N5 - OB Exam 2: Unit 2 & 3

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action? A. "My lips and fingers are tingling." B. "My contractions are really intense now." C. "My mouth and lips are so dry." D. "I feel burning in my perineum."

A. "My lips and fingers are tingling."

Ch 14: 4. When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: A. 15 to 30 minutes B. 5 to 10 minutes C. 45 to 60 minutes D. 60 to 75 minutes

A. 15 to 30 minutes

At which time is it most important to monitor for umbilical cord prolapse? A. After rupture of membranes B. At the onset of labor C. During transitional labor D. When the fetus is crowning

A. After rupture of membranes

Which cardinal movement of delivery is the nurse correct to document by station? A. Descent B. Flexion C. Extension D. Internal Rotation

A. Descent

Ch 13: 6. A laboring woman is admitted to the labor and birth suite at 6-cm dilation. She would be in which phase of the first stage of labor? A. Latent B. Active C. Transition D. Early

B. Active

Ch 13: 2. Which fetal lie is most conducive to a spontaneous vaginal birth? A. Transverse B. Longitudinal C. Perpendicular D. Oblique

B. Longitudinal

Ch 13: 7. Which assessment would indicate that a woman is in true labor? A. Membranes are ruptured and fluid is clear. B. Presenting part is engaged and not floating. C. Cervix is 4 cm dilated, 90% effaced. D. Contractions last 30 seconds, every 5 to 10 minutes.

C. Cervix is 4 cm dilated, 90% effaced.

11. The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? a. Duration b. Intensity c. Frequency d. Peak

a. Duration

23. The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? a. External electronic fetal monitoring b. Fetal blood pH c. Fetal oxygen saturation d. Fetal position

a. External electronic fetal monitoring

17. A patient calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to: a. Lightening b. Start of labor c. Placenta previa d. Rupture of the membranes

a. Lightening

9. A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the patient to do at this time? a. Push with contractions and rest between them b. Hold her breath while pushing during contractions c. Begin pushing as soon as the cervix has dilated to 8 cm d. Pant while pushing

a. Push with contractions and rest between them

Ch 14: 2. Several hours later, the client complains of nausea and turns to her partner and angrily tells him to not touch her and to go away. a. What assessment needs to be done to determine what is happening? b. What explanation can you offer Carrie''s partner regarding her change in behavior?

a. The nurse should perform a vaginal examination to validate that Carrie is in the transition phase (8 to 10 cm dilated). b. Explain to her partner that she is in the transition phase of the first stage of labor and that her behavior is typical, since she is having hard contractions frequently. Reassure him not to take Carrie's comments personally, but to stay and be supportive to her.

15. Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? a. Braxton Hicks contractions get closer together with activity. b. Braxton Hicks contractions usually decrease in intensity with walking. c. Braxton Hicks contractions do not last long enough to be true labor. d. Braxton Hicks contractions cause "ripening" of the cervix.

b. Braxton Hicks contractions usually decrease in intensity with walking.

13. The nurse is assessing a pregnant patient at 37 weeks gestation and notes that the fetus is at zero station. When questioned by the patient as to what that means, the nurse should point out which event has occurred? a. Flexion b. Engagement c. Extension d. Expulsion

b. Engagement

30. What is fetal tachycardia likely caused by? a. Compression of the umbilical cord b. Maternal infection c. Compression of the fetal head d. Maternal hypertension

b. Maternal infection

8. As labor progresses, the nurse should expect to assess that the contractions are developing which characteristics? a. More intense, less frequent, of longer duration b. More intense, more frequent, of longer duration c. No changes in intensity, more frequent, of shorter duration d. No changes in intensity or frequency, of shorter duration

b. More intense, more frequent, of longer duration

2. For what reason would a pregnant woman have an external cephalic version procedure? a. The fetus is in fetal distress b. The fetus is breech c. The woman is positive for Group B strep d. The woman is diagnosed with an infection

