OB Exam 2 - chapters 18,19,20,21

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? 1. Call for help. 2. Insert a Foley catheter. 3. Start oxytocin (Pitocin). 4. Notify the primary health care provider immediately.

ANS: 4. Notify the primary health care provider immediately.

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. What goal is the nurse attempting to achieve by performing this practice? a. To improve the accuracy of blood loss estimation, which usually is a subjective assessment b. To determine which pad is best c. To demonstrate that other nurses usually underestimate blood loss d. To reveal to the nurse supervisor that one of them needs some time off

ANS: A

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? (Select all that apply.) a. The mother should check the photo identification (ID) of any person who comes to her room. b. The baby should be carried in the parents arms from the room to the nursery. c. Because of infant security systems, the baby can be left unattended in the clients room. d. Parents should use caution when posting photographs of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person

ANS: A, D, E

The nurse providing care for the laboring woman should understand that variable FHR decelerations are caused by: A. Altered fetal cerebral blood flow B. Umbilical cord compression C. Uteroplacental insufficiency D. Fetal hypoxemia

ANS: B. Correct: Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord.

A 25-year-old gravida 3, para 2 client gave birth to a 9-pound, 7-ounce boy, 4 hours ago after augmentation of labor with oxytocin (Pitocin). She presses her call light, and asks for her nurse right away, stating Im bleeding a lot. What is the most likely cause of postpartum hemorrhaging in this client?a.Retained placental fragments b.Unrepaired vaginal lacerations c.Uterine atony d.Puerperal infection

ANS: C

A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior? a.A nulliparous woman will experience a strong urge to bear down. b.Perineal bulging will show. c.A nulliparous woman will remain quiet with her eyes closed between contractions. d.The amount of bright red bloody show will increase.

ANS: C

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. Which physiologic alteration is the cause for the diaphoresis and diuresis that this client is experiencing? a.Elevated temperature caused by postpartum infection b.Increased basal metabolic rate after giving birth c.Loss of increased blood volume associated with pregnancy d.Increased venous pressure in the lower extremities

ANS: C

What is the primary rationale for the thorough drying of the infant immediately after birth? a.Stimulates crying and lung expansion b.Removes maternal blood from the skin surface c.Reduces heat loss from evaporation d.Increases blood supply to the hands and feet

ANS: C

What should the nurses next action be if the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day? a.Immediately inform the physician. b.Have the laboratory draw blood for reanalysis. c.Recognize that this count is an acceptable range at this point postpartum. d.Immediately begin antibiotic therapy.

ANS: C

Where is the point of maximal intensity (PMI) of the FHR located? a.Usually directly over the fetal abdomen b.In a vertex position, heard above the mothers umbilicus c.Heard lower and closer to the midline of the mothers abdomen as the fetus descends and internally rotates d.In a breech position, heard below the mothers umbilicus

ANS: C

Which clinical finding indicates that the client has reached the second stage of labor? a.Amniotic membranes rupture. b.Cervix cannot be felt during a vaginal examination. c.Woman experiences a strong urge to bear down. d.Presenting part of the fetus is below the ischial spines.

ANS: C

Which documentation on a womans chart on postpartum day 14 indicates a normal involution process? a.Moderate bright red lochial flow b.Breasts firm and tender c.Fundus below the symphysis and nonpalpable d.Episiotomy slightly red and puffy

ANS: C

Parents who have not already done so need to make time for newborn follow-up of the discharge. According to the American Academy of Pediatrics (AAP), when should a breastfeeding infant first need to be seen for a follow-up examination? a. 2 weeks of age b. 7 to 10 days after childbirth c. 4 to 5 days after hospital discharge d. 48 to 72 hours after hospital discharge

ANS: D

What are the most common causes for subinvolution of the uterus?a.Postpartum hemorrhage and infection b.Multiple gestation and postpartum hemorrhage c.Uterine tetany and overproduction of oxytocin d.Retained placental fragments and infection

ANS: D

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the client in emptying her bladder.

