Unit 2 - Practice Test - ch 2,6,7,8

35. After the membranes have ruptured, the nurse should assess the fetal heart rate (FHR) for ________ minute(s).

1 The FHR is checked for 1 full minute to ensure that the infant is not in distress from cord compression resultant from the lost buoyancy.

Which hormone initiates the maturation of the ovarian follicle? a. Estrogen b. Follicle-stimulating hormone c. Progesterone d. Luteinizing hormone

b. Follicle-stimulating hormone Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle.

What is the least amount of sensation that one perceives as pain? a. Tolerance b. Threshold c. Level d. Abatement

b. Threshold Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.

35. The ___________ is a period of years during which the woman's ability to reproduce gradually declines.

climacteric The climacteric is a period of years during which the woman's ability to reproduce gradually declines.

36. Where the labia majora and the labia minora meet is known as the fourchette or ___________________ __________.

obstetrical perineum Where the labia majora and the labia minora meet is known as the fourchette or obstetrical perineum. Lacerations in this area often occur during childbirth

34. The nurse explains that the "four Ps" of the birth process are __________, __________, __________, and __________.

powers, passenger, passage, psyche The four interrelated components of the process of labor and birth, called the "four Ps," are powers, passenger, passage, and psyche.

36. The ______________ ___________, also called the psychoprophylactic method, is the basis of most childbirth preparation classes in the United States.

Lamaze method The Lamaze method, also called the psychoprophylactic method, is the basis of most childbirth preparation classes in the United States.

In males the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH) from the anterior pituitary stimulate testosterone production in the ________ cells of the testes.

Leydig The Leydig cells in the testes are stimulated by the FSH and LH to produce testosterone.

The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management? a. Slow abdominal breathing b. Guided relaxation c. Listening to music d. Massage

Massage According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter fibers and "closes the gate."

33. _____________________________ is a lower-than-normal amount of amniotic fluid.

Oligohydramnios Oligohydramnios is a lower amount than normal of amniotic fluid.

The nurse is educating high school students about puberty. What will the nurse indicate regulates the production of sperm and secretion hormones? a. Testes b. Vas deferens c. Ejaculatory ducts d. Prostate gland

Testes The testes have two functions: manufacture of spermatozoa and secretion of androgens.

The husband of a woman in labor asks, "What does it mean when the baby is at minus 1 station?" After giving an explanation, what statement by the husband indicates that teaching was effective? a. "Fetal head is above the ischial spines." b. "Fetal head is below the ischial spines." c. "Fetal head is engaged in the mother's pelvis." d. "Fetal head is visible at the perineum."

a. "Fetal head is above the ischial spines." Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines. Minus stations are above the ischial spines.

A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block? a. "I'm having a contraction. Can I get the pudendal block now?" b. "I'll get the pudendal block right before I deliver." c. "The nurse midwife will insert the needles into my vagina." d. "It takes a few minutes after the medicine is administered to make me feel numb."

a. "I'm having a contraction. Can I get the pudendal block now?" The pudendal block does not block pain from contractions and is given just before birth.

The nurse is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters of the obstetric conjugate? a. 10 to 10.5 b. 11 to 11.5 c. 12.5 to 13 d. 14 to 14.5

a. 10 to 10.5 The obstetric conjugate is approximately 1.5 to 2 centimeters shorter than the diagonal conjugate.

A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, "My doctor won't induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need?" What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12

a. 6 The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG).

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency

a. A well-oxygenated fetus Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus

a. Abnormal clotting An epidural block is not used if a woman has abnormal blood clotting.

One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action? a. Check the fundus for position and firmness. b. Report to the doctor immediately. c. Change the pads and chart the time. d. Time how long it takes to soak one pad.

a. Check the fundus for position and firmness. Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism

a. Chorioamnionitis Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.

What chemical substance(s) produced in the body acts as a natural pain reliever? a. Endorphins b. Morphine c. Codeine d. Atropine

a. Endorphins Endorphins are natural body substances that are similar to morphine and may explain why laboring women need smaller doses of analgesia.

What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in the mother

a. Fetal distress Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.

The physician performs an amniotomy on a laboring woman. What will be the nurse's priority assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes

a. Fetal heart rate The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.

33. When the nurse reads in the history and physical of a pregnant patient that she has a platypelloid pelvis, the nurse is aware that this pelvis has a narrow _____________ diameter, making a vaginal birth unlikely.

anteroposterior The platypelloid pelvis is very narrow from front to back (anteroposterior). The shape of this pelvis makes vaginal delivery unlikely.