b. The fetus is breech

33. A patient in labor complains of feeling dizzy, light-headedness and nausea, with a blood pressure of 90/60. What should be the first response of the nurse? a. Give the patient a bolus of IV fluid b. Turn the patient to her left side c. Call the obstetrician or nurse midwife d. Give the patient an antiemetic medication for the nausea

b. Turn the patient to her left side

21. A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration? a. Early decelerations b. Variable decelerations c. Prolonged decelerations d. Late decelerations

b. Variable decelerations

19. During which time is the nurse correct to document the end of the third stage of labor? a. Following fetal birth b. When pushing begins c. At the time of placental delivery d. When the mother is moved to the postpartum unit

c. At the time of placental delivery

16. Which is the most important nursing assessment of the mother during the fourth stage of labor? a. The mother's psyche b. Blood pressure c. Hemorrhage d. Heart rate

c. Hemorrhage

24. A woman nearing the end of the first stage of labor reports that her membranes spontaneously ruptured. What should the nurse do next? a. Test a sample of the amniotic fluid for protein b. Ask her to bear down with the next contraction c. Elevate her hips to prevent cord prolapse d. Assess fetal heart rate for fetal safety

d. Assess fetal heart rate for fetal safety

7. Which intervention should be the highest priority for the nurse caring for a patient who is in labor? a. Offering pain relief measures b. Involving the partner/family with the labor and delivery care c. Monitoring appropriate fluid intake d. Assessment of fetal response to labor

d. Assessment of fetal response to labor

35. The nurse has performed a sterile vaginal examination on her patient and reports the exam as 4 cm, 50%, -1. What does this represent? a. Effacement, station and dilation b. Dilation, station and fetal lie c. Dilation, effacement and status of membranes d. Dilation, effacement and station

d. Dilation, effacement and station

31. A patient in active labor starts to complain of circumoral numbness and tingling in her fingertips. What should the nurse do? a. Increase IV fluids b. Give the woman pain medications c. Obtain an arterial blood gas d. Encourage the woman to slow down her breathing

d. Encourage the woman to slow down her breathing

28. What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? a. Administrating IV ephedrine b. Administrating IV naloxone c. Maintaining the client in a supine position d. Starting an IV and hanging IV fluids

d. Starting an IV and hanging IV fluids

Ch 14: 1. When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? A. Hold your breath and push through entire contraction. B. Use chest-breathing with the contraction. C. Pant and blow during each contraction. D. Wait until you feel the urge to push.

D. Wait until you feel the urge to push.

29. Members of the labor and delivery unit are reviewing principles of electronic fetal monitoring. Which facts are regarded as accurate? Select all that apply. a. The normal FHR is 110-160 b. An FHR of 130 is considered fetal tachycardia c. An acceleration of the FHR from the baseline of 120 bpm to 135 bpm for 20 seconds is considered abnormal d. Accelerations in the FHR are considered a sign of fetal well-being e. A deceleration of the FHR may be benign, depending on when it occurs in relation to uterine contractions

a. The normal FHR is 110-160 d. Accelerations in the FHR are considered a sign of fetal well-being e. A deceleration of the FHR may be benign, depending on when it occurs in relation to uterine contractions

Ch 13: 9. Physiologic preparation for labor would be demonstrated by: A. Decrease in Braxton Hicks contractions felt by mother B. Weight gain and an increase in appetite by mother C. Lightening, whereby the fetus drops into true pelvis D. Fetal heart rate accelerations and increased movements

