NURS 215 - Exam 1 - Chapters 16, 21, 22
Ch 21 1. A woman at 32 weeks' gestation is admitted in preterm labor. On the nurse's admission assessment, which of following findings would cause the nurse to question the administration of a tocolytic agent? A) Cervical dilation of 5 cm B) Strong, regular contractions C) Fetus in a breech presentation D) A spontaneous abortion in an earlier pregnancy
ANS: A
Ch. 16 1. A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? A) uterus becomes globular C) umbilical cord shortens D) mucous plug is expelled B) fetal head at vaginal opening
ANS: A
Ch. 16 12. A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful? A) "We can get up and walk around after receiving combined spinal—epidural analgesia." B) "Higher anesthetic doses are needed for patient-controlled epidural analgesia." C) "A pudendal nerve block is highly effective for pain relief in the first stage of labor." D) "Local infiltration using lidocaine is an appropriate method for controlling contraction pain."
ANS: A
Ch. 16 15. A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? A) encouraging the woman to push when she has a strong desire to do so B) alleviating perineal discomfort with the application of ice packs C) palpating the woman's fundus for position and firmness D) completing the identification process of the newborn with the mother
ANS: A
Ch. 16 16. The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse prioritize in this situation? A) Continue to monitor the FHR because this pattern is benign. B) Perform a vaginal exam to assess cervical dilation and effacement. C) Stay with the client while reporting the finding to the primary care provider. D) Administer oxygen after turning the client on her left side.
ANS: A
Ch. 16 17. The nurse is performing Leopold's maneuvers as part of the initial assessment. Which action would the nurse do first? A) Feel for the fetal buttocks or head while palpating the abdomen. B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C) Palpate for the presenting part in the area just above the symphysis pubis. D) Determine flexion by pressing downward toward the symphysis pubis.
ANS: A
Ch. 16 18. The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time? A) Have the woman change her position. B) Administer oxygen. C) Notify the health care provider. D) Continue to monitor the pattern every 15 minutes.
ANS: A
Ch. 16 4. Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A) latent phase of the first stage. B) active phase of the first stage. C) transition phase of the first stage. D) perineal phase of the second stage.
ANS: A
Ch. 16 6. 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
ANS: A
Ch. 16 8. 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
ANS: A
Ch. 21 10. When caring for a client with premature rupture of membranes (PROM), the nurse observes an increase in the client's pulse. What should the nurse do next? A) Assess the client's temperature. B) Monitor the client for preterm labor. C) Assess for cord compression. D) Monitor the fetus for respiratory distress.
ANS: A
Ch. 21 12. Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with PPROM has completed how many weeks of gestation? A) less than 37 weeks B) less than 36 weeks C) less than 38 weeks D) less than 35 weeks
ANS: A
Ch. 21 17. A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. The nurse notes on assessment cool, clammy skin, confusion, and vital signs: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize? A) Rule out shock. B) Rule out pregnancy. C) Attach EFM. D) Establish IV access.
ANS: A
Ch. 21 19. A woman at 37 weeks gestation presents to the labor and delivery area with symptoms of abruptio placentae. Which action should the nurse prioritize? A) Ensure large bore IV access is obtained B) Placement of the mother on her back C) Complete a urine dipstick for proteinuria D) Obtain vital signs especially blood pressure
ANS: A
Ch. 21 4. A client at 34 weeks gestation has reported to the hospital in labor. The following is documented on history and physical assessment: • No rupture of membranes, mild cramping, no bleeding • Reassuring pattern on fetal heart monitor • Cervix is dilated 3 cm, effacement 30%. The nurse anticipates which treatment plan? A) Admission to the hospital, bed rest, and tocolytic agent B) Discharge instructions including rest and increased fluids C) Admission to the hospital for continued labor and vaginal birth D) Admission to the hospital and immediate cesarean birth
ANS: A
Ch. 21 9. A nurse is caring for a client at 38 weeks gestation who is diagnosed with chorioamnionitis. On which intervention should the nurse place priority? A) Administer oxytocin. B) Monitor WBC count. C) Assess temperature. D) Assess amniotic fluid.