A pregnant woman asks the nurse, "Will I be able to have a vaginal delivery?" The nurse knows that which is the most favorable pelvic type for vaginal birth? a. Gynecoid b. Android c. Anthropoid d. Platypelloid

a. Gynecoid The gynecoid pelvis is the typical female pelvis and is most favorable for vaginal birth.

What is the most appropriate nursing action to take when a laboring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 liters via mask. d. Notify the doctor.

a. Help her breathe into her cupped hands. Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.

A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the woman's change in behavior? a. Labor has progressed to the transition phase. b. She lacked adequate preparation for the labor experience. c. The woman would benefit from a different form of analgesia. d. The contractions have increased from mild to moderate intensity

a. Labor has progressed to the transition phase. If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

The nurse encourages the members of a prenatal class to seriously consider breastfeeding. What does breast milk provide in addition to nourishment for the infant? a. Maternal antibodies b. Stimulus for red blood cell production c. Endorphins that soothe the infant d. Hormones that stimulate growth

a. Maternal antibodies Breast milk provides maternal antibodies to the infant that give the child acquired immunity from some diseases for several months.

The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia

a. Maternal tachycardia Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol.

A group of nursing students plans to teach a class of sixth-grade girls about menstruation. What correct information will the nursing students teach to the class? a. Menarche usually occurs around 12 years of age. b. Ovulation occurs regularly from the very first cycle. c. A regular cycle is established by the third period. d. Typically, menstrual flow is heavy and lasts up to 10 days.

a. Menarche usually occurs around 12 years of age. The beginning of menstruation, called menarche, occurs at about 12 years of age. Early cycles are irregular and anovulatory.

A mother is anxious about her ability to breastfeed after her child is born because of her small breast size. What would be an important point to teach this mother? a. Milk is produced in ducts and lobules regardless of breast size. b. Supplementing breastfeeding with formula allows the infant to receive adequate nutrition. c. Breast size can be increased with exercise. d. Drinking extra milk during pregnancy allows breasts to produce adequate amounts of milk. ANS: A

a. Milk is produced in ducts and lobules regardless of breast size. Breast size does not influence the ability to secrete milk.

An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, "Please give me something for the pain. I can't take the pain!" What is the priority nursing diagnosis? a. Pain related to uterine contractions b. Knowledge deficit related to the birth experience c. Ineffective coping related to inadequate preparation for labor d. Risk for injury related to lack of prenatal care

a. Pain related to uterine contractions The most important issue for this woman, at this time, is effective pain management.

A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. What action by the physician will the nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency cesarean section.

a. Perform an amniotomy. Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact.

How should the nurse intervene to relieve perineal bruising and edema following delivery? a. Place an ice pack on the area for 12 hours. b. Place a warm pack on the perineal area for 24 hours. c. Administer aspirin to relieve inflammation. d. Change the perineal pad frequently.

a. Place an ice pack on the area for 12 hours. An ice pack can be placed on the mother's perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours after delivery.

What does the nurse explain is used to soften the cervix with a "cervical ripening" agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation

a. Prostaglandin gel insertion Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.

A nurse instructs a woman's labor coach to comfort her by firmly pressing on her lower back. What is this technique? a. Sacral pressure b. Distraction c. Effleurage d. Conscious relaxation

a. Sacral pressure Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labor.

A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask.

a. Stop the oxytocin infusion. Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. What is this presentation? a. Vertex b. Military c. Brow d. Face

a. Vertex In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

32. After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________.

amnioinfusion A warm saline bolus is instilled in the uterus to "float" the fetus to relieve pressure on the cord.

A newly married couple tells the nurse they would like to wait a few years before starting a family. Which statement made by the man indicates an understanding about sexual activity and pregnancy? a. "My wife can't get pregnant if I withdraw before climax." b. "A man can secrete semen before ejaculation." c. "If we don't have intercourse very often, my wife won't get pregnant." d. "It is safe to ejaculate outside the vagina."

b. "A man can secrete semen before ejaculation." Semen may be secreted during sexual intercourse before ejaculation.

A nurse is planning to teach couples about the physiology of the sex act. What correct information will the nurse provide? a. "Fertilization of an ovum requires penetration by several sperm." b. "An ovum must be fertilized within 24 hours of ovulation." c. "It takes 4 to 5 days for sperm to reach the fallopian tubes." d. "Sperm live for only 24 hours following ejaculation."

b. "An ovum must be fertilized within 24 hours of ovulation." After ovulation, the egg lives for only 24 hours. Sperm must be available during that time if fertilization is to occur.

