M/N - Week 3 - Durham/Chapman Ch. 8 Davis NCLEX Practice Q's - Exam 2

A nurse is explaining to a patient the maternal factors that trigger labor. Which of the following should the nurse mention? Select all that apply. 1. Stretching of uterine muscles 2. Desire of the mother 3. Pressure on the cervix 4. Release of oxytocin 5. Increase in estrogen

1, 3, 4, 5 1. Stretching of uterine muscles 3. Pressure on the cervix 4. Release of oxytocin 5. Increase in estrogen Feedback 1: Uterine muscles are stretched to the threshold point, leading to release of prostaglandins that simulate contractions. Feedback 2: The desire of the mother is not a labor trigger, unfortunately. Feedback 3: Increased pressure on the cervix stimulates the nerve plexus, causing release of oxytocin by the maternal pituitary gland, which then stimulates contractions. Feedback 4: Oxytocin stimulates myometrial contractions. Oxytocin and prostaglandin work together to inhibit calcium binding in muscle cells, raising intracellular calcium levels and activating contractions. Feedback 5: Estrogen increases, stimulating the uterine response.

A nurse performs effleurage on a laboring patient to help distract her from her pain. This intervention is an example of which type of pain management? 1. Cutaneous stimulation 2. Thermal stimulation 3. Mental stimulation 4. Social stimulation

1. Cutaneous stimulation Effleurage is cutaneous stimulation done by lightly stroking the abdomen in rhythm with breathing during contractions. Thermal stimulation involves the application of warmth or cold, such as use of warm showers or ice packs, to the body to distract from pain. Mental stimulation includes the use of focal points, imagery, and music to help the woman to concentrate on something outside her body. This helps her to focus away from the pain. Social stimulation might include the emotional support provided by a significant other and/or a doula.

While a patient is early in labor, she explains to her nurse that she and her husband have taken childbirth classes that that focus on birth without fear by education and environmental control and relaxation. The nurse recognizes that this couple most likely attended which type of classes? 1. Dick-Read method 2. Lamaze 3. Bradley 4. Aromatherapy

1. Dick-Read method The Dick-Read method advocates birth without fear by education and environmental control and relaxation. The Lamaze approach promotes psychoprophylaxis with conditioning and breathing. The Bradley approach is a husband-coached childbirth and support method that focuses on working with and managing the pain rather than being distracted from it. Aromatherapy involves the use of essential oils to promote relaxation and decrease the perception of pain.

A woman entering the second stage of labor reports that she feels the urge to bear down. The nurse recognizes that this phenomenon is known as which of the following? 1. Ferguson's reflex 2. Valsalva technique 3. Lightening 4. Braxton-Hicks contraction

1. Ferguson's reflex The urge to push or bear down is known as Ferguson's reflex. The Valsalva technique involves holding one's breath while bearing down, also called closed glottis pushing. It does not refer to the urge to push. Lightening refers to the descent of the fetus into the true pelvis that occurs approximately 2 weeks before term in first-time pregnancies. Braxton-Hicks contractions are irregular uterine contractions that do not result in cervical change and are associated with false labor.

While assisting a patient who is in active labor, the nurse assesses her uterine contractions and observes the following: the time from one contraction starting to the time the next one starts is about 4 minutes; the time from the beginning of a contraction to the end of the same contraction is about 40 seconds; and the uterine wall is resistant to indentation when the nurse presses on it with her thumb. How would the nurse sum up these observations? 1. Frequency: 4 minutes; duration: 40 seconds; intensity: moderate 2. Frequency: 40 seconds; duration: 4 minutes; intensity: mild 3. Frequency: 4 minutes; duration: 40 seconds; intensity: strong 4. Frequency: 40 seconds; duration: 4 minutes; intensity: strong

1. Frequency: 4 minutes; duration: 40 seconds; intensity: moderate Frequency is the time from the beginning of one contraction to the beginning of another, which in this case is 4 minutes. Duration is the time from the beginning of a contraction to the end of the same contraction, which in this case is 40 seconds. Intensity is the strength of the contraction, with mild referring to a uterine wall that is easily indented during a contraction, moderate being resistant to indentation (which is the case here), and strong being unable to indent.

