OB Final Review
The nurse is describing the pre-embryonic stage of fetal development to a group of students. Place the events in their proper sequence for this stage. Formation of the zygote Cleavage Formation of the morula Formation of the blastocyst Implantation
Formation of the zygote Cleavage Formation of the morula Formation of the blastocyst Implantation Rationale: The pre-embryonic stage begins with fertilization and the formation of a zygote. Mitosis or cleavage occurs. After four cleavages, the 16 cells appear as a solid ball of cells or morula. With additional cell division, the morula divides into specialized cells, the blastocyst and trophoblast. The trophoblast attaches itself to the surface of the endometrium and implantation occurs.
Why is general anesthesia not commonly used in labor and delivery? Select all that apply. a) A pregnant woman has a risk for vomiting and aspiration. b) In an emergency situation, it takes too long to administer. c) Physiologic changes make it more difficult to intubate a pregnant woman. d) General anesthesia readily crosses the placenta. e) Malignant hypothermia is a common side effect in pregnant women.
a) A pregnant woman has a risk for vomiting and aspiration. d) General anesthesia readily crosses the placenta. Rationale: General anesthesia is not commonly used in labor and delivery because all anesthetic agents cross the placenta and affect the fetus. Common complications include fetal depression, uterine relaxation, and potential maternal vomiting and aspiration. Malignant hypothermia is rare and is no more likely to occur in a pregnant client than in a nonpregnant client. General anesthesia can be started quickly and causes rapid loss of consciousness.
A postpartum mother has the following lab data recorded: a negative rubella titer. What is the appropriate nursing intervention? a) Administer rubella vaccine before discharge. b) Assess the rubella of the baby c) No action needed. d) Notify the health care provider.
a) Administer rubella vaccine before discharge. Rationale: Rubella is a virus, which when contracted during pregnancy has significant complications for the fetus. The illness is mild to the adult but can result in the infant being born deaf and blind. There is no cure, the CDC recommends all individuals be vaccinated against rubella. If the titer is negative, the mother does not have protection against rubella and the next pregnancy would be at risk. She should receive the vaccination prior to discharge from the hospital. This makes option A incorrect. Assessing the rubella titer of the baby would not mean anything. The baby has not had rubella and has not received antibodies against rubella from the mother. Notifying the health care provider is not a priority, as most institutions have standing orders to administer the rubella vaccine if the mother's rubella titer is negative.
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate? a) Assess the newborn for signs of respiratory distress. b) Reassure the parents that this is an expected pattern. c) Notify the health care provider immediately. d) Tell the parents not to worry since his color is fine.
a) Assess the newborn for signs of respiratory distress. Rationale: Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.
The nurse is developing a presentation for a group of young adult women about premenstrual syndrome. Which of the following would the nurse include as possible treatment options? Select all that apply. a) Diuretic therapy b) Decrease in water intake c) Antipsychotic medications d) NSAIDs e) Vitamin and mineral supplements f) Reduction of caffeine intake
a) Diuretic therapy d) NSAIDs e) Vitamin and mineral supplements f) Reduction of caffeine intake Rationale: Treatment options for PMS include lifestyle changes such as reduction in caffeine intake, a well-balanced diet with increased water intake, and limited alcohol intake. Vitamin and mineral supplements, NSAIDs, and diuretic therapy may be used. Antidepressants and antianxiety agents, not antipsychotic agents, may also be options.
The nurse is explaining to a primigravida how the zygote becomes implanted into the uterus. How would the nurse describe the structure formed in this process known as the blastocyst? a) First one, then two layers of cells surround a fluid-filled space. b) A group of cells is forming what will become the embryo. c) The endometrium is enriched in nutrients in preparation for pregnancy. d) A ball of about 16 identical cells is formed when the zygote divides
a) First one, then two layers of cells surround a fluid-filled space. Rationale: The zygote divides rapidly, until it forms a ball of about 16 identical cells, which is then called a morula. The morula is then swept down the fallopian tube and into the uterus, a process that takes approximately 7 to 9 days. The lining of the uterus, or endometrium, has become rich in nutrients in preparation for the pregnancy. Just before the morula reaches the uterus, the cells begin to form layers; first one, then two layers surround a fluid-filled space, called a blastocyst. Another group of cells form what will become the embryo.