Which statement indicates a woman understands activity limitations for the management of preterm labor? a. "After my shower in the morning, I do the laundry and straighten up the house; then I rest." b. "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day." c. "I have a 2-year-old to care for, but I try to rest as much as I can." d. "I get really bored at home, so I go to the shopping mall for just a little while."

b. "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day." Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

What statement indicates a woman has correct information about oogenesis? a. "Women make fewer ova as they age." b. "Women have all of their ova at the time they are born." c. "Ova production begins at birth and continues until puberty." d. "New ova are made every month from puberty to climacteric."

b. "Women have all of their ova at the time they are born." Oogenesis (formation of immature ova) does not occur after fetal development. Females are born with about 2 million immature ova, which rapidly reduce by adulthood.

The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths per minute. What should be the patient's rate while performing slow breathing? a. 9 b. 11 c. 15 d. 20

b. 11 The range of respirations should be no lower than half of the base rate and no more rapid than double the base rate.

What assessment should be taken immediately after the anesthesiologist administers an epidural block to a laboring woman? a. Bladder for distention b. Blood pressure c. Sensation in the lower extremities d. Intravenous fluid flow rate

b. Blood pressure Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also important but not an initial assessment.

A 10-year-old girl asks the nurse, "What is the first sign of puberty?" What is the correct nursing response? a. An increase in height b. Breast development c. Appearance of axillary hair d. The first menstrual period

b. Breast development The first outward change of puberty in girls is the development of breasts at about 10 to 11 years of age.

The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warm fluids to drink b. By helping the patient to ambulate in the room c. By seating the patient upright in a straight-back chair d. By positioning the patient on her right side

b. By helping the patient to ambulate in the room Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.

When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a woman's pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension

b. By reducing blood flow to the uterus Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression of the cord

b. Cervical laceration Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.

What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema

b. Cold pack to the perineum Ice is applied to the perineum to reduce bruising and edema.

What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions? a. Offer warm liquids to the patient. b. Encourage the patient to pant. c. Engage the patient in conversation. d. Assist the patient to the knee-chest position.

b. Encourage the patient to pant. Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt conversation during contractions. Walking intensifies contractions.

When describing the female reproductive tract to a pregnant woman, the nurse would explain that which uterine layer is involved in implantation? a. Perimetrium b. Endometrium c. Myometrium d. Internal os

b. Endometrium The endometrium is the inner mucosal layer of the uterus that is governed by cyclical hormonal changes. It is functional during menstruation and during the implantation of a fertilized ovum.

What marks the end of the third stage of labor? a. Full cervical dilation b. Expulsion of the placenta and membranes c. Birth of the infant d. Engagement of the head

b. Expulsion of the placenta and membranes The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief? a. Frequently asking for ice chips b. Facial grimacing c. Changing positions in bed d. Covering her face with her hands

b. Facial grimacing Facial grimacing may be an indicator of unexpressed pain.

It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. How would the nurse record this presentation? a. Complete breech b. Frank breech c. Double footling d. Buttocks presentation

b. Frank breech When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.

After several hours of labor, a nursing assessment reveals that a woman's cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False

b. Hypotonic The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix.

b. Increase fetal lung maturity. Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

A pregnant woman's membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her obstetrician if she has a temperature above 37.8° C (100° F). c. Massage her breasts to promote uterine relaxation. d. Rest in a side-lying Trendelenburg position with hips elevated.

b. Notify her obstetrician if she has a temperature above 37.8° C (100° F). For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8° C (100° F).

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub.

b. Notify the charge nurse immediately. Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.

The nurse is assisting with pelvic inlet measurements on a pregnant woman. What measurement will provide the nurse with information about whether the woman can deliver vaginally? a. Diagonal conjugate b. Obstetric conjugate c. Transverse diameter d. Anteroposterior diameter

b. Obstetric conjugate This measurement determines if the fetus can pass through the birth canal.

What is the Dick-Read method of childbirth preparation based on? a. Mild sedation throughout labor b. Relaxation techniques c. Skin stimulation d. Deep massage

b. Relaxation techniques The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.

When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate? a. Urinary retention b. Severe lower back pain c. A shorter labor process d. Nausea

b. Severe lower back pain If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mother's sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.

The nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" What is the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the woman's partner to locate a registered nurse. d. Assist with deep breathing to slow the labor process.

b. Stay with the woman and use the call bell to get help. If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by "walking" fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift.

b. The fundus is assessed by "walking" fingers from the side of the uterus to the midline. Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.

A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent? a. Nausea and vomiting b. Vomiting and aspiration c. Abdominal cramping d. Intestinal obstruction

b. Vomiting and aspiration The major adverse effect of general anesthesia is aspiration of stomach contents.

37. A nursing student is observing prenatal exams in the office setting. The health care provider informs the student that the fetal position is LSA. The student interprets this as a ____________________ presentation.

breech LSA is the abbreviation for Left Sacrum Anterior. This is a breech presentation.

The nurse has explained menstruation to a 13-year-old girl. What statement indicates the girl needs additional education? a. "Periods last about 5 days." b. "My cycle should get regular in 6 months." c. "I should expect heavy bleeding with clots." d. "Periods come about every 4 weeks."

c. "I should expect heavy bleeding with clots." Clots are not normally seen in menstrual discharge. A normal menstrual flow is 30 to 40 mL blood and 30 to 50 mL serous fluid.

While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. What is the nurse's most informative response? a. "When you feel increased fetal movement" b. "When contractions are 10 minutes apart" c. "When membranes have ruptured" d. "When abdominal or groin discomfort occurs"

c. "When membranes have ruptured" Ruptured membranes are an indication that the woman should go to the hospital or birthing center.

A female patient reports her menstrual cycle consistently occurs every 32 days. What day of her cycle can the woman anticipate ovulation? a. 14 b. 16 c. 18 d. 20

c. 18 Ovulation occurs when a mature ovum is released from the follicle about 14 days before the onset of the next menstrual period.

The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous cesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy

c. 35-year-old multigravida with history of precipitate birth A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset. If the woman's tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth.

What will the nurse explain to a 12-year-old patient when describing what characterizes nocturnal emissions? a. A drop in testosterone level b. Sexual stimulation c. Absence of sperm in ejaculate d. Association with violent dreams

c. Absence of sperm in ejaculate Nocturnal emissions, also known as "wet dreams," occur without sexual stimulation and contain no sperm. Testosterone levels are constant until midlife.

What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8° C.

c. Amniotic fluid is watery and pale green. Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.

What is the most important nursing intervention during the fourth stage of labor? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding.

c. Assess for hemorrhage. Immediately after giving birth, every woman is assessed for signs of hemorrhage.

A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing.

c. Blow in short breaths. If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down.

Where are the secretions responsible for nourishing sperm excreted from? a. Vas deferens b. Epididymis c. Cowper's gland d. Scrotum

c. Cowper's gland The Cowper's gland secretions nourish the sperm.

What contraction duration and interval does the nurse recognize could result in fetal compromise? a. Duration shorter than 30 seconds, interval longer than 75 seconds b. Duration shorter than 90 seconds, interval longer than 120 seconds c. Duration longer than 90 seconds, interval shorter than 60 seconds d. Duration longer than 60 seconds, interval shorter than 90 seconds

c. Duration longer than 90 seconds, interval shorter than 60 seconds Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

An infant is delivered with the use of forceps. What should the nurse assess for in the newborn? a. Loss of hair from contact with forceps b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation

c. Facial asymmetry Pressure from forceps may injure the infant's facial nerve, which is evidenced by facial asymmetry.

A 14-year-old boy is at the pediatric clinic for a checkup. What physical changes of puberty will the nurse indicate are related to the production of testosterone? a. Stimulation of production of white cells and platelets b. Promotion of growth of small bones c. Increase in muscle mass and strength d. Decrease in production of sebaceous gland secretions

c. Increase in muscle mass and strength Testosterone increases muscle mass, promotes strength and growth of long bones, and enhances production of red blood cells.

What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine b. Decrease flow of intravenous (IV) fluids c. Increase oxygen to 10 L/minute d. Prepare to increase oxytocin drip

c. Increase oxygen to 10 L/minute The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.

A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor pain. What statement is accurate about a patient's expression of pain? a. It reduces the patient's perception of pain. b. It is intensified by the vertex position of the fetus. c. It is influenced by culture. d. It can be completely controlled by nonpharmacological techniques.

c. It is influenced by culture. Culture influences how women feel about birth and what is an acceptable response to pain.

A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor? a. It can cause medication given at later stages to be ineffective. b. It will have no complications for the mother or infant. c. It may result in respiratory depression to the newborn. d. It will speed up labor and increase pain.

c. It may result in respiratory depression to the newborn. The risk of narcotic analgesics is that they cross the placenta and can cause fetal respiratory depression.