21.A nurse is helping a woman in labor manage her pain. Which of the following pain relief measures would best indicate the nurse's understanding of the gate control theory of pain? 1. Gently stroking the woman's abdomen 2. Assisting with the administration of an epidural 3. Dispensing an analgesic ordered by the primary care provider 4. Encouraging the patient to meditate

1. Gently stroking the woman's abdomen The gate control theory of pain states that sensation of pain is transmitted from the periphery of the body along ascending nerve pathways to the brain. Because of the limited number of sensations that can travel along these pathways at any given time, an alternate activity can replace travel of the pain sensation, thus closing the gate control at the spinal cord and reducing pain impulses traveling to the brain. Based on this premise, the application of pressure to certain areas of the body, the cutaneous stimulation such as effleurage (gentle stroking of the abdomen), or the use of heat or cold can have a direct effect on closing the gate, which then limits the transmission of pain. Pain relief measures based on the gate control theory of pain involve the application of cutaneous or thermal stimulation to the body, not the administration of a medication. Pain relief measures based on the gate control theory of pain involve the application of cutaneous or thermal stimulation to the body, not the administration of a medication. Pain relief measures based on the gate control theory of pain involve the application of cutaneous or thermal stimulation to the body, not meditation.

A woman in labor is dilated 2 cm, effaced 30%, and has contractions that occur every 7 minutes and last 35 seconds. She describes the contractions as feeling like "bad cramps" but is still talkative and able to relax. The nurse recognizes that this woman is in which phase of the first stage of labor? 1. Latent phase 2. Active phase 3. Transitional phase 4. Expulsive phase

1. Latent phase The latent phase is the early and slower part of labor with an average length of 9 hours for primiparous and 5 hours for multiparous women. Women in this phase are talkative and able to relax with the contractions. Characteristics of this phase are cervical dilation from 0 to 3 cm with effacement from 0% to 40%, along with contractions occurring every 5 to 10 minutes, lasting 30 to 45 seconds, and being of mild intensity. Women often describe these contractions as feeling like strong menstrual cramps. The active phase is characterized by cervical dilation of 4 to 7 cm with effacement of 40% to 80%. Contractions become more intense, occurring every 2 to 5 minutes with a duration of 45 to 60 seconds. The woman tends to be more serious and fatigued in this phase and turns inward. The transition phase is characterized by cervical dilation of 8 to 10 cm with complete (100%) effacement. Contractions are intense, occur every 1 to 2 minutes, and last 60 to 90 seconds. It is the shortest but most difficult phase of the first stage of labor, and the woman is typically exhausted and has trouble concentrating. Expulsive refers to the second stage of labor, not a phase of the first. It involves the delivery of the baby.

4.Early in labor, a patient tells the nurse that she would like an unmedicated birth, in general, but would like some pain relief that is fast-acting, that she can administer hersef, and that will not interfere with the normal physiology and progress of labor. Which of the following should the nurse suggest to the patient? 1. Parenteral opioids 2. Nitrous oxide 3. Epidural anesthesia 4. General anesthesia

1. Parenteral opioids Parenteral opioids are considered a medication and can cause neonatal respiratory depression, so they do not meet the criteria of the patient. Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered by the laboring woman using a mouth tube or face mask, when she determines that she needs it. It can be started and stopped at any point during labor, according to the needs and preferences of the woman. It takes effect in about 50 seconds after the first breath, and the effect is transient. It is has no adverse effects on the normal physiology and progress of labor. Epidural anesthesia involves placement of a very small catheter and injection of local anesthesia and or analgesia between the fourth and fifth vertebrae into the epidural space. It involves the administration of a medication and is rather involved to set up, so it does not meet the criteria of the patient. General anesthesia is not typically used in vaginal births.

In explaining to a patient factors that help the fetal head to mold during labor and birth and thus fit through the maternal pelvis, which of the following should the nurse mention? 1. The presence of membranous spaces between the bones (sutures) and fontanels of the fetal skull 2. The action of estrogen to soften cartilage and increase elasticity of the ligaments 3. The action of relaxin to soften cartilage and increase elasticity of the ligaments 4. The gender of the fetus

1. The presence of membranous spaces between the bones (sutures) and fontanels of the fetal skull Molding is the ability of the fetal head to change shape to accommodate/fit through the maternal pelvis. The membranous spaces between the bones (sutures) and fontanels of the fetal skull (intersections of these sutures) allow the skull bones to overlap and mold to fit through the birth canal. Estrogen and relaxin soften cartilage and increase elasticity of the ligaments of the woman's pelvis joints. This helps the fetal skull fit through the pelvis but is not a factor that causes the fetal head itself to mold. The gender of the fetus is not related to the ability of the fetal head to mold.

