ATI Testbank Questions- OB Exam #2 part III

A client who is 32 weeks pregnant telephones the nurse at her obstetricians office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is: a. You should come into the office and let the doctor check you. b. Acetaminophen is acceptable during pregnancy. You should not take aspirin, however. c. Back pain is common at this time during pregnancy because you tend to stand with a sway back. d. Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.

a. You should come into the office and let the doctor check you. A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The client needs to be assessed for preterm labor before providing pain relief.

Which assessment finding in the postpartum client following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b. Urine output >30 mL/hr c. Rebound skin turgor <5 seconds d. Pulse rate <120 beats/min

b. Urine output >30 mL/hr In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hr; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/min may be indications of hypovolemia.

When assessing the A of the acronym REEDA, the nurse should assess the: a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

c. edges of the episiotomy. In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage.

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

a. Distended bladder The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus.

After a birth complicated by a shoulder dystocia, the infants Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should: a. palpate the infants clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.

a. palpate the infants clavicles. Because of the shoulder dystocia, the infants clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.

A dose of dexamethasone 12 mg was administered to a client in preterm labor at 8:30 AM on March 12. The nurse knows that the next dose must be scheduled for: a. 2:30 PM on March 12. b. 8:30 PM on March 12. c. 8:30 AM on March 13. d. 2:30 PM on March 13.

c. 8:30 AM on March 13. The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 2:30 PM on March 12, 8:30 PM on March 12, and 2:30 PM on March 13 do not fall within this recommendation.

The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment? a. Check for edema. b. Check for range of motion. c. Check for adequate reflexes. d. Check for deep vein thrombosis.

d. Check for deep vein thrombosis. Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis. Edema is checked by palpating and pressing on the top of the foot, range of motion is not a postpartum assessment, and reflexes are checked at the patellar area.

A client who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurses priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of non-additive intravenous fluid. d. Reposition the client with her hips slightly elevated.

a. Notify the health care provider promptly. Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the client at high risk for uterine rupture. The client is now at high risk for shock. Non-additive intravenous fluids should be increased. Repositioning the client with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.

Which vaccinations are indicated for the postpartum client if she does not have immunity? (Select all that apply.) a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM

a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results.

Which finding would indicate an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL

b. Heart rate of 122 bpm Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.

The fetus in a breech presentation is often born by cesarean birth because: a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the client delivers vaginally.

b. compression of the umbilical cord is more likely. After the fetal legs and trunk emerge from the clients vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a. Have the client drink carbonated beverages to promote urinary excretion. b. Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the client to do pelvic floor exercises to combat potential stress incontinence.

d. Teach the client to do pelvic floor exercises to combat potential stress incontinence. Educating the client to use pelvic floor exercises will help strengthen pelvic muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the client is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period.

Birth for the nulliparous client with a fetus in a breech presentation is usually: a. cesarean section. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.

a. cesarean section. Birth for the nulliparous client with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.

A labor client has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, what birth method is available? a. Vaginal birth with vacuum extraction b. Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d. Insertion of Foley catheter into empty bladder to provide more room for fetal descent

c. Cesarean section The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the client should be prepped for a cesarean section.

Which is the best measure to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing abdominal muscles

c. Early and frequent ambulation Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs, but do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention.

Which assessment finding indicates uterine rupture? a. Fetal tachycardia occurs. b. The client becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.

d. Contractions abruptly stop during labor. A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.

Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/min b. Maternal change of position to knee-chest c. Administration of tocolytic agent d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area

a. Administration of oxygen via face mask at 8 to 10 L/min b. Maternal change of position to knee-chest c. Administration of tocolytic agent e. Vaginal elevation Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.

The nurse is teaching a nonbreastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

a. Avoid massaging the breasts. d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft. The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production.

Which assessment finding indicates a complication in the client attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction

a. Complaint of pain between the scapulae A client attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.

If the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? a. Document the finding. b. Tell the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis.

a. Document the finding. An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. Because this is a normal finding, there is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated.

Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Client who is bottle feeding her first child d. Client who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

a. Gravida 5, para 5 The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse.

The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a. I will gently pat the perineum dry rather than wipe. b. I will only use the perineal bottle after bowel movements. c. I will use cold water in the perineal bottle as I cleanse. d. I will use the perineal bottle without touching the perineum.

a. I will gently pat the perineum dry rather than wipe. d. I will use the perineal bottle without touching the perineum. The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements.

Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs

a. Incomplete uterine relaxation A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.

Which of the following would indicate an abnormal finding during the postpartum period? a. Lochia flow changing from alba to rubra b. Unable to palpate uterine fundus at 6-week postpartum checkup c. Presence of afterbirth pains d. Lochia flow heavier in the early morning 2 days following vaginal birth

a. Lochia flow changing from alba to rubra Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding. The uterine fundus should no longer be palpable at 2 weeks postbirth. Afterbirth pains during the postpartum period are a normal finding based on involution of the uterus. Lochia flow may be heavier on arising because of the effects of gravity and pooling of blood while recumbent.

Rho(D) immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative

a. Mother Rh-negative, baby Rh-positive An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mothers blood, not the infants.

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold c. Patient reports she took two sitz baths in 12 hours d. Edges of the perineal laceration are well approximated

a. No swelling or edema to the perineal area Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma.

The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurses next action? a. Palpate the patients bladder for fullness. b. Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d. Reassure the patient that she is making adequate progress.

a. Palpate the patients bladder for fullness. The fetal presenting part is expected to descend at a minimal rate of 1 cm/hr in the nullipara and 2 cm/hr in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.