C. Lightening, whereby the fetus drops into true pelvis

3. At delivery, the infant is face down with the face toward the mother's right side. What position would the nurse note the infant is in? a. LOA b. LOP c. ROA d. ROP

a. LOA

32. The patient who has received a dose of morphine (duramorph) is beginning to experience pruritus. Which medication is used to treat this? a. Low-dose naloxone b. Diphenhydramine c. Dilaudid d. Sublimaze

b. Diphenhydramine

14. A nurse is conducting an in-service program for staff nurses working in the labor unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure? a. Promoting the woman's feelings of control b. Providing clear information about procedures c. Allowing the woman time to be alone d. Encouraging the woman to use relaxation techniques

c. Allowing the woman time to be alone

18. A 32-year-old woman presents in active labor. The fetus is in a cephalic presentation, occiput facing toward the front and to the right of the mother's pelvis and is in a flexed attitude. How does the nurse document the position of the fetus? a. LOA b. LOP c. ROA d. ROP

c. ROA

Ch 14: 7. Which of the following practices would not be included in a physiologic birth? A. Early induction of labor <39 weeks gestation B. Freedom of movement for the laboring woman C. Continuous presence and support throughout labor D. Encouraging spontaneous pushing when urge felt

A. Early induction of labor <39 weeks gestation

A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? A. to constrict the uterine blood vessels B. to reduce boggy nature of the uterus C. to remove pieces left attached to uterine wall D. to lessen the chances of conducting an episiotomy

A. to constrict the uterine blood vessels

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. A. uterine resting tone B. frequency of contractions C. change in temperature D. change in blood pressure E. intensity of contractions

A. uterine resting tone B. frequency of contractions E. intensity of contractions

Ch 13: 4. As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: A. Discomfort level is greater with false labor. B. Progressive cervical changes occur in true labor. C. There is a feeling of nausea with false labor. D. There is more fetal movement with true labor. The correct response is B. Progressive cervical changes occur in true labor. This is not the case with false labor.

B. Progressive cervical changes occur in true labor.

Ch 14: 2. During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? A. Moderate amount of dark red lochia drainage on peripad B. Uterine fundus palpated to the right of the umbilicus C. An oral temperature reading of 100.6° F D. Perineal area bruised and edematous beneath her ice pack

B. Uterine fundus palpated to the right of the umbilicus

Ch 13: 3. Which of the following observations would suggest that placental separation is occurring? A. Uterus stops contracting altogether. B. Umbilical cord pulsations stop. C. Uterine shape changes to globular. D. Maternal blood pressure drops.

C. Uterine shape changes to globular.

Ch 14: 5. The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? A. Reposition the client on the left side. B. Begin 100% oxygen via face mask. C. Document this as indicating a normal pattern. D. Call the health care provider immediately.

C. Document this as indicating a normal pattern.

Ch 14: 3. When managing a client's pain during labor, nurses should: A. Make sure the agents given do not prolong labor B. Know that all pain relief measures are similar C. Support the client's decisions and requests D. Not recommend nonpharmacologic methods

C. Support the client's decisions and requests

Ch 13: 5. The shortest but most intense phase of labor is the: A. Latent phase B. Active phase C. Transition phase D. Placental expulsion phase

C. Transition phase

Ch 14: 6. By the end of the second stage of labor, the nurse would expect which of the following events? The A. cervix is fully dilated and effaced B. placenta is detached and expelled C. fetus is born and on mother's chest D. woman to request pain medication

C. fetus is born and on mother's chest

25. Which action is a priority when caring for a woman during the fourth stage of labor? a. Assessing the uterine fundus b. Offering fluids as indicated c. Encouraging the woman to void d. Assisting with perineal care

a. Assessing the uterine fundus

20. A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? a. Respiratory depression b. Urinary retention c. Abdominal distention d. Hyperreflexia

a. Respiratory depression

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? A. "You have no trouble walking around and using the bathroom after you receive the epidural." B. "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." C. "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it." D. "If you end up having a cesarean, the epidural can be used for anesthesia during surgery."

A. "You have no trouble walking around and using the bathroom after you receive the epidural."

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize? A. Encourage her through the contractions, explaining why she cannot receive any pain medication. B. Call the anesthetist from the nurse's station to retry the epidural. C. Call the primary care provider, and obtain a reduced dose of meperidine. D. Give the meperidine because she needs pain relief now.