A woman with her first pregnancy believes she is in labor and calls her obstetrician's office. Which of the following criteria for going to the birthing facility should the nurse mention to the woman? Select all that apply. 1. Contractions are 10 minutes apart 2. Rupture of membranes occurs 3. Contractions last at least 30 seconds 4. She experiences intense pain 5. Increase in bloody show

2, 3, 4, 5 2. Rupture of membranes occurs 3. Contractions last at least 30 seconds 4. She experiences intense pain 5. Increase in bloody show Feedback 1: A general rule of thumb for first-time pregnancy with no risk factors is to wait until contractions are 5 minutes apart, lasting 60 seconds, and are regular. Feedback 2: The woman should go to the birthing center when her membrane ruptures (water breaks). Feedback 3: A general rule of thumb for first-time pregnancy with no risk factor is to wait until contractions are 5 minutes apart, lasting 60 seconds, and are regular. Feedback 4: The woman should go to the birthing center when she experiences intense pain. Feedback 5: The woman should go to the birthing center when there is an increase of bloody show.

A patient who is in labor has just experienced rupture of membranes. Which of the following should be priority actions for the nurse to take at this time? Select all that apply. 1. Assist the patient into the lithotomy position 2. Assess the fetal heart rate 3. Assess the amniotic fluid for color, amount, and odor 4. Instruct the woman to bear down with the urge to push 5. Document the date and time of rupture of membranes

2, 3, 5 2. Assess the fetal heart rate 3. Assess the amniotic fluid for color, amount, and odor 5. Document the date and time of rupture of membranes Feedback 1: Just because the patient's membranes have ruptured does not mean that she is ready to deliver the baby immediately, which would warrant the lithotomy position. Feedback 2: The nurse should assess the fetal heart rate as there is an increased risk of umbilical cord prolapse with rupture of membranes. Feedback 3: The nurse should assess the amniotic fluid for color, amount, and odor, as meconium-stained fluid may be an indication of fetal compromise in utero. Feedback 4: The woman should not be instructed to bear down with the urge to push until she is fully effaced and dilated, which do not necessarily coincide with the rupture of membranes. Feedback 5: The nurse should document the date and time of the rupture of membranes, characteristics of the fluid, and the fetal heart rate.

A woman in labor is dilated 9 cm, effaced 100%, and has contractions that occur almost every minute and last 90 seconds. She is exhausted and has trouble concentrating. The nurse recognizes that this woman is in which phase of the first stage of labor? 1. Latent phase 2. Active phase 3. Transitional phase 4. Expulsive phase

2. Active phase The latent phase is the early and slower part of labor with an average length of 9 hours for primiparous and 5 hours for multiparous women. Women in this phase are talkative and able to relax with the contractions. Characteristics of this phase are cervical dilation from 0 to 3 cm with effacement from 0% to 40%, along with contractions occurring every 5 to 10 minutes, lasting 30 to 45 seconds, and being of mild intensity. Women often describe these contractions as feeling like strong menstrual cramps. The active phase is characterized by cervical dilation of 4 to 7 cm with effacement of 40% to 80%. Contractions become more intense, occurring every 2 to 5 minutes with a duration of 45 to 60 seconds. The woman tends to be more serious and fatigued in this phase and turns inward. The transition phase is characterized by cervical dilation of 8 to 10 cm with complete (100%) effacement. Contractions are intense, occur every 1 to 2 minutes, and last 60 to 90 seconds. It is the shortest but most difficult phase of the first stage of labor, and the woman is typically exhausted and has trouble concentrating. Expulsive refers to the second stage of labor, not a phase of the first. It involves the delivery of the baby.

A patient who is near term has called the obstetrician's office saying that she's nervous that she may be in labor. The nurse should tell the patient that true labor is characterized by which of the following? 1. Lightening and contractions that vary in frequency, duration, and intensity 2. Contractions that occur at regular intervals and increase in frequency, duration, and intensity 3. Occurrence on or within a day or two of the estimated due date 4. Rupture of membranes

2. Contractions that occur at regular intervals and increase in frequency, duration, and intensity Lightening refers to the descent of the fetus into the true pelvis that occurs approximately 2 weeks before term in first-time pregnancies. It is not a sign of true labor. Moreover, true labor contractions increase in frequency, duration, and intensity, they don't vary in these measures. True labor contractions occur at regular intervals and increase in frequency, duration, and intensity. True labor does not depend on the woman's estimated due date and can occur well before or after the date. Spontaneous rupture of the membranes may occur before the onset of labor but typically occurs during labor. Thus, it is not a sure sign of the beginning of true labor.