Which assessment finding would lead the nurse to suspect infection as the cause of a client's PROM? a) Foul odor b) Ferning c) Blue color on Nitrazine testing d) Yellow-green fluid
a) Foul odor Rationale: A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would suggest meconium. A blue color on Nitrazine testing and ferning indicate the presence of amniotic fluid.
A woman yesterday delivered a child with a cleft palate. The newborn is in the special care nursery and the mother has seen the newborn only at delivery. The nurse's priority is to assist the mother to a) Grieve the loss of the perfect baby b) Care for herself c) Visit the child in the nursery d) Review causes of a cleft palate
a) Grieve the loss of the perfect baby Rationale: Grief is the response to loss. The process of mourning will take precedence over the mother's self-care in this initial period. The nurse will assess the mother to note her physical condition, but the mother will be focused on the child. The mother can be assisted to determine the appropriate time to see the child, and then attachment can be promoted.
Which of the following are areas of leading health indicators in the Healthy People initiative? Select all that apply. a) Injury and violence b) Technology c) Obesity and overweight d) Physical activity e) Immunization
a) Injury and violence c) Obesity and overweight d) Physical activity e) Immunization Rationale: Obesity and overweight, physical activity, injury and violence, and immunization all represent areas of leading health indicators.
A client is in the transitional phase of labor. Which of the following would the nurse most likely find? Select all that apply. a) Irritability with restlessness b) Contractions occurring every 3 minutes c) Strong desire to push d) Apprehension mixed with excitement e) Cervical effacement of 70% f) Cervical dilation of 6 cm
a) Irritability with restlessness c) Strong desire to push Rationale: A strong desire to push occurs most often in the transitional phase of the first stage of labor. During this phase the woman commonly experiences increased apprehension and irritability with restless movements and feelings of loss of control and being overwhelmed. Cervical dilation from 4 to 7 cm characterizes the active phase of the first stage of labor. Contractions occurring every 2 to 5 minutes are associated with the active phase of the first stage of labor. The woman in the early or latent phase of the first stage of labor often is filled with apprehension but is excited about the start of labor. During the active phase of the first stage of labor, cervical effacement of 40% to 80% occurs.
The nurse is explaining the procedure for ultrasound to a pregnant patient and is discussing the amniotic fluid and how they will determine if there is too much or too little fluid. The patient asks about the purpose of the amniotic fluid What should the patient be informed? a) It provides unrestricted movement b) It provides symmetrical growth c) It regulates temperature d) It is for the physical protection of the growing fetus e) It produces hormones
a) It provides unrestricted movement b) It provides symmetrical growth c) It regulates temperature d) It is for the physical protection of the growing fetus Rationale: Amniotic fluid fills the amniotic cavity. It serves four main functions for the fetus: physical protection, temperature regulation, provision of unrestricted movement, and symmetrical growth.
Which of the following factors are known to contribute to vaginal yeast infections? Select all that apply. a) Poorly controlled diabetes b) Use of oral contraceptives c) Recent antibiotic therapy d) High hormone levels during pregnancy e) Excessive physical exercise f) Inflammation of Skene's and Bartholin's glands.
a) Poorly controlled diabetes b) Use of oral contraceptives c) Recent antibiotic therapy d) High hormone levels during pregnancy Rationale: Reported risk factors for the overgrowth of C. albicans include recent antibiotic therapy, which suppresses the normal protective bacterial flora; high hormone levels owing to pregnancy or the use of oral contraceptives, which cause an increase in vaginal glycogen stores; and uncontrolled diabetes mellitus or HIV infection, because they compromise the immune system. Exercise and glandular inflammation are not noted risk factors for yeast infections.
A nurse is working in an ambulatory healthcare clinic located in a poor neighborhood. Which nursing intervention would most likely provide the greatest benefit for the women and their children seen at this clinic? a) Providing them with drug samples for therapy b) Educating the parents about preventative care c) Cautioning them about home safety issues d) Promoting healthy sleep and rest habits
a) Providing them with drug samples for therapy Rationale: Preventive care is not as important as ensuring that women and children get the medicine needed. Home safety is not as important as ensuring that women and children get the medicine needed. People who live in poverty and many who live on very low incomes do not have enough money to afford the medications needed for therapy. Providing them with drug samples is a common intervention. Proper sleep and rest are not as important as ensuring that the child gets the medicine needed.
