3302-Exam 2

Signs of third stage of labor

(Delivery of Placenta) -Globular shaped uterus -Rise in the fundus -Sudden gush of blood -Lengthening of the cord

Fetal Heart Rate: Bradycardia

*Lasts at least 10 mins -Mild: 100-109 -Moderate: 70-99 -Severe: <70

Fetal Heart Rate: Tachycardia

*Lasts at least 10 mins -Mild: 161-180 -Severe: >180 Possible causes: increase in sympathetic tone, fever, dehydration, hyperthyroidism, anemia, smoking, fetal hypoxemia, corioamnitis

Effacement

-cervix becomes shorter and thinner -estimated as a % First time mom will be fully effaced before dilated

The nurse reviews the prescription from the primary care provider to begin an amnioinfusion. The nurse knows that an amnioinfusion is indicated for which of the following reasons? (select all that apply) 1. oligohydramnios 2. hydramnios 3. fetal cord compression 4. hydration 5. meconium is in amniotic fluid

1, 3, 5

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1.Left occipital anterior (LOA) 2.Left sacral posterior (LSP) 3.Right mentum anterior (RMA) 4.Right sacral posterior (RSP)

1.Left occiput anterior (LOA)

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1.Change in maternal pulse rate from 76 to 98 bpm. 2.Change in fetal heart rate from 128 to 102 bpm. 3.Maternal blood pressure of 150/100. 4.Maternal temperature of 102.4ºF

2.Change in fetal heart rate from 128 to 102 bpm.

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure

3. Presence of abdominal pain.

A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1.Administer bethamethasone (Celestone) 12 mg IM daily 2.Maintain strict bed rest. 3.Assess cervical dilation. 4.Regulate intravenous (Ringer's lactate: drip rate to 150 cc/hr).

3.Assess cervical dilation.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1.Left upper quadrant (LUQ). 2.Left lower quadrant (LLQ). 3.Right upper quadrant (RUQ). 4.Right lower quadrant (RLQ)

3.Right upper quadrant (RUQ).

After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1.The fetus is becoming hypoxic. 2.The fetus is becoming alkalotic. 3.The fetus is in the middle of a sleep cycle. 4.The fetus has a healthy nervous system.

4.The fetus has a healthy nervous system.

Fetal Heart Rate: Normal variability

6-25 bpm

Fetal Heart Rate: Marked variability

>25 bpm -Associated with fetal hypoxia, may need to immediately deliver and have a resuscitation team ready

A nurse is caring for a client who is receiving oxytocin (pitocin)for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A. frequency of every 2 min B. duration of 90 to 120 seconds C. intensity of 60 to 90 mm hg D. resting tone of 15 mm hg

B. duration of 90 to 120 seconds

Which of the following positions should a nurse place a client prior to a c-section birth? A. trendelenburg with the lower ext elevated B. L lateral side-lying with head elevated C. prone with a wedge under R hip D. supine with a wedge under R hip

D supine, on her back. Placing wedge under one of her hips will tilt the client so that she will not have vena cava compression.

A nurse is reviewing the fetal monitor tracing of a client who is in active labor. The nurse knows that a fetus receives more oxygen during which of the following? A. peak of uterine contraction B. increment of the uterine contraction C. decrement of the uterine contraction D. relaxation between uterine contractions

D. Relaxation between uterine contractions

Abruptio Placentae (Placental abruption)

Premature separation of the placenta from its implantation site -Intense pain and sudden -Most common risk factors: Hypertension, cocaine abuse, blunt external trauma (car wreck, abuse), smoking

Contraction duration

how long contractions are - from beginning of one contraction to the end of that same contraction

Contraction frequency

how often the contractions occur - from beginning of one to start of next

If the deceleration is variable in nature, the nurse should......

put the patient on the left side-lying position to attempt to relieve the pressure off of the cord.

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? 1. Cephalohematoma 2. Mongolian spots 3. Telangiectatic nevi 4. Molding

1. Cephalohematoma

A woman, 32 weeks' gestation, contracting every 3 min x 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema

1. Low urinary output.

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line.

1. The mass appeared on the second day after birth. 4. The mass appears on only one side of the head. Explanation: 1. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days. 4. Cephalohematomas do not cross the suture lines.

A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate

1. The woman talks and laughs during contractions.

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1."I am so excited to be in labor." 2."I can't stand this pain any longer!" 3."I need ice chips because I'm so hot." 4."I have to push the baby out right now!"