ANS: D

Which of the following statements is used to describe a characteristic of a uterine contraction? Select all that apply. 1. Frequency (how often contractions occur) 2. Intensity (the strength of the contraction at its peak) 3. Resting tone (the tension in the uterine muscle between contractions) 4. Appearance (shape and height) 5. Attitude (the way the uterus presents itself)

ANS: 1, 2, 3

The nurse is monitoring the fetal heart rate (FHR) of a client. When would the nurse observe early decelerations? 1. During uterine contractions 2. When external sound is applied 3. When the abdomen is palpated 4. During regular fetal movement

ANS: 1. During uterine contractions

While monitoring the fetal heart rate (FHR) of a client, the nurse notes tachycardia. What is a probable cause for this condition? 1. Early signs of fetal distress 2. Maternal hypothermia 3. Maternal hypoglycemia 4. Atrioventricular dissociation

ANS: 1. Early signs of fetal distress

When assessing uterine activity, nurses should be aware of what? 1. The examiner's hand should be placed on the fundus before, during, and after contractions 2. The frequency and duration of contractions are measured in seconds for consistency 3. Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together 4. The resting tone between contractions is described as either placid or turbulent

ANS: 1. The examiner's hand should be placed on the fundus before, during, and after contractions

Fetal well-being during labor is assessed by monitoring what? 1. The response of the fetal heart rate (FHR) to uterine contractions (UCs) 2. Maternal pain control 3. Accelerations in the FHR 4. An FHR greater than 110 beats/minute

ANS: 1. The response of the fetal heart rate (FHR) to uterine contractions (UCs)

After monitoring the fetal heart activity the nurse documents the fetal heart rate (FHR) to be in category II, according to the three-tier FHR classification system. What findings would the nurse have observed? 1. Minimal variability. 2. Moderate variability. 3. Less than 110 beats/minute. 4. Accelerations were present.

ANS: 1. minimal variability

The primary health care provider has asked the nurse to draw blood for an umbilical cord acid-base determination test. What should the nurse do in this situation? 1. Administer terbutaline (Brethine) before the test. 2. Collect blood from both umbilical artery and vein. 3. First perform the fetal scalp stimulating technique. 4. Only collect blood from the baby's umbilical artery.

ANS: 2. Collect blood from both umbilical artery and vein.

Which area does the nurse assess to hear loud, clear fetal heart sounds? 1. Fetal head 2. Fetal back 3. Fetal neck 4. Fetal abdomen

ANS: 2. Fetal back

The nurse is assessing the fetal heart rate in a pregnant client with diabetes during the first stage of labor. At what time intervals should the nurse perform FHR tracing? 1. 5 minutes 2. 60 minutes 3. 15 minutes 4. 30 minutes

ANS: 3. 15 minutes

The nurse instructs a pregnant client to breathe through the mouth and keep it open while pushing during labor. What is the rationale for this nursing intervention? 1. Avoiding nasal congestion in the client 2. To decrease efforts required for pushing 3. Facilitating increased oxygen to the fetus 4. To avoid deceleration in fetal heart rate

ANS: 3. Facilitating increased oxygen to the fetus

The nurse is caring for a client with electronic fetal monitoring using a spiral electrode. How is the use of a spiral electrode different from the use of an ultrasound transducer? 1. It is used only during the antepartum period. 2. It is used when the cervix has not yet dilated. 3. It is applied firmly to the maternal abdomen. 4. It is used after the membranes have ruptured.

ANS: 4. It is used after the membranes have ruptured.

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the womans vital signs, which finding would be of greatest concern to the nurse? a.Temperature 37.9 C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg b.Temperature 37.4 C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg c.Temperature 38 C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg d.Temperature 36.8 C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg

ANS: A

A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this womans fundus? a.1 centimeter above the umbilicus b.2 centimeters below the umbilicus c.Midway between the umbilicus and the symphysis pubis d.Nonpalpable abdominally

ANS: A

In recovery, if a woman is asked to either raise her legs (knees extended) off the bed or flex her knees, and then place her feet flat on the bed and raise her buttocks well off the bed, the purpose of this exercise is to assess what? a.Recovery from epidural or spinal anesthesia b.Hidden bleeding underneath her c.Flexibility d.Whether the woman is a candidate to go home after 6 hours

ANS: A

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh, baby Rh+ b. Mother Rh, baby Rh c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh

ANS: A

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (enzyme immunoassay [EIA] 0.8); hematocrit, 30%. How should the nurse best interpret these data? a.Rubella vaccine should be administered. b.Blood transfusion is necessary. c.Rh immune globulin is necessary within 72 hours of childbirth. d. Kleihauer-Betke test should be performed.