A. Encourage her through the contractions, explaining why she cannot receive any pain medication.

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? A. Have the client pant and blow through the contraction. B. Have the client lightly push to meet the need. C. Have the client divert the energy to squeezing a hand. D. Assist the client to a Fowler's position.

A. Have the client pant and blow through the contraction.

The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? A. Help the woman change positions. B. Discontinue supplemental oxygen. C. Position the woman on her side with a pillow under her left hip. D. Start an oxytocic infusion and decrease the rate of IV fluids.

A. Help the woman change positions.

Ch 13: 8. Interventions that are underutilized in promoting a normal birth. Select all that apply. A. Oral nutrition and fluids in labor B. Open glottis pushing in the second stage of labor C. Skin-to-skin contact after birth for infant bonding D. Routine artificial rupture of membranes (amniotomy) E. Labor induction with Pitocin given intravenously F. Routine episiotomy to shorten labor length

A. Oral nutrition and fluids in labor B. Open glottis pushing in the second stage of labor C. Skin-to-skin contact after birth for infant bonding

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes? A. Provide supplemental oxygen. B. Assist the client to a supine position. C. Discontinue intravenous (IV) fluid. D. Stop the epidural infusion.

A. Provide supplemental oxygen.

Ch 13: 1. When determining the frequency of contractions, the nurse would measure which of the following? A. Start of one contraction to the start of the next contraction B. Beginning of one contraction to the end of the same contraction C. Peak of one contraction to the peak of the next contraction D. End of one contraction to the beginning of the next contraction

A. Start of one contraction to the start of the next contraction

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response? A. Support the client's decision and call the obstetrician. B. Suggest a less extreme alternative such as a sedative. C. Gently remind the client of her goal of a natural birth and encourage and help her. D. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her.

A. Support the client's decision and call the obstetrician.

The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins? A. The cervix is softening B. The uterus is relaxing C. The cervix is dilating D. The perineum is relaxing

A. The cervix is softening

Which assessment finding is most important as labor progresses? A. The uterus relaxes completely between contractions. B. The client is remaining in control of emotions. C. Labor is completed within 18 hours. D. The pulse and respirations rise with the work of labor.

A. The uterus relaxes completely between contractions.

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? A. Uteroplacental insufficiency B. Maternal tachycardia C. Maternal fatigue D. Cord compression

A. Uteroplacental insufficiency

At what time is the laboring client encouraged to push? A. When the cervix is fully dilated B. When she feels the urge to push C. When the health care provider has arrived D. When the fetal head can be seen

A. When the cervix is fully dilated

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location? A. at the level of the umbilicus B. between the umbilicus and symphysis pubis C. one finger breadth below the umbilicus D. 2 cm above the umbilicus

A. at the level of the umbilicus

A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor? A. first, active B. first, latent C. second D. third

A. first, active

A client in labor has been administered an epidural for anesthesia. Which assessment findings should the nurse prioritize? A. maternal hypotension and fetal bradycardia B. maternal hypotension and fetal tachycardia C. maternal hypertension and fetal bradycardia D. maternal hypertension and fetal tachycardia

A. maternal hypotension and fetal bradycardia

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A. moderate B. strong C. intense D. mild

A. moderate

A nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group identifies which finding as indicating normal fetal acid-base status? Select all that apply. A. sinusoidal pattern B. recurrent variable decelerations C. fetal bradycardia D. absence of late decelerations E. moderate baseline variability

A. sinusoidal pattern B. recurrent variable decelerations C. fetal bradycardia

Ch 14: 1. A 20-year-old primigravida at term, comes to the birthing center in active labor (dilation 5 cm and 80% effaced, -1 station) with ruptured membranes. She states she wants an "all-natural" birth without medication. Her partner is with her and appears anxious but supportive. On the admission assessment, this client's prenatal history is unremarkable; vital signs are within normal limits; FHR via Doppler ranges between 140 and 144 bpm and is regular. a. Based on your assessment data and the woman''s request not to have medication, what nonpharmacologic interventions could you offer her? b. What positions might be suggested to facilitate fetal descent?

