quiz 2 questions

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic?

A cephalohematoma

Interventions that are underutilized in promoting a normal birth. Select all that apply. a. Oral nutrition and fluids in labor b. Open glottis pushing in the second stage of labor c. Skin-to-skin contact after birth for infant bonding d. Routine artificial rupture of membranes (amniotomy) e. Labor induction with Pitocin given intravenously f. Routine episiotomy to shorten labor length

A, B, C

The cardinal movements of labor include which of the following? Select all that apply. a. Extension and rotation b. Descent and engagement c. Presentation and position d. Attitude and lie e. Flexion and expulsion

A, B, E

After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? a. Foramen ovale b. Ductus arteriosus c. Ductus venosus d. Umbilical vein

a

When determining the frequency of contractions, the nurse would measure which of the following? a. Start of one contraction to the start of the next contraction b. Beginning of one contraction to the end of the same contraction c. Peak of one contraction to the peak of the next contraction d. End of one contraction to the beginning of the next contraction

a

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely."

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?

Longitudinal

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?

Nothing. Normal time for stage three is 5 to 30 minutes.

The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply.

Oxytocin Progesterone Prostaglandins

When going through the transition phase of labor, women often feel out of control. What do women in the transition phase of labor need the most?

Positive reinforcement

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?

The cervix takes around 12 to 16 hours to dilate during first pregnancy.

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

The frequency of the contractions is every 5 minutes.

A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? a. Gonorrhea and chlamydia b. Thrush and enterobacter c. Staphylococcus and syphilis d. Hepatitis B and herpes

a

Which of the following observations would suggest that placental separation is occurring? a. Uterus stops contracting altogether. b. Umbilical cord pulsations stop. c. Uterine shape changes to globular. d. Maternal blood pressure drop

c

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: a. Initial period of reactivity b. Second period of reactivity c. Decreased responsiveness period d. Sleep period for newborns

b

A client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: a. Hypertonic labor b. Precipitate labor c. Hypotonic labor d. Dysfunctional labor

c

A nursing student questions the nursery nurse why they don't bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of: a. Jaundice b. Infection c. Hypothermia d. Anemia

c

By the end of the second stage of labor, the nurse would expect which of the following events? a. The cervix is fully dilated and effaced b. placenta is detached and expelled c. fetus is born and on mother's chest d. woman to request pain medication

c

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

cervix

When managing a client's pain during labor, nurses should: a. Make sure the agents given do not prolong labor b. Know that all pain relief measures are similar c. Support the client's decisions and requests d. Not recommend nonpharmacologic method

c

Which assessment would indicate that a woman is in true labor? a. Membranes are ruptured and fluid is clear. b. Presenting part is engaged and not floating. c. Cervix is 4 cm dilated, 90% effaced. d. Contractions last 30 seconds, every 5 to 10 minutes.

c

Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. Two soft spots palpated between the cranial bones b. A spongy area of edema outlined on the head c. Head circumference 32 cm, chest 34 cm d. Asymmetry of the head with overriding bones

c

Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation?

shoulder

At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as: a. 5 points b. 6 points c. 7 points d. 8 points

d

The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: a. Stimulate uterine contractions b. Numb cervical pain receptors c. Prevent cervical lacerations d. Soften and efface the cervix

d

A laboring woman is admitted to the labor and birth suite at 6 cm dilation. She would be in which phase of the first stage of labor? a. Latent b. Active c. Transition d. Early

b

The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to promote: a. Conjugation of bilirubin b. Blood clotting c. Foreman ovale closure d. Digestion of complex proteins

b

The nurse is developing a plan of care for a woman experiencing dystocia. Which of the following nursing interventions would be the nurse's high priority? a. Changing the woman's position frequently b. Providing comfort measures to the woman c. Monitoring the fetal heart rate patterns d. Keeping the couple informed of the labor progress

c

The shortest but most intense phase of labor is the: a. Latent phase b. Active phase c. Transition phase d. Placental expulsion phase

c

A nurse is conducting an in-service program for a group of nurses working in the prenatal clinic. When discussing the theories about the onset of labor, the nurse points out which factor as a possible cause? Select all that apply.

release of oxytocin by the pituitary prostaglandin production in the myometrium

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? a. Transporting the newborn in an isolette b. Maintaining a warm room temperature c. Placing the newborn on a warmed surface d. Drying the newborn immediately after birth

d

Because the newborn's red blood cells break down much sooner than those of an adult, what might result? a. Anemia b. Bruising c. Apnea d. Jaundice

d

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?

increase even if relaxing and taking a shower

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic?

relaxin

After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have: a. Intense back pain b. Frequent leg cramps c. Nausea and vomiting d. A precipitous birth

a

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

b

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

restoration of blood flow to uterus and placenta

The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor? a. Hepatitis b. Herpes simplex virus c. Toxoplasmosis d. Human papillomavirus

b

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

molding

Which statement made by the client in the early phase of labor requires clarification?