ANS: A

What is the most critical nursing action in caring for the newborn immediately after the birth? a.Keeping the airway clear b.Fostering parent-newborn attachment c.Drying the newborn and wrapping the infant in a blanket d.Administering eye drops and vitamin K

ANS: A

When should discharge instruction, or the teaching plan that tells the woman what she needs to know to care for herself and her newborn, officially begin? a. At the time of admission to the nurses unit b. When the infant is presented to the mother at birth c. During the first visit with the physician in the unit d. When the take-home information packet is given to the couple

ANS: A

Which component of the physical examination are Leopolds maneuvers unable to determine? a.Gender of the fetus b.Number of fetuses c.Fetal lie and attitude d.Degree of the presenting parts descent into the pelvis

ANS: A

Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand?a.Client is considered to be in active labor when she arrives at the facility with contractions. b.Client can have only her male partner or predesignated doula with her at assessment. c.Children are not allowed on the labor unit. d. NonEnglish speaking client must bring someone to translate.

ANS: A

When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective? a.Dilation of the cervix b.Descent of the fetus to 2 station c.Rupture of the amniotic membranes d.Increase in bloody show

ANS: A (The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor, indicates that the woman is in true labor. Engagement and descent of the fetus are not synonymous and may occur before labor. ROM may occur with or without the presence of labor. Bloody show may indicate a slow, progressive cervical change (e.g., effacement) in both true and false labor.)

The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication? a.Intrauterine infection b.Hemorrhage c.Precipitous labor d.Supine hypotension

ANS: A (When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of the contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.)

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.) a.Nonreassuring or abnormal FHR pattern b.Inadequate uterine relaxation c.Vaginal bleeding d.Prolonged second stage e.Prolapse of the cord

ANS: A, B, C, D, E

If a woman is at risk for thrombus and is not ready to ambulate, which nursing intervention would the nurse use? (Select all that apply.) a. Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots b. Having her flex, extend, and rotate her feet, ankles, and legs c. Having her sit in a chair d. Immediately notifying the physician if a positive Homans sign occurs e. Promoting bed rest

ANS: A, B, D

Which physiologic factors are reliable indicators of impending shock from postpartum hemorrhage? (Select all that apply.) a. Respirations b. Skin condition c. Blood pressure d. Level of consciousness e. Urinary output

ANS: A, B, D, E

Which practices contribute to the prevention of postpartum infection? (Select all that apply.) a. Not allowing the mother to walk barefoot at the hospital b. Educating the client to wipe from back to front after voiding c. Having staff members with conditions such as strep throat, conjunctivitis, and diarrhea stay home d. Instructing the mother to change her perineal pad from front to back each time she voids or defecates e. Not permitting visitors with cough or colds to enter the postpartum unit

ANS: A, C, D

Many new mothers experience some type of nipple pain during the first weeks of initiating breastfeeding. Should this pain be severe or persistent, it may discourage or inhibit breastfeeding altogether. Which factors might contribute to this pain? (Select all that apply.) a. Improper feeding position b. Large-for-gestational age infant c. Fair skin d. Progesterone deficiency e. Flat or retracted nipples

ANS: A, C, E

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: A. Change the woman's position B. Notify the care provider C. Assist with amnioinfusion D. Insert a scalp electrode

ANS: A. Change the woman's position. Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava.

The nurse caring for the laboring woman should understand that early decelerations are caused by: A. Altered fetal cerebral blood flow B. Umbilical cord compression C. Uteroplacental insufficiency D. Spontaneous rupture of membranes

ANS: A. Correct: Early decelerations are the fetus's response to fetal head compression.

The nurse providing care for the laboring woman should understand that accelerations with fetal movement: A. Are reassuring B. Are caused by umbilical cord compression C. Warrant close observation D. Are caused by uteroplacental insufficiency

ANS: A. Correct: Episodic accelerations in the FHR occur during fetal movement and are indications of fetal well-being.