a. • Progressive relaxation techniques of locating, then releasing tension from one muscle group at a time until the entire body is relaxed • Visual imagery such as taking a journey in the woman's mind to a relaxing place that is far away from the discomfort of labo • Music to bring about a calming effect as well as a distraction or attention focusing to divert attention away from the laboring process; focusing on sound or rhythm helps release tension and promote relaxation • Massage/acupressure to enhance relaxation, improve circulation, and reduce pain in labor; counterpressure on the lower back to help relieve back pain • Breathing techniques for effective attention-focusing strategies to enhance coping mechanisms during labor b. • Upright positions such as walking, swaying, slow-dancing with her partner, or leaning over a birthing ball will all enhance comfort and use the force of gravity to facilitate fetal descent. • Kneeling and leaning forward will help relieve back pain. • Pelvic rocking on hands and knees and lunging with one foot elevated on a chair may help with internal fetal rotation and speed a slow labor.

6. The patient reports to triage and states that she has been having contractions every five minutes for seven hours. Which factor should the nurse consider to determine if the patient is in true labor? a. The cervix is showing a pattern of effacement and dilation b. This is the patient's 3rd baby c. The contractions have been increasing in duration and intensity d. The patient states her membranes ruptured approximately an hour ago

a. The cervix is showing a pattern of effacement and dilation

5. The nurse knows to look for these signs during a third stage of labor. Select all that apply a. The umbilical cord gets longer b. There is a gush of blood c. The uterus changes shape d. The baby is at +2 station e. The mother's water breaks

a. The umbilical cord gets longer b. There is a gush of blood c. The uterus changes shape

26. A nurse caring for a pregnant client in labor observes that the fetal heart rate is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. a. Turn the client to her left side b. Reduce IV fluids c. Administer O2 by mask d. Assess client for underlying causes e. Ignore questions from the client

a. Turn the client to her left side c. Administer O2 by mask d. Assess client for underlying causes

22. The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: a. Fetal bradycardia b. Baseline FHR c. Short-term variability d. Baseline variability

b. Baseline FHR

27. A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? a. Boggy, soft uterus b. Sudden gush of blood from the vagina c. Shortening of the umbilical cord d. Increase in amount of amniotic fluid

b. Sudden gush of blood from the vagina

10. Assessment of the pregnant woman indicates the presenting part of the fetus is at the level of the ischial spines. The nurse knows to document this as which station? a. -2 b. -1 c. 0 d. +1

c. 0

4. In order to have a more accurate picture of the intensity of the laboring woman's contractions, the nurse knows to anticipate placement of? a. Fetal scalp electrode b. External tocodynamometer c. Intrauterine pressure catheter d. Amniotomy hook

c. Intrauterine pressure catheter

12. A nursing student is observing an initial prenatal visit. The student states "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is? a. "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." b. "It is flat and narrow, making it extremely difficult for the neonate to pass through." c. It is rounded in shape and allows ample room for the neonate to fit through the passageway." d. "It is elongated, the width is roomy but the length is narrow."

c. It is rounded in shape and allows ample room for the neonate to fit through the passageway."

34. A patient in triage is states the fetus is in the breech position. Which of the following is a nursing priority? a. Maternal temperature of 101 F b. FHR of 150 bpm without accelerations c. Rupture of membranes d. Maternal blood pressure of 100/60

c. Rupture of membranes

1. The laboring client is showing late decelerations on the fetal monitor. What does the nurse know about late decelerations? a. These represent compression of the cord and are not worrisome b. They are a sign of impending delivery c. They are a sign of fetal distress and need intervention d. They are a normal part of the laboring process

c. They are a sign of fetal distress and need intervention