5.A nurse is monitoring a woman's progress during active labor. The nurse observes that the woman's cervix has thinned and shortened dramatically in the past 15 minutes. The nurse recognizes that this phenomenon is known as which of the following? 1. Dilation 2. Effacement 3. Bearing down 4. Lightening

2. Effacement Dilation is the enlargement or opening of the cervical os. The cervix dilates from closed to 10 cm in diameter. Effacement is the shortening and thinning of the cervix. Before the onset of labor, the cervix is 2 to 3 cm long and approximately 1 cm thick. The degree of effacement is measured in percentage and goes from 0% to 100%. Bearing-down powers occur once the cervix is fully dilated (10 cm), and the woman feels the urge to push; she will involuntarily bear down. Lightening refers to the descent of the fetus into the true pelvis that occurs approximately 2 weeks before term in first-time pregnancies.

A nurse is caring for a patient who is in the active phase of the first stage of labor. How often should the nurse monitor fetal heart rate and contractions during this phase? 1. Every 5 to 10 minutes 2. Every 15 to 20 minutes 3. Every 30 to 40 minutes 4. Every 45 to 60 minutes

2. Every 15 to 20 minutes The nurse should monitor fetal heart rate and contractions every 15 to 20 minutes in the active phase of the first stage of labor.

A patient is in the first stage of labor. Which position should the nurse encourage the patient to assume to increase the pelvic outlet and aid the descent of the fetus? 1. Lithotomy 2. Upright 3. Supine 4. Prone

2. Upright The lithotomy position is commonly used in the United States for the second stage of labor for the delivery of the baby, but not in the first stage. The upright position has shown benefits of aiding in the descent of the infant and more effective contractions that result in shorter labor. It has also been shown to increase the pelvic outlet and better align the fetus with the pelvic inlet. The supine position is not recommended because it is associated with compression of the maternal descending aorta and ascending vena cava that could result in a compromised cardiac output and supine hypotension, resulting in decreased placental perfusion. The prone position would not be safe or feasible for a woman giving birth.

A nurse is working with a patient from Pakistan who is in her third trimester and is experiencing a high-risk pregnancy. Which of the following approaches should the nurse take in caring for this patient? 1. Take precisely the same approach the nurse would take with any other client 2. Use the beliefs, values, customs, and expectations of the woman to shape her plan of care 3. Avoid using nonverbal communication 4. Base care on the understanding that this woman's needs are the same as those of other Pakistani women the nurse has worked with

2. Use the beliefs, values, customs, and expectations of the woman to shape her plan of care The nurse should not take the same approach with every patient but rather should base the nurse's care on the individual needs of the patient, which are affected by that patient's culture. Culture influences all aspects of a woman's response to labor. Thus, the nurse should use the beliefs, values, customs, and expectations of the woman to shape her plan of care for labor and birth, as much as possible. The nurse should learn to use nonverbal communication in an appropriate way, not avoid using it. Everyone relies on nonverbal communication to some extent, and such communication can be especially important when the patient is not a native speaker of English. Although the patient's needs will be influenced by her culture, she is still an individual and should be treated accordingly. There are subcultures within cultures, and the needs of one particular nationality or ethnic group are not all the same.

13.About a few weeks before her due date, a patient who is in her first pregnancy calls her obstetrician's office and says that it feels like the baby has moved down in her abdomen and that she can breathe more easily, although she feels like she needs to urinate all the time now. She wonders whether this means that she is about to go into labor. Which of the following should the nurse tell her? 1. "That is called a Braxton-Hicks contraction. It is harmless and not a sign of true labor." 2. "That is called nesting. It means that you will likely begin labor within 24 hours." 3. "That is called lightening. It means that you are probably just a couple of weeks away from labor." 4. "That is called a true contraction. It means that you are in labor. Get to the hospital as soon as possible."

3. "That is called lightening. It means that you are probably just a couple of weeks away from labor." This phenomenon is lightening, not Braxton-Hicks contractions, which are irregular uterine contractions that do not result in cervical change and are associated with false labor. This phenomenon is lightening, not nesting, which is a burst of energy or a feeling of needing to put everything in order in the weeks preceding labor and delivery. Lightening refers to the descent of the fetus into the true pelvis that occurs approximately 2 weeks before term in first-time pregnancies. The woman may feel she can breathe more easily but may experience urinary frequency from increased bladder pressure. In subsequent pregnancies, this may not occur until labor begins. This phenomenon is lightening, not a true contraction.