Fetal tachycardia is most common during: A. Maternal fever B. Umbilical cord prolapse C. Regional anesthesia D. MgSO4 administration

ANS: A. Maternal fever Fetal tachycardia can be considered an early sign of fetal hypoxemia and can also result from maternal or fetal infection.

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time? a. Run warm water on her breasts during a shower. b. Apply ice to the breasts for comfort. c. Express small amounts of milk from the breasts to relieve the pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

ANS: B

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. What is the primary purpose of this activity? a.To facilitate maternal-newborn interaction b.To stimulate the uterus to contract c.To prevent neonatal hypoglycemia d.To initiate the lactation cycle

ANS: B

The nurse should be cognizant of which postpartum physiologic alteration? a.Cardiac output, pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth. b.Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth. c.Lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. d.Hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth

ANS: B

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a.Admission to the hospital at the start of labor b.When accelerations of the FHR are noted c.On maternal perception of perineal pressure or the urge to bear down d.When membranes rupture

ANS: B

What information should the nurse understand fully regarding rubella and Rh status? a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination. c. Rh immunoglobulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immunoglobulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

ANS: B

What is the rationale for the administration of an oxytocic (e.g., Pitocin, Methergine) after expulsion of the placenta? a.To relieve pain b.To stimulate uterine contraction c.To prevent infection d.To facilitate rest and relaxation

ANS: B

When caring for a newly delivered woman, what is the best measure to prevent abdominal distention after a cesarean birth? a. Rectal suppositories b. Early and frequent ambulation c. Tightening and relaxing abdominal muscles d. Carbonated beverages

ANS: B

Which statement by a newly delivered woman indicates that she knows what to expect regarding her menstrual activity after childbirth? a.My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter. b.My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles. c.I will not have a menstrual cycle for 6 months after childbirth. d.My first menstrual cycle will be heavier than normal and then will be light for several months after.

ANS: B

Which statement concerning the third stage of labor is correct? a.The placenta eventually detaches itself from a flaccid uterus. b.An expectant or active approach to managing this stage of labor reduces the risk of complications. c.It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface. d.The major risk for women during the third stage is a rapid heart rate.

ANS: B

Which statement regarding the postpartum uterus is correct? a.At the end of the third stage of labor, the postpartum uterus weighs approximately 500 g. b.After 2 weeks postpartum, it should be abdominally nonpalpable. c.After 2 weeks postpartum, it weighs 100 g. d.Postpartum uterus returns to its original (prepregnancy) size by 6 weeks postpartum.

ANS: B

The breast-feeding mother should be taught to expect which changes to the condition of the breasts? (Select all that apply.) a.Breast tenderness is likely to persist for approximately 1 week after the start of lactation. b.As lactation is established, a mass may form that can be distinguished from cancer by its positional shift from day to day. c.In nonlactating mothers, colostrum is present for the first few days after childbirth. d.If suckling is never begun or is discontinued, then lactation ceases within a few days to a week. e.Little change occurs to the breasts in the first 48 hours

ANS: B, C, D

Postpartum fatigue (PPF) is more than just feeling tired. It is a complex phenomenon affected by physiologic, psychologic, and situational variables. Which factors contribute to this phenomenon? (Select all that apply.) a. Precipitous labor b. Hospital routines c. Bottle feeding d. Anemia e. Excitement

ANS: B, D, E

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor? a.I passed some thick, pink mucus when I urinated this morning. b.My bag of waters just broke. c.The contractions in my uterus are getting stronger and closer together. d.My baby dropped, and I have to urinate more frequently now.

ANS: C (Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes (ROM) often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.)

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next?a.Immediately notify the womans primary health care provider. b.Prepare to administer an oxytocic to stimulate uterine activity. c.Document the findings because they reflect the expected contraction pattern for the active phase of labor. d.Prepare the woman for the onset of the second stage of labor

ANS: C (The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta. In addition, the nurse documents these findings in the clients medical record. This labor pattern indicates that the client is in the active phase of the first stage of labor. Nothing indicates a need to notify the primary health care provider at this time. Oxytocin augmentation is not needed for this labor pattern; this contraction pattern indicates that the woman is in active labor. Her contractions will eventually become stronger, last longer, and come closer together during the transition phase of the first stage of labor. The transition phase precedes the second stage of labor, or delivery of the fetus.)

