increased fetal hemoglobin

1 & 5 -Loss of blood -Increased fetal hemoglobin --Blood loss of about 500 mL may occur during delivery --Increased fetal hemoglobin helps the fetus carry an increased amount of oxygen during labor. --Fibrinogen levels increase during pregnancy to prevent hemorrhaging during labor. P. 147, 156

Which respiratory assessment findings in the neonate would the nurse report immediately? Select all that apply. 1. Grunting respirations 2. Flaring of the nostrils 3. Heart rate above 110 beats/min. 4. Cyanosis of the hands and feet. 5. Respiratory rate higher than 60 breaths/min.

1, 2, 5 -Grunting respirations -Flaring of the nostrils -Respiratory rate higher than 60 breaths/min --Also includes: rib retractions, persistent cyanosis (other than of the hands and feet), and sustained heart rate greater than 160 beats/min or less than 110 beats/min. P. 158

Which measurement of cervix dilation in centimeters indicates the transition phase of labor? 1. 4 to 7 2. 5 to 6 3. 1 to 4 4. 7 to 10

7 to 10. --Transition phase is the third phase of the first stage of labor. --> During this phase the cervix will dilate from 7 to 10 cm. **Active phase of labor: Dilation of the cervix will be 4 to 7 cm. **Latent phase of labor: Cervical dilation is 1 to 4 cm. P. 155

Which conditions increase the risk of fetal bradycardia? Select all that apply. 1. Fetal hypoxia 2. Maternal dehydration 3. Maternal hypoglycemia 4. Fetal response to meperidine hydrochloride (Demerol) 5. Umbilical cord compression

1, 3, 5 -Fetal hypoxia (decreases HR as a result of decreased oxygen supply to the fetus). -Maternal hypoglycemia (one of the causes of fetal bradycardia, due to the glucose level affecting the FHR). -Umbilical cord compression (results in respiratory distress in the fetus due to the nuchal cord compression). --FHR below 110 beats/min for 10 + minutes leads to fetal bradycardia. P. 140

In which order would the nurse teach the procedure of administering an intramuscular injection to a newborn? 1. Inject slowly and remove needle quickly. 2. Prepare the medication for injection and put on gloves. 3. Locate the correct site and cleanse with an alcohol wipe. 4. Massage the site with an alcohol swab and calm the infant. 5. Reposition the infant, wash hands, and document in the record. 6. Hold the leg and insert the needle at a 90-degree angle into the vastus lateralis muscle.

2, 3, 6, 1, 4, 5 -Prepare the medication for injection and put on gloves. -Locate the correct site and cleanse with an alcohol wipe. -Hold the leg and insert the needle at a 90-degree angle into the vastus lateralis muscle. -Inject slowly and remove needle quickly. -Massage the site with an alcohol swab and calm the infant. -Reposition the infant, wash hands, and document in the record. P. 159-160

Which physiological changes occur in a patient during labor? Select all that apply. 1. Increased gastrointestinal motility 2. Increased progesterone 3. Increased blood glucose 4. Increased cardiac output 5. Increased oxygen consumption

4 & 5 -Increased cardiac output (Uterine contractions release 400 mL of blood into the vascular system). -Increased oxygen consumption (caused by the increased physical activity of labor). P. 146

Fifteen minutes after birth, the heart rate of an infant is 100 beats per minute, body posture is flexed and there is minimal response to stimulation. The infant has a slow weak cry, with a pink body and blue extremities. What is the Apgar score of this infant? Record your answer using a whole number.

7 -Apgar score for 100 beats/min = 2 -Flexed body posture = 2 -Minimal response to stimulation = 1 -Slow, weak cry = 1 -Pink body with blue extremities = 1 P. 158

Which finding is a sign of impending labor? 1. Increased vaginal discharge 2. Baby dropping 3. Increased libido 4. Diarrhea

Increased vaginal discharge. --Braxton Hicks contractions (increasing in intensity), increased vaginal discharge, and bloody show are always signs of impending labor. P. 132

Phases of contractions:

Increment: The period of increasing strength. Peak, or acme: The period of greatest strength. Decrement: The period of decreasing strength.

The nurse is assisting a patient in labor documents that the fetus is presented in the frank breech position. Which assessment finding supports this conclusion? 1. Presence of fetal buttocks at the cervix. 2. Presence of bilateral fetal feet at the cervix. 3. Presence of the fetus in the left occiput anterior position. 4. Presence of the fetus in the right mentum anterior position.

Presence of fetal buttocks at the cervix. **Footling breech position: When both feet of the fetus are at the cervix. **Vertex presentation: The fetus is in the left occiput anterior position. **Face presentation: The right mentum anterior position. P. 129