Which narcotic antagonist is used to reverse narcotic-induced respiratory depression? a. Hydroxyzine (Vistaril) b. Phenobarbital c. Naloxone (Narcan) d. Nitrous oxide

c. Naloxone (Narcan) Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics.

A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. On her back with her head lower than the rest of her body d. Supine with her legs elevated and bent at the knee

c. On her back with her head lower than the rest of her body The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.

What is the function of contractions during the second stage of labor? a. Align the infant into the proper position for delivery b. Dilate and efface the cervix c. Push the infant out of the mother's body d. Separate the placenta from the uterine wall

c. Push the infant out of the mother's body The contractions push the infant out of the mother's body as the second stage of labor ends with the birth of the infant.

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula.

c. Reposition the woman on her side. Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fear related to the probable need for cesarean delivery. c. Dysuria related to prolonged labor and decreased intake. d. Risk for injury related to hemorrhage.

d. Risk for injury related to hemorrhage. In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.

The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, "Please give me something." What is the most appropriate pain relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery.

c. Stay and breathe with her during contractions. The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.

Why is the relaxation phase between contractions important? a. The laboring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward delivery at these times.

c. The contractions can interfere with fetal oxygenation. Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

What is the nurse primarily concerned about maintaining in the initial care of the newborn? a. Fluid intake b. Feeding schedule c. Thermoregulation d. Parental bonding

c. Thermoregulation Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.

The nurse uses a diagram to demonstrate the fimbriae when teaching nursing students about the female anatomy. What is true about fimbriae? a. They form the passageway for the sperm to meet the ovum. b. They are the site of fertilization. c. They are fingerlike projections that "capture" the ovum. d. They propel the egg through the fallopian tube.

c. They are fingerlike projections that "capture" the ovum. Fimbriae are the fingerlike projections from the infundibulum that "capture" the ovum at ovulation and conduct it into the fallopian tube.

The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this stage of labor? a. They get the infant positioned for delivery. b. They push the infant into the vagina. c. They dilate and efface the cervix. d. They get the mother prepared for true labor.

c. They dilate and efface the cervix. The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency

c. Warm flush Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push? a. "At the beginning of a contraction, hold your breath and push for 10 seconds." b. "Take a deep breath and push between contractions." c. "Begin pushing when a contraction starts and continue for the duration of the contraction." d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation."

d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation." When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.

A 12-year-old female pediatric patient experienced menarche 3 months ago. Her mother voices concern to the pediatric office nurse regarding the irregularity of her daughter's menstrual cycle. What is the nurse's best response? a. "Worrying is not the answer." b. "I will talk to the pediatrician about a gynecological referral." c. "I can only discuss this with your daughter." d. "Early cycles are often irregular."

d. "Early cycles are often irregular." Early cycles are often irregular and may be anovulatory. Regular cycles are usually established within 6 months to 2 years of the menarche. In an average cycle, the flow (menses) occurs every 28 days, plus or minus 5 to 10 days.

A mother asks the nurse, "When will I know my child has entered puberty?" What will the nurse state based on an understanding of changes associated with puberty? a. "Your daughter will have her first period." b. "You'll recognize puberty by the mood swings." c. "The child becomes interested in the opposite sex." d. "Secondary sex characteristics, such as pubic hair, appear.

d. "Secondary sex characteristics, such as pubic hair, appear." Puberty begins when the secondary sex characteristics appear. Puberty ends when mature sperm are formed in the male and when regular menstrual cycles occur in the female.

How long does sperm remain viable in the female reproductive tract? a. 12 hours b. 1 day c. 2 days d. 4 days

d. 4 days Sperm can remain viable in the reproductive tract of the female for as long as 4 to 5 days.

Why should the nurse encourage the mother to void during the fourth stage of labor? a. A full bladder could interfere with cervical dilation. b. A full bladder could obstruct progress of the infant through the birth canal. c. A full bladder could obstruct the passage of the placenta. d. A full bladder could predispose the mother to uterine hemorrhage.

d. A full bladder could predispose the mother to uterine hemorrhage. A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.

The nurse is educating a pregnant patient who expects to breastfeed. The nurse knows that when a patient breastfeeds, which portions of the breast secrete milk? a. Lactiferous sinuses b. Lobes c. Montgomery's glands d. Alveoli

d. Alveoli The alveoli secrete milk.