"I have been at 3 cm for hours and I am making no progress."

The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at zero station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

Engagement

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA

A nurse observes a 3-day-old term newborn that is starting to appear mildly jaundiced. What might explain this condition? a. Physiologic jaundice secondary to breast-feeding b. Hemolytic disease of the newborn due to blood incompatibility c. Exposing the newborn to high levels of oxygen d. Overfeeding the newborn with too much glucose water

a

When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: a. 15 to 30 minutes b. 5 to 10 minutes c. 45 to 60 minutes d. 60 to 75 minutes

a

Which of the following findings in a newborn would be considered normal? a. Passage of meconium within the first 24 hours b. Respiratory rate of 80 breaths per minute c. Yellow skin tones at 10 hours after birth d. Bleeding from the umbilicus area

a

Which of the following practices would not be included in a physiologic birth? a. Early induction of labor <39 weeks' gestation b. Freedom of movement for the laboring woman c. Continuous presence and support throughout labor d. Encouraging spontaneous pushing when urge felt

a

As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: a. Discomfort level is greater with false labor. b. Progressive cervical changes occur in true labor. c. There is a feeling of nausea with false labor. d. There is more fetal movement with true labor

b

The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: a. Encourage ambulation every 30 minutes b. Provide pain relief measures c. Monitor the Pitocin infusion rate closely d. Prepare the woman for an amniotomy

b

Physiologic preparation for labor would be demonstrated by: a. Decrease in Braxton Hicks contractions felt by mother b. Weight gain and increase in appetite by mother c. Lightening, whereby the fetus drops into true pelvis d. Fetal heart rate accelerations and increased movements

c

The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of: a. Respiratory distress syndrome b. Bottle mouth syndrome c. Sudden infant death syndrome d. GI regurgitation syndrome

c

The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? a. Reposition the client on the left side. b. Begin 100% oxygen via face mask. c. Document this as indicating a normal pattern. d. Call the health care provider immediately.

c

When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate: a. Abnormal gastrointestinal newborn transition and needs to be reported b. An intestinal anomaly that needs immediate surgery c. A patent anus with no bowel obstruction and normal peristalsis d. A malabsorption syndrome resulting in fatty stools

c

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. Hypothyroidism b. Cystic fibrosis c. Phenylketonuria d. Sickle cell disease

c

The nurse performs a physical examination on a newborn 2 hours after birth. Which of the following findings indicate a need for a pediatric consultation? Select all that apply: a. Respiratory rate of 50 breaths per minute b. Intermittent episodes of apnea, lasting <10 seconds each c. Absent Moro reflex when startled d. Preauricular skin tag noted on left ear e. White raised bumps noted on nose and face f. Yellow blanching of the skin when pressure applied to the nose

c, f

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? a. Increase surfactant levels b. Stabilize the newborn's temperature c. Destroy Rh-negative antibodies d. Oxidize bilirubin on the skin

d

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

d

When assessing the following women, which would the nurse identify as being at the greatest risk for preterm labor? a. Woman who had twins in a previous pregnancy b. Client living in a large city close to the subway c. Woman working full time as a computer programmer d. Client with a history of a previous preterm birth

d

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as: a. Cervical insufficiency b. Contracted pelvis c. Maternal disproportion d. Fetopelvic disproportion

d

Which of the following newborns could be described as breathing normally? a. Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm. b. Newborn B is breathing diaphragmatically with sternal retractions, at a rate of 70 bpm. c. Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis. d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.

d

Which one of the following immunizations is most commonly received by newborns before hospital discharge? a. Pneumococcus b. Varicella c. Hepatitis A d. Hepatitis B

d

Which fetal lie is most conducive to a spontaneous vaginal birth? Transverse Longitudinal Perpendicular Oblique

longitudinal

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

After conducting a review class on the labor and birth process for a group of nurses working in the community clinic, the nurse determines that the teaching was successful when the group identifies which factors as affecting the labor process? Select all that apply.

powers passenger patience

A nurse knows that a doula can be part of a laboring client's health care team. Which intervention would the nurse explain to the client is part of the doula's responsibility?

providing support and explanations during labor and birth

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:

the buttocks are presenting first with both legs extended up toward the face.