ANS: A
Ch. 22 11. The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention? A) a forceps and vacuum-assisted birth B) a precipitous birth C) artificial rupture of membranes D) a cesarean birth
ANS: A
Ch. 22 13. A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which should the nurse monitor the fetus? A) fetal hypoxia B) preeclampsia C) coagulation defects D) placental pathology
ANS: A
Ch. 22 14. A nurse is providing care to a multiparous client. The client has a history of cesarean births. The nurse anticipates the need to closely monitor the client for which condition? A) placenta accreta B) placenta abruption C) preeclampsia D) oligohydramnios
ANS: A
Ch. 22 15. A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding? A) has previous lower abdominal incision B) had prior classic uterine incision C) had prior transfundal uterine surgery D) has contracted pelvis
ANS: A
Ch. 22 3. A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time? A) Avoid any discussion of the situation with the couple. B) Allow the couple to spend as much time as they want with their stillborn infant. C) Give the parents a lock of the infant's hair. D) Assist the family in making arrangements for their stillborn infant.
ANS: A
Ch. 22 9. The nurse is requested to assist the physician with an external version. What intervention should the nurse perform prior to and immediately after the external version? A) A nonstress test B) An electrocardiogram C) Administer tocolytics D) Administer a narcotic analgesic
ANS: A
Ch. 16 13. A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply A) cervical dilation of 6 cm B) contractions every 2 to 3 minutes C) cervical effacement of 90% D) contractions every 90 seconds E) strong desire to push
ANS: A, B
Ch. 21 16. The nurse is educating a group of pregnant women about risk factors associated with preterm labor. Which factor would the nurse include in the teaching? Select all that apply A) alcohol use during pregnancy B) lack of prenatal care C) victim of intimate partner violence D) hyperemesis gravidarium E) Asian descent
ANS: A, B, C
Ch. 21 5. A client is 2 weeks past her due date, and her health provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply A) The fetus is in a longitudinal lie. B) The cervix is ripe. C) A presenting part is engaged. D) Cephalopelvic disproportion is present. E) Maternal blood pressure is normal. F) There is absence of eclampsia.
ANS: A, B, C
Ch. 21 7. A pregnant patient is diagnosed with preterm labor. What should the nurse teach the patient to help prevent the reoccurrence of preterm labor? Select all that apply A) Drink 8 to 10 glasses of fluid each day. B) Report any signs of ruptured membranes. C) Remain on bed rest except to use the bathroom. D) Lie flat on the back should uterine contractions occur. E) Engage in mild activities of daily living with frequent rest periods.
ANS: A, B, C
Ch. 21 13. A pregnant 36-year-old woman has presented to the emergency department with vaginal bleeding. While reviewing the client's history, the nurse suspects placenta previa when which risk factors are found in her record? Select all that apply A) infertility treatment B) smoking C) advancing maternal age D) previous induced surgical abortion E) hypotension
ANS: A, B, C, D
Ch. 22 10. The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply A) epidurals B) excessive analgesia C) multiple gestation D) maternal exhaustion E) maternal diabetes F) high fetal station at complete cervical dilation G) shoulder dystocia
ANS: A, B, C, D, F, G
Ch. 21 11. A pregnant client is brought to the health care facility with signs of premature rupture of the membranes (PROM). Which conditions and complications are associated with PROM? Select all that apply A) prolapsed cord B) abruptio placenta C) spontaneous abortion D) placenta previa E) preterm labor
ANS: A, B, E
Ch. 21 8. The nurse is preparing discharge instructions for a pregnant patient experiencing preterm rupture of membranes. What should the nurse include in this teaching? Select all that apply A) Avoid douching. B) Resume regular coitus. C) Take a tub bath at least once per day. D) Expect malodorous vaginal discharge. E) Measure oral temperature twice a day.