A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia? a. Reduced fetal heart rate b. Long, intense contractions c. Sudden leg cramps d. Bladder distention

d. Bladder distention A side effect of an epidural block is urine retention because the anesthesia interferes with the woman's ability to have an urge to void. The patient may have to be catheterized.

A laboring patient requests hot and cold applications be applied to her abdomen for pain control. How will this intervention act to control pain? a. By increasing endorphin production b. By facilitating effacement and dilation c. By producing increasing pain tolerance d. By stimulation of large nerve fibers

d. By stimulation of large nerve fibers The gate control theory explains how pain impulses reach the brain for interpretation. It supports several nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the conduction of impulses through small-diameter fibers. Techniques to stimulate large-diameter fibers and "close the gate" to painful impulses include massage, palm and fingertip pressure, and heat and cold applications.

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section." What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience

d. Grieving related to loss of expected birth experience Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.

Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation

d. Hyperventilation Hyperventilation is sometimes a problem if a woman is breathing rapidly.

The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia? a. Restrict oral fluids. b. Keep legs flexed. c. Walk with assistance as soon as possible. d. Lie flat for several hours.

d. Lie flat for several hours. The woman would be advised to remain flat for several hours after the block to decrease the chance of postspinal headache.

What signifies the end of puberty for a male? a. Facial hair is evident. b. Erections can be sustained. c. Ejaculate is greater than 5 mL. d. Mature sperm are formed.

d. Mature sperm are formed. Puberty ends for a male when mature sperm are formed by the testes.

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows that what indicates the beginning of true labor? a. Contractions that are relieved by walking b. Discomfort in the abdomen and groin c. A decrease in vaginal discharge d. Regular contractions becoming more frequent and intense

d. Regular contractions becoming more frequent and intense In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

For what is the decrease in estrogen and progesterone during the menstrual cycle responsible? a. Degeneration of the corpus luteum b. Ovulation c. Follicle maturation d. Shedding of the endometrium

d. Shedding of the endometrium The fall in estrogen and progesterone causes the endometrium to break down, resulting in menstruation.

A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported and give her a back massage b. Supine with legs bent at the knee c. Standing with support d. Sitting up and leaning forward on the over-bed table

d. Sitting up and leaning forward on the over-bed table A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.

A new mother is distressed and tearful about the elevated dome over her infant's posterior fontanelle. The nurse responds, "This condition will resolve itself in a few days." What is the cause? a. Prolonged pressure against the partially dilated cervix b. Small leak of fluid through the posterior fontanelle c. Pressure of the forceps during delivery d. The effect of the vacuum extractor

d. The effect of the vacuum extractor The "chignon" is due to the effect of the vacuum extractor and will disappear in a few days.

At 1 and 5 minutes of life, a newborn's Apgar score is 9. What does the nurse understand that a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in stable condition.

d. The newborn is in stable condition. Apgar scoring is a system for evaluating the infant's need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is stable.

The nurse is speaking with a couple trying to conceive a child. What will the nurse remind the couple is a factor that can decrease sperm production? a. Infrequent sexual intercourse b. The man not being circumcised c. The penis and testes being small d. The testes being too warm

d. The testes being too warm The scrotum is suspended away from the perineum to lower the temperature of the testes for sperm production.

What does the nurse note when measuring the frequency of a laboring woman's contractions? a. How long the patient states the contractions last b. The time between the end of one contraction and the beginning of the next c. The time between the beginning and the end of one contraction d. The time between the beginning of one contraction and the beginning of the next

d. The time between the beginning of one contraction and the beginning of the next The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.

A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurse's best response to explain the frequent blood pressure assessments? a. They ensure that unsafe levels of hypertension do not occur. b. They help assess for the need for further pain relief. c. They monitor the progress of labor. d. They ensure adequate placental perfusion.

d. They ensure adequate placental perfusion. The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading to fetal hypoxia.

The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use of frequent position changes

d. Use of frequent position changes A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor.

A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth? a. Eclampsia b. Placental abruption c. Congestive heart failure d. Uterine rupture

d. Uterine rupture Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous cesarean birth.

35. The massage technique that stimulates the large-diameter fibers in order to block impulses from the small-diameter fibers is ____________________.

effleurage Effleurage stimulates the large-diameter fibers and blocks the pain impulses from the small-diameter fibers.

34. A(n) _______________ is a narrow cone inserted into the cervix to "ripen" the cervix to increase uterine contractions.

laminaria A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water.