2. "I can't stand this pain any longer!"

The nurse is assessing the Bishop score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1.Gestational age. 2.Rupture of membranes. 3.Cervical dilatation. 4.Fetal station .5.Cervical position.

3, 4, and 5

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta

3. Abruptio placentae.

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline 2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body 3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Where should the nurse place a fetoscope best to hear the fetal heart beat? 1.Left upper quadrant. 2.Right upper quadrant. 3.Left lower quadrant. 4.Right lower quadrant.

3. Left lower quadrant.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The gestational age of the fetus. 2. The maternal blood pressure. 3. The relationship between the decelerations and the labor contractions. 4.The placement of the fetal heart electrode in relation to the fetal position

3. The relationship between the decelerations and the labor contractions.

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1.Hematocrit 48%. 2.Potassium 5.5 mEq/L. 3.Platelets 75,000. 4.Sodium 130 mEq/L

3.Platelets 75,000. Should be over 100,000 I think

A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures

4. Client has no grand mal seizures

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is NOT one of these essential factors? 1. Chemical 2. Mechanical 3. Thermal 4. Psychologic

4. Psychologic

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. Inform the mother that the rate is normal.

The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1.Late decelerations. 2.Hyperthermia. 3.Hypotension. 4.Early decelerations

1. Late decelerations. Late decels = placental insufficiency. After 40 weeks the placenta begins to not work as well (has a "shelf life")

Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Select all that apply. 1. Cover the newborn's eyes at all times, even when not under the lights. 2. Close the newborn's eyelids before applying eye patches. 3. Keep the baby in a diaper 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.

2. Close the newborn's eyelids before applying eye patches. 3. Keep the baby in a diaper 5. Reposition the baby every 2 hours.

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations

2. Drop in blood pressure.

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: 1. Transition period 2. First period of reactivity 3. Organizational stage 4. Second period of reactivity

2. First period of reactivity

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her hips. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus

2. Flex the woman's thighs sharply toward her hips.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1.Contraction frequency and duration. 2.Maternal temperature. 3.Cervical dilatation and effacement. 4.Maternal pulse rate

2. Maternal temperature.

The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick counts

2. Signs of preterm labor.

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction while another occurred 10 seconds after the contraction and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow

3. Cord compression

A client, 37 weeks' gestation is 6 cm dilated, contractions are moderate to strong and occurring 2-3 mins apart, and last 40-60 secs. She is starting to become very restless and is requesting an epidural. This client is in what phase of labor? 1. Transistion 2. 1st 3. 2nd 4. Active

4. Active

Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia.

A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1.The baby is in the breech position. 2.The baby is in the horizontal lie. 3.The baby's presenting part is engaged. 4.The baby's chin is resting on its chest

4. The baby's chin is resting on its chest

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? 1. Breech presentation. 2. Station + 3. 3. Oligohydramnios. 4. Dilation 2 cm

1. Breech presentation.

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm

1. Chest circumference 31.5 cm, head circumference 33.5 cm

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? 1. "The white spots on my baby's nose are called milia, and are harmless." 2. "The whitish cheeselike substance in the creases is vernix, and will be absorbed." 3. "The red spots with a white center on my baby are abnormal acne." 4. "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician.

3. "The red spots with a white center on my baby are abnormal acne." Explanation: 3. Red spots with white or yellow centers are erythema toxicum. The peak incidence is at 24 to 48 hours of life. The condition rarely presents at birth or after 5 days of life. The cause is unknown, and no treatment is necessary.

A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dl. The best nursing action is to: 1. Recheck the blood sugar in 4 hours. 2. Begin an IV of 10% dextrose. 3. Feed the baby 1 ounce of formula. 4. Document the findings in the chart.

4. Document the findings in the chart. Rationale 1: Infants of diabetic mothers should be fed frequently, and should have their blood sugar assessed frequently. Four hours is too long a time frame. Rationale 2: A blood sugar reading of 47 mg/dl is considered normal for a neonate. No IV is needed. Rationale 3: Feeding would be appropriate if the infant's blood sugar were below 45 mg/dl, but this infant's reading is 47. Rationale 4: A blood sugar level of 47 mg/dl is a normal finding; documentation is an appropriate action.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings

1.Put the client in the knee chest position.