ANS: A, E
Ch. 22 12. A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The health care provider suspects the client has amniotic fluid embolism. What other signs or symptoms would alert the nurse to the presence of this condition in the client? Select all that apply A) cyanosis B) arrhythmia C) hyperglycemia D) hematuria E) pulmonary edema
ANS: A, E
Ch. 16 10. A nursing student correctly identifies the most desirable position to promote an easy birth as which position? A) breech B) occiput anterior C) face and brow D) shoulder dystocia
ANS: B
Ch. 16 2. A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? A) increased energy level with alternating strong and weak contractions B) moderately strong contractions every 4 minutes, lasting about 1 minute C) contractions noted in the front of abdomen that stop when she walks D) pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds
ANS: B
Ch. 16 20. The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize? A) Side-lying position B) Pain relief measures C) Immediate cesarean birth D) Oxytocin administratioan
ANS: B
Ch. 16 5. A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal birth. Which pelvic shape would the nurse have noted? A) platypelloid B) gynecoid C) android D) anthropoid
ANS: B
Ch. 16 7. After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching? A) "This type of monitoring is the most accurate method for our baby." B) "Unfortunately, I'm going to have to stay quite still in bed while it is in place." C) "This type of monitoring can only be used after my membranes rupture." D) "You'll be inserting a special electrode into my baby's scalp."
ANS: B
Ch. 21 18. At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with? A) Bed rest and hydration at home B) Hospitalization, tocolytic, and corticosteroids C) An emergency cesarean birth D) Careful monitoring of fetal kick counts
ANS: B
Ch. 21 3. A pregnant client is admitted to a health care unit with disseminated intravascular coagulation (DIC). Which prescription is the nurse most likely to receive regarding the therapy for such a client? A) Administer a ratio of 1 unit of blood to 4 units of frozen plasma. B) Administer cryoprecipitate and platelets. C) Aim at keeping the client's hematocrit above 20%. D) Give each unit of blood to raise the hematocrit by 3 g/dL.
ANS: B
Ch. 21 6. After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting. What should the nurse do? A) Assess the vagina for full dilation. B) Notify the physician and stop the infusion. C) Instruct the patient to breathe in and out rapidly. D) Administer oral orange juice for added potassium.
ANS: B
Ch. 22 17. A woman arrives in the L & D unit in the beginning early phase with her contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the woman in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the woman for which priority assessment caused by a rapid birth? A) Assess bladder for fullness. B) Check perineal area frequently for bleeding. C) Assess the woman's breathing and intervene if necessary. D) Assess and administer pain medication as needed.
ANS: B
Ch. 22 4. After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A) "Holding a pillow against my incision will help me when I cough." B) "I'm going to have to wait a few days before I can start breastfeeding." C) "I guess the nurses will be getting me up and out of bed rather quickly." D) "I'll probably have a tube in my bladder for about 24 hours or so."
ANS: B
Ch. 22 5. When caring for a client requiring a forceps-assisted birth, the nurse would be alert for: A) increased risk for uterine rupture. B) potential lacerations and bleeding. C) increased risk for cord entanglement. D) damage to the maternal tissues.
ANS: B
Ch. 22 6. A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? A) less than 5 hours B) less than 3 hours C) less than 4 hours D) less than 8 hours
ANS: B
Ch. 22 20. The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize? A) Include a set of piper forceps when the table is prepped. B) Apply pressure to the woman's lower back with a fisted hand. C) Assist with Nitrazine and fern tests. D) Prepare to assist with external version.
ANS: D
Ch. 21 20. A client reports bright red, painless vaginal bleeding during her 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. Which immediate care measures are initiated? Select all that apply A) Place the woman on bedrest maintaining the supine position. B) Determine the time the bleeding began and about how much blood has been lost. C) Obtain baseline vital signs and compare to those vital signs previously obtained. D) Assist the client in stirrups and perform a pelvic examination. E) Attach external monitoring equipment to record fetal heart sounds and kick counts.