A 45-year-old pregnant woman with type O blood has had an amniocentesis to rule out Down syndrome. The fetus has type AB blood. What can the nurse warn the patient is a likely outcome if some fetal blood mixed with maternal blood during the procedure? a) The baby will have postdelivery jaundice. b) Placental abruption c) The baby will develop hemolytic anemia. d) Preterm delivery
a) The baby will have postdelivery jaundice. Rationale: The infant and mother have ABO incompatibility. The result is a development of antibodies and breaking down of the blood resulting in jaundice in the infant after delivery. The mixing of some fetal blood with maternal blood during the amniocentesis would not cause placental abruption or preterm delivery. Hemolytic anemia is caused by Rh incompatibility, not ABO incompatibility.
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because: a) These measurements may not change until after the blood loss is large b) Maternal anxiety adversely affects these vital signs c) They relate more to change in condition than to the amount of blood lost d) The body's compensatory mechanisms activate and prevent any changes
a) These measurements may not change until after the blood loss is large Rationale: The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 mL of blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus and on perineal pads, mattresses, and the floor.
Which of the female reproductive tract structures would the nurse describe to a group of young women as contain rug that enable it to dilate during labor and birth? a) Vagina b) Cervix c) Vulva d) Fallopian tube
a) Vagina Rationale: The vagina is a tubular, fibromuscular organ lined with mucous membrane that lies in a series of transverse folds called rugae. These rugae allow for extreme dilation of the canal during labor and birth. The cervix, the lower portion of the uterus, is composed of fibrous connective tissue that dilates during labor. The fallopian tube transports the ovum from the ovary to the uterus. The vulva is a collective term used to refer to the external female reproductive organs (mons pubis, labia majora and minora, clitoris, vestibular structures, and perineum).
The nurse is assessing a pregnant woman's health literacy during a prenatal visit. Which of the following would the nurse identify as impacting the woman's health literacy? Select all that apply. a) Woman's level of emotional distress b) Last grade completed in school c) Woman's employment status d) Lack of familiarity with the information e) Complexity of information
a) Woman's level of emotional distress d) Lack of familiarity with the information e) Complexity of information Rationale: Health literacy refers to the ability to read, understand, and use health care information. When new or unfamiliar information is presented or when emotional distress is present, reading ability and understanding are reduced. The last grade completed in school does not equate with reading ability. In addition, appearance, verbal ability, employment status, and educational level cannot reveal persons who do not read well.
The nursing student correctly identifies which of the following to be responsible for opening the door to childbirth education classes and bringing fathers back into the picture? (Check all that apply.) a) advocating birth without medication b) using only midwives c) advocating pain management d) focusing on relaxation techniques
a) advocating birth without medication d) focusing on relaxation techniques Rationale: "Natural childbirth" in the 1950's advocated birth without medication and focused on relaxation techniques. These techniques opened the door to childbirth education classes and helped to bring the father back into the picture. Giving pain medication and only using midwives did not play a role in getting classes introduced or getting the father more involved.
The nursing instructor is informing the students about the changes that have taken place due to the poor mortality rate of women during childbirth. She instructs the students that during the 17th and 18th centuries which of the following contributed deaths during childbirth? (Check all that apply.) a) hemorrhage b) exhaustion c) dehydration d) infection e) seizures f) lack of prenatal vitamins
a) hemorrhage b) exhaustion c) dehydration d) infection e) seizures Rationale: During the 17th and 18th centuries, women giving birth often died as a result of exhaustion, dehydration, infection, hemorrhage, or seizures. Although prenatal vitamins are known to help prevent certain complications, the lack of them at this time did not add to the high incidence of deaths.
At which time should the nurse screen a pregnant woman for group B streptococcus infection? a) 28 week' gestation b) 36 weeks' gestation c) 16 weeks' gestation d) 32 weeks' gestation
b) 36 weeks' gestation Rationale: All pregnant women should be screened for group B streptococcus infection at 35 to 37 weeks' gestation.
Which of the following would lead the nurse to suspect that a postpartum woman is having a problem? a) Increased levels of clotting factors b) Acute decrease in hematocrit c) Pulse rate of 60 beats/minute d) Elevated white blood cell count
b) Acute decrease in hematocrit Rationale: Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding.