A nurse is determining the Apgar score of a newborn. The nurse observes that the newborn has slow, irregular respiratory effort, a heart rate of 90 beats per minute, some flexion of extremities, a grimace, and a pink body with blue extremities. Which Apgar score should the nurse report? 1. 1 2. 3 3. 5 4. 7

3. 5 Each of the five signs reported in this scenario warrants a score of "1," which results in a total neonatal Apgar score of "5."

A patient has just entered the third stage of labor, and the nurse is awaiting delivery of the placenta. Which of the following should the nurse expect as a sign that delivery of the placenta is imminent? 1. The further descent of the uterus 2. Shortening of the umbilical cord at the introitus 3. A sudden gush of blood from the vagina 4. Rupture of membranes

3. A sudden gush of blood from the vagina The uterus rises, not descends, and assumes a ball shape just before delivery of the placenta. The umbilical cord lengthens, not shortens, at the introitus just before delivery of the placenta. A sign that signifies the impending delivery of the placenta includes a sudden gush of blood from the vagina. The rupture of membranes (water breaking) would have occurred before delivery of the baby and is not an imminent sign of delivery of the placenta.

Early in labor, a patient tells the nurse that she had an awful experience with pain in her last pregnancy and would like strongest pain relief option available for a vaginal birth. Which of the following should the nurse suggest to the patient? 1. Parenteral opioids 2. Nitrous oxide 3. Epidural anesthesia 4. General anesthesia

3. Epidural anesthesia Parenteral opioids blunt but do not eliminate pain, and therefore are not the strongest form of pain relief in labor and delivery. Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered by the laboring woman using a mouth tube or face mask, when she determines that she needs it. As an analgesic, it relieves pain, but does not block it as effectively as an epidural. Epidural anesthesia involves placement of a very small catheter and injection of local anesthesia and/or analgesia between the fourth and fifth vertebrae into the epidural space. It has the potential of 100% blockage of pain. General anesthesia is not typically used in vaginal births.

A nurse is assisting a patient who has finished delivering her baby vaginally and is now delivering the placenta. The nurse recognizes that the woman is in which stage of labor? 1. First 2. Second 3. Third 4. Fourth

3. Third The first stage begins with the onset of labor and ends with complete cervical dilation. The second stage begins with complete dilation of the cervix and ends with delivery of the baby. The third stage begins after delivery of the baby and ends with delivery of the placenta. The fourth stage begins after delivery of the placenta and is completed 4 hours later; it is the immediate postpartum period.

A patient who is near full term has just gone into labor, and an ultrasound shows that the fetus' buttocks are presenting, with thighs and legs completely flexed. The nurse recognizes that this fetal presentation is which of the following? 1. Cephalic vertex 2. Cephalic brow 3. Complete breech 4. Frank breech

4. Frank breech In a cephalic presentation, the head is the presenting part. In a cephalic vertex presentation, the head is sharply flexed and the chin is touching the thorax. In a cephalic presentation, the head is the presenting part. In a cephalic brow presentation, the neck is partially extended with the brow as the presenting part. In a breech presentation, the presenting part is the buttock. In a complete breech, the thighs are completely flexed and the legs extended over the anterior surfaces of the body. In a breech presentation, the presenting part is the buttock. In a frank breech, the thighs and legs are completely flexed.

A nurse is assisting a patient in the fourth stage of labor. The nurse recognizes that which of the following is the primary means by which bleeding is stopped and hemostasis achieved during this stage? 1. Application of an ice pack to the perineum 2. Administration of a coagulant 3. Compression with a large bandage 4. Vasoconstriction produced by a well-contracted myometrium

4. Vasoconstriction produced by a well-contracted myometrium Although an ice pack may be applied to the perineum during this stage to relieve pain, it is not the primary means by which bleeding is stopped and hemostasis achieved. It is not typical to administer a coagulant to a woman at this point. Although the woman may have a bandage or dressing applied to her at this stage, it is not the primary means by which bleeding is stopped and hemostasis achieved. After the placenta delivers, the primary mechanism by which hemostasis is achieved at the placental site is vasoconstriction produced by a well-contracted myometrium.