Under the Newborns and Mothers Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. What is the correct interpretation of this legislation? a. 24; 72 b. 24; 96 c. 48; 96 d. 48; 120

ANS: C (dr. G said 48 and 72 but this question from the book says 48 and 96 so if she uses quizlet id go off this answer unless its fill in the blank)

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a.Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips b.Determining the frequency by timing from the end of one contraction to the end of the next contraction c.Evaluating the intensity by pressing the fingertips into the uterine fundus d.Assessing uterine contractions every 30 minutes throughout the first stage of labor

ANS: C The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips. Many women may experience labor pain in the lower segment of the uterus, which may be unrelated to the firmness of the contraction detectable in the uterine fundus. The frequency of uterine contractions is determined by palpating from the beginning of one contraction to the beginning of the next contraction. Assessment of uterine activity is performed in intervals based on the stage of labor.

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. What amount of blood loss does the postpartum nurse anticipate? (Select all that apply.) a.100 ml b.250 ml or less c.300 to 500 ml d.500 to 1000 ml e.1500 ml or greater

ANS: C, D

The nurse providing care for the laboring woman should understand that late FHR decelerations are caused by: A. Altered cerebral blood flow B. Umbilical cord compression C. Uteroplacental insufficiency D. Meconium fluid

ANS: C. Correct: Uteroplacental insufficiency would result in late decelerations in the FHR.

Fetal bradycardia is most common during: A. Intraamniotic infection B. Fetal anemia C. Prolonged umbilical cord compression D. Tocolytic treatment using ritodrine

ANS: C. Prolonged umbilical cord compression Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternalhypotension.

A client is concerned that her breasts are engorged and uncomfortable. What is the nurses explanation for this physiologic change? a.Overproduction of colostrum b.Accumulation of milk in the lactiferous ducts and glands c.Hyperplasia of mammary tissue d.Congestion of veins and lymphatic vessels

ANS: D

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurses highest priority in this situation? a.Prepare the woman for imminent birth. b.Notify the womans primary health care provider. c.Document the characteristics of the fluid. d.Assess the fetal heart rate (FHR) and pattern

ANS: D

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia does the nurse expect to find when evaluating this client? a.Lochia rubra b.Lochia sangra c.Lochia alba d.Lochia serosa

ANS: D

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath three times daily, and a stool softener. Which information regarding the clients condition is most closely correlated with these orders? a. Woman is a gravida 2, para 2. b.Woman had a vacuum-assisted birth. c.Woman received epidural anesthesia. d.Woman has an episiotomy.

ANS: D

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurses highest priority at this time? a. Beginning an intravenous (IV) infusion of Ringers lactate solution b. Assessing the womans vital signs c. Calling the womans primary health care provider d. Massaging the womans fundus

ANS: D

The nurse performs a vaginal examination to assess a clients labor progress. Which action should the nurse take next? a.Perform an examination at least once every hour during the active phase of labor. b.Perform the examination with the woman in the supine position. c.Wear two clean gloves for each examination. d.Discuss the findings with the woman and her partner.

ANS: D (The nurse should discuss the findings of the vaginal examination with the woman and her partner, as well as report the findings to the primary care provider. A vaginal examination should be performed only when indicated by the status of the woman and her fetus. The woman should be positioned so as to avoid supine hypotension. The examiner should wear a sterile glove while performing a vaginal examination for a laboring woman.)

When a nulliparous woman telephones the hospital to report that she is in labor, what guidance should the nurse provide or information should the nurse obtain? a.Tell the woman to stay home until her membranes rupture. b.Emphasize that food and fluid intake should stop. c.Arrange for the woman to come to the hospital for labor evaluation. d.Ask the woman to describe why she believes she is in labor.

ANS: D Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data. The initial nursing activity should be to gather data about the womans status. The amniotic membranes may or may not spontaneously rupture during labor.

1While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should: a.Change the woman's position b.Discontinue the oxytocin infusion c.Insert an internal monitor d.Document the finding in the client's record

ANS: a. change the woman's position