A woman comes to the prenatal clinic suspecting that she is pregnant and assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? Select all that apply. a) Ultrasound visualization of the fetus b) Positive pregnancy test c) Absence of menstruation d) Ballottement e) Auscultation of a fetal heart beat f) Softening of the cervix
b) Positive pregnancy test d) Ballottement f) Softening of the cervix Rationale: Probable signs of pregnancy include a positive pregnancy test, ballottement, and softening of the cervix (Goodell's sign). Ultrasound visualization of the fetus, auscultation of a fetal heart beat, and palpation of fetal movements are considered positive signs of pregnancy. Absence of menstruation is a presumptive sign of pregnancy.
What is the primary function of uterine contractions after delivery of the infant and placenta? a) Return the uterus to normal size b) Seal off the blood vessels at the site of the placenta c) Stop the flow of blood d) Close the cervix
b) Seal off the blood vessels at the site of the placenta Rationale: The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood, but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, options A, C, and D are secondary to the constriction of blood vessels at the placental site.
A nurse is caring for a client in her third stage of labor. Which of the following would the nurse assess as indicating placental separation? Select all that apply. a) A relaxed and distended uterus b) Umbilical cord descending lower down c) Renewed bearing down efforts by client d) Falling downward of uterus in the abdomen e) Fresh gushing of blood from the vagina
b) Umbilical cord descending lower down c) Renewed bearing down efforts by client e) Fresh gushing of blood from the vagina Rationale: The signs of placental separation include a fresh gush of blood from the vagina, lengthening of the umbilical cord, and renewed bearing-down efforts by the client. When the client is in her third stage of labor, these indicate placental separation. A rising upwards of the uterus and a well-contracted globular uterus are the other signs of placental separation. Falling downward of the uterus in the abdomen and a relaxed uterus are the signs of uterine atony.
A nurse teaches new parents that the best way to help prevent infections in the newborn is which of the following? a) keep them warm at all times b) breastfeed c) keep them inside for the first month of life d) limit visitors
b) breastfeed Rationale: A major source of IgA, which helps in immunity, is human breast milk. Thus, breastfeeding is believed to have significant immunological advantages over formula. The other options such as keeping them in for a month and keeping them warm will not help prevent infections. Keeping the child away from people who have an infection might stop them from getting that infection. Doing so will not help build up the infant's immunity.
A nurse is instructing students on how to check an episiotomy and perineum of a woman after Which of the following are normal in the early postpartum period? (Select all that apply.) a) redness b) edema c) slight bruising d) discharge
b) edema c) slight bruising Rationale: During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness or discharge.
A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? a) "How do you feel about delivering your baby at 36 weeks?" b) "Your baby is premature and needs monitoring in the NICU." c) "We still need to monitor him closely for problems." d) "You are lucky to have given birth to a term newborn."
c) "We still need to monitor him closely for problems." Rationale: A baby born at 36 weeks' gestation is considered a late-preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn.
An LGA newborn has a blood glucose level of 23 mg/dL. Which of the following would the nurse do next? a) Initiate blow-by oxygen therapy. b) Feed the newborn 2 ounces of formula. c) Administer intravenous glucose immediately. d) Place the newborn under a radiant warmer.
c) Administer intravenous glucose immediately. Rationale: If an LGA newborn's blood glucose level is below 25 mg/dL, the nurse should institute immediate treatment with intravenous glucose regardless of the clinical symptoms. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.
When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval? a) Every 15 minutes b) Every 4 hours c) Every 30 minutes d) Every 60 minutes
c) Every 30 minutes Rationale: During the active phase of labor, FHR is monitored every 30 minutes. The woman's temperature is typically assessed every 4 hours during the first stage of labor. Contractions and vital signs are monitored every 30 to 60 minutes during the latent phase; contractions are assessed every 15 minutes during the transition phase.
After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? a) Side-lying b) Supine c) Knee-chest d) Sitting
c) Knee-chest Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.
The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which of the following would the nurse identify as the priority intervention? a) Oxytocin administration b) Immediate cesarean birth c) Pain relief measures d) Position changes
c) Pain relief measures Rationale: Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman's ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman's already high level of pain.