ANS: B, C, E
Ch. 22 19. The nurse is receiving shift handoff for a client with dystocia. Which nursing interventions are most appropriate in the plan of care? Select all that apply A) Bedrest in the side- lying position B) Nipple stimulation C) Administration of an enema D) Administration of a tocolytic E) Emotional support
ANS: B, C, E
Ch. 21 14. A graduate nurse (GN) is caring for a woman being inducted via oxytocin infusion. The client is currently reporting a headache and is vomiting. The graduate nurse thinks that the client is getting near the end of labor. However, the GNs preceptor intervenes by performing which interventions immediately after hearing this report? Select all that apply A) administering IV ondansetron for the nausea/vomiting B) discontinuing the oxytocin infusion C) increasing IV fluid rate D) notifying the health care provider immediately E) calling respiratory therapy to obtain ABGs on this client
ANS: B, D
Ch. 21 15. During labor, a woman undergoing induction with oxytocin should be monitored frequently. Which assessment findings should result in the oxytocin being discontinued immediately and the health care provider notified? Select all that apply A) Hard contractions every 4-5 minutes lasting 45 to 60 seconds per contraction. B) Contractions strong at 80 mm Hg pressure with each contraction. C) Fetal heart rate fluctuation between 140-170 beats/min D) Resting uterine pressure at 10-15 mm Hg by monitor. E) Contractions lasting between 90-120 seconds occurring every 2-3 minutes.
ANS: B, E
Ch. 16 14. Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A) -2 B) -1 C) 0 D) +1
ANS: C
Ch. 16 19. The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor? A) every 2 to 4 hours B) every 45 to 60 minutes C) every 15 to 30 minutes D) every 10 to 15 minutes
ANS: C
Ch. 16 3. A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A) latent phase of the first stage of labor. B) active phase of the first stage of labor. C) transition phase of the first stage of labor. D) pelvic phase of the second stage of labor.
ANS: C
Ch. 16 9. 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) intense B) strong C) moderate D) mild
ANS: C
Ch. 21 2. A pregnant client in her 34th week of gestation is diagnosed with amnionitis due to group B streptococcus. The nurse monitors the client closely based on the understanding that the client is at risk for which of the following? A) Fetal hydrops B) Fetal macrosomia C) Preterm birth D) Neural tube defect
ANS: C
Ch. 22 1. Mrs. Carter is admitted to the labor and birth unit. The lab results of her cervical culture for group B streptococcal were positive. What priority intervention will be initiated? A) Preparation for cesarean section to prevent exposure of the baby. B) Observation of the baby in newborn intensive care unit for 72 hours. C) Ampicillin or cefazolin intravenous is given before delivery. D) Culture of mother and baby within 24 hours after birth.
ANS: C
Ch. 22 2. A woman develops a pathologic retraction ring during labor. On assessment, you would expect to find its appearance as which? A) A mottling surrounding the cervix. B) An ecchymotic area over the symphysis pubis. C) A line of indentation over the lower abdomen. D) A protrusion over the uterine fundus.
ANS: C
Ch. 22 7. A patient who comes to the emergency department states that she has not felt any fetal movement for several days. The physician who cannot hear a heartbeat suspects fetal death. Once fetal death is confirmed by ultrasound, the physician immediately induces labor. Why is it important in this case to induce labor as soon as possible? A) to lessen the grief B) to distract the patient C) to prevent coagulopathy D) to prevent infection
ANS: C
Ch. 22 16. A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used. A. Fetal malpresentation B. Multiple gestation C. Labor dystocia D. Abnormal fetal heart rate tracing E. Suspected macrosomia
ANS: C, D, A, B, E
Ch. 16 11. A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse most likely use when explaining this measure? A) "This technique focuses on manipulating body tissues." B) "The technique requires focusing on a specific stimulus." C) "This technique redirects energy fields that lead to pain." D) "The technique involves light stroking of the abdomen with breathing."
ANS: D
Ch. 22 18. A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate 130mbpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication? A) compression on the inferior vena cava B) an amniotic embolism to the lungs C) an undiagnosed abdominal aorta aneurysm D) uterine rupture
ANS: D
Ch. 22 8. The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do? A) Bolus the client with another dose of medication through the epidural. B) Place the client in a knee—chest position. C) Turn the client on her left side. D) Prepare the client for a cesarean birth.
ANS: D