Mrs. Timms is a G1 P0. She is in active labor. One of your nursing diagnoses is "Risk for trauma to the woman or fetus related to intrapartum complications or a full bladder." What would be an appropriate nursing action in achieving the goal of "no complications due to a full bladder"? a) Place a Foley catheter into the bladder b) Get the woman up to void every two hours c) Palpate the area above the symphysis pubis every two hours d) Do a sterile "in and out" catheterization every two hours
c) Palpate the area above the symphysis pubis every two hours Rationale: Another source of trauma that can interfere with the progress of labor is a full bladder. Every two hours palpate the area just above the symphysis pubis feeling for a rounded area of distention, which indicates the bladder is full.
Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? a) Crackles on auscultation b) Costal breathing pattern c) Respiratory rate 45, irregular d) Nasal flaring, rate 65
c) Respiratory rate 45, irregular Rationale: Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.
One of the theories about the onset of labor is the prostaglandin theory. While not being conclusively proven that the action of prostaglandins initiate labor, it is known that prostaglandins do play a role in labor. What is an action of prostaglandins? a) Stimulates uterine muscle to relax b) Initiates cervical dilation c) Softens cervix d) Initiates relaxation of perineum
c) Softens cervix Rationale: The prostaglandin theory is another theory of labor initiation. Prostaglandins influence labor in several ways, which include softening the cervix and stimulating the uterus to contract. However, evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is inconclusive.
Which of the following would the nurse least expect to administer to a woman experiencing postpartum hemorrhage? a) Carboprost b) Methylergonovine c) Terbutaline d) Oxytocin
c) Terbutaline Rationale: Terbutaline is a tocolytic agent used to halt preterm labor. It would not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.
Assessment reveals that a woman's cervix is approximately 1 cm in length. The nurse would document this as: a) 75% effaced b) 0% effaced c) 100% effaced d) 50% effaced
d) 50% effaced Rationale: A cervix 1 cm in length is described as 50% effaced. A cervix that measures approximately 2 cm in length is described as 0% effaced. A cervix 1/2 cm in length would be described as 75% effaced. A cervix 0 cm in length would be described as 100% effaced.
A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? a) Taking-in b) Expectations c) Transition to mastery d) Reality
c) Transition to mastery Rationale: The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.
While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? a) Alert the physician stat and turn the newborn to her right side. b) Lower the newborn's head to stimulate crying. c) Administer oxygen via facial mask by positive pressure. d) Aspirate the oral and nasal pharynx with a bulb syringe.
d) Aspirate the oral and nasal pharynx with a bulb syringe. Rationale: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.
The nurse in a free clinic is caring for a 1-year-old girl and her single mother. Which action would be most important initially? a) Obtaining food stamps for the family b) Discussing family beliefs c) Observing the mother/child interaction d) Assessing the child's cognitive level
d) Assessing the child's cognitive level Rationale: A single mother using a free clinic suggests that she is living in poverty and that the child could be malnourished. Children living in poverty are more likely than other children to experience poor nutrition and inadequate health care. This could affect the child's cognitive development. Family beliefs, language barrier, and neglect are less likely to be an issue with this child's health. It's not known if food stamps are needed. Assessment is the priority.
The nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth, identifying this as postpartum: a) Depression b) Psychosis c) Bipolar disorder d) Blues
d) Blues Rationale: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: a) Molding b) Cephalhematoma c) Microcephaly d) Caput succedaneum
d) Caput succedaneum Rationale: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.
A woman who is 42 weeks pregnant comes to the clinic. Which of the following would be most important? a) Checking for spontaneous rupture of membranes b) Asking her about the occurrence of contractions c) Measuring the height of the fundus d) Determining an accurate gestational age
d) Determining an accurate gestational age Rationale: Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.
The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? a) Strong, brisk motor skills b) Wasted appearance of extremities c) Birthweight of 7 lb 14 oz d) Difficulty in arousing to a quiet alert state
d) Difficulty in arousing to a quiet alert state Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term.
Which of the following findings on a prenatal visit at 10 weeks might lead the nurse to suspect a hydatidiform mole? a) Complaint of frequent mild nausea b) Blood pressure of 120/84 mm Hg c) History of bright red spotting 6 weeks ago d) Fundal height measurement of 18 cm
d) Fundal height measurement of 18 cm Rationale: Findings with a hydatidiform mole may include uterine size larger than expected. Mild nausea would be a normal finding at 10 weeks' gestation. Blood pressure of 120/84 would not be associated with hydatidiform mole and depending on the woman's baseline blood pressure may be within acceptable parameters for her. Bright red spotting might suggest a spontaneous abortion.
During the development of the fetus, its chronic villi eventually meet with an area of uterine tissue to form the placenta. Which of the following statements accurately describes a function of the placenta. Select all answers that apply. a) It permits blood to bypass the right ventricle b) It cushions the fetus against injury c) It protects the umbilical cord d) It produces hormones that help maintain the pregnancy e) It slows the maternal immune response f) It carries waste away for excretion by the mother
d) It produces hormones that help maintain the pregnancy e) It slows the maternal immune response f) It carries waste away for excretion by the mother Rationale: The placenta supplies the developing organism with food and oxygen, carries waste away for excretion by the mother, slows the maternal immune response so that the mother's body does not reject the fetal tissues, and produces hormones that help maintain the pregnancy. Wharton's jelly protects the umbilical cord and the foramen ovale permits most of the blood to bypass the right ventricle. The amniotic fluid cushions the fetus against injury.
When palpating the fundus during a contraction, the nurse notes that is feels like a chin. The nurse interprets this finding as indicating which type of contraction? a) Mild b) Strong c) Intense d) Moderate
d) Moderate Rationale: A contraction that feels like the chin typically represents a moderate contraction. A contraction described as feeling like the tip of the nose indicates a mild contraction. A strong contraction feels like the forehead.
A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The nurse discusses the risk of transmitting the infection to her newborn, explaining that this infection is transmitted to the newborn through the: a) Breast milk b) Amniotic fluid c) Birth canal d) Placenta
d) Placenta Rationale: The syphilis spirochete can cross the placenta at any time during pregnancy. It is not transmitted via amniotic fluid, passage through the birth canal, or breast milk.
A woman develops HELLP syndrome. During labor, which of the following orders would you question? a) Assess the urine output every hour. b) Urge her to lie on her left side during labor. c) Assess her blood pressure every 15 minutes. d) Prepare her for epidural anesthesia.
d) Prepare her for epidural anesthesia. Rationale: A consequence of the HELLP syndrome is poor blood coagulation. Epidural anesthesia is not recommended when blood coagulation is in doubt.
A client is exhibiting signs of early engorgement, but her milk is still flowing easily. Which of the following suggestions would the nurse give to treat engorgement? a) Apply ice packs before a feeding. b) Have the baby nurse on both breasts with every feeding. c) Restrict fluid intake. d) Take a warm shower before a feeding.
d) Take a warm shower before a feeding. Rationale: Using warm compresses or a taking warm shower with water flowing over the breasts will soften the breast tissue before a feeding. Applying ice packs may be beneficial to reduce inflammation, but doing so is most appropriate after the feeding, because cold application causes vasoconstriction. The woman should maintain adequate fluid intake. It is not necessary for the baby to nurse on both breasts during every feeding.
A woman is in the second stage of labor and is crowning. Which diameter of the fetal skull, which is the smallest, should align with the anteroposterior diameter of the mother's pelvis, which is the narrowest diameter at the pelvic inlet? a) Occipitomental b) Suboccipitobregmatic c) Occipitofrontal d) Transverse (biparietal)
d) Transverse (biparietal) Rationale: The anteroposterior diameter of the pelvis, a space approximately 11 cm wide, is the narrowest diameter at the pelvic inlet so the best presentation for birth is when the fetus presents a transverse (biparietal) diameter (the narrowest fetal head diameter, at 9.25 cm) to this. The other diameters of the fetal skull that are listed are all larger.
The nurse through assessment can best differentiate between placenta previa and abruptio placentae by which of the following signs and or symptoms. a) Bleeding amount and consistency. b) Low back pain. c) Shape of the abdomen. d) Uterine tone and contractions of the uterus.
d) Uterine tone and contractions of the uterus. Rationale: With placenta previa the bleeding is often bright red and painless, with abruptio placentae the bleeding is usually dark and painful. The uterus is firm and hard and painful with the abruption; the uterus is often soft and lacks tone with the previa. The contractions of the uterus, low back pain, or the shape of the abdomen do not help to distinguish between placenta previa and abruption placentae.