The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas

a. Sitz baths four times a day c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

When reviewing the prenatal record of a client at 42 weeks gestation, the nurse recognizes that induction of labor is indicated based on the finding of: a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-pound weight gain at each of the last two weekly visits.

a. reduced amniotic fluid volume. Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-pound weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation.

The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 4- to 6-inch stain on the peripad c. 1- to 4-inch stain on the peripad d. Less than a 1-inch stain on the peripad

b. 4- to 6-inch stain on the peripad Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: Scantless than a 1-inch stain on the peripad Light1- to 4-inch stain Moderate4- to 6-inch stain Heavysaturated peripad Excessivesaturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.

During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken by the nurse in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the client not to push until you prepare vacuum extraction device for physician. d. Reposition the client to facilitate birth.

b. Ask the physician if he or she would like you to prepare for a surgical method of birth. In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it can cause additional problems. Vacuum extraction will not help solve this birth issue and may lead to further complications. Repositioning of the client may not be effective to relieve this condition and facilitate birth.

The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.) a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

b. Feeling of pelvic fullness d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa).

Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b. Fetal distress c. Maternal comfort during labor d. Irregular labor contraction pattern

b. Fetal distress A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration and clients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert pressure.

Which pelvic shape is most conducive to vaginal labor and birth? a. Android b. Gynecoid c. Platypelloid d. Anthropoid

b. Gynecoid The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch. The prognosis for a vaginal birth is good. Only 30% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth.

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a. I may not have a bowel movement until the 2nd postpartum day. b. If I breastfeed and supplement with formula, I wont need any birth control. c. I know my normal pattern of bowel elimination wont return until about 8 to 10 days. d. If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband.

b. If I breastfeed and supplement with formula, I wont need any birth control. For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.

A 20-year-old gravida 1, para 0, is determined to be at 42 weeks gestation on admission to the labor and birth unit. The client is not in labor at the current time but has been sent over by her physician to be admitted for the induction of labor. The client indicates to you that she would rather go home and wait for natural labor to start. How should the nurse respond to the clients request? a. There is no way to tell if any complications would arise. Because the client is not presenting with any problems, the nurse should call the health care provider and inform her or him of the clients decision to go home and wait. b. Inform the client that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. c. Tell the client that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the client will be sent home. d. Tell the client that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physicians directions.

b. Inform the client that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the client wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore, it is best for the client to remain in a supervised clinical setting. Indicating that the client could possibly go home would place the client at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks.

A client is diagnosed with anaphylactoid syndrome. Which therapeutic intervention does the nurse suspect will be included in the plan of care? a. Normal amniotic fluid b. Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d. Internal fetal monitoring

b. Initiation of CPR and other life support measures Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated.

Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the client is in active labor

b. Keeping underpads and linens as dry as possible Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.

Which technique is least effective for the client with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees

b. Lying supine and relaxing Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth? a. Quantity of lochia rubra b. Pain management techniques c. Frequency of vital signs and fundal checks d. Assessment of infection risk from loss of skin integrity

b. Pain management techniques A cesarean section is major surgery. Pain relief is provided in various ways, including patient-controlled analgesia and oral and intramuscular analgesics. Postvaginal birth pain is managed with oral analgesic combinations that include acetaminophen; the quantity of lochia, frequency of vital signs, and fundal checks and assessment of infection risk are the same for both types of birth.

Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that apply.) a. Increased risk for placenta previa b. Painful uterine contractions c. Increased resting tone d. Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction

b. Painful uterine contractions c. Increased resting tone e. Increased uterine pressure Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus, there is an increased risk for placental abruption as compared with placenta previa, which is based on malpresentation of the placental attachment. The contractions are painful but not effective for progression of labor.

A client with polyhydramnios was admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless, but the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the client in a high Fowler position.

b. Perform a vaginal examination. A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.

A client in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will be prescribed for at-home continuation of the tocolytic effect? a. Buccal oxytocin (Pitocin) b. Terbutaline sulfate (Brethine) c. Calcium gluconate (Calgonate) d. Magnesium sulfate

b. Terbutaline sulfate (Brethine) The client receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. Pitocin increases the strength of contractions and is used to augment or stimulate labor. Buccal Pitocin dosing is uncontrollable. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.

The nurse decides to perform a prescribed PRN intermittent sterile catheterization on a postpartum client if which occurs? (Select all that apply.) a. The client has not voided but the bladder cannot be palpated. b. The fundus is displaced from the midline and the client has been unable to void. c. The client has been medicated for pain but she has not voided; the fundus is midline. d. The amount voided is less than 150 mL and the fundus is displaced from the midline.

b. The fundus is displaced from the midline and the client has been unable to void. d. The amount voided is less than 150 mL and the fundus is displaced from the midline. The nurse makes the decision to perform an intermittent sterile catheterization if the client is unable to void, the amount is less than 150 mL, and the fundus is displaced. A nonpalpable bladder and firm fundus at or below the umbilicus and in the midline confirm that the bladder is empty and rule out urinary retention with overflow.

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

b. The fundus is palpable two fingerbreadths above the umbilicus. The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum, but is still appropriate.

The Centers for Disease Control and Prevention (CDC) recommends the use of which personal protective equipment with which the nurse is likely to come into contact? a. Any body fluids b. Any client at any time c. Blood and blood products d.Any client suspected of being HIV-positive

c. Blood and blood products Possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids. Only certain body fluids can cause contamination. It is not necessary to wear protective equipment continually with all clients. Protective equipment is important with a client if the nurse is at risk for contamination with blood or certain body fluids. The equipment does not have to be worn with casual contact.

A pregnant client who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered an fFN (fetal fibronectin) test. Which instructions should be given to the client related to this clinical test? a. Client must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Client should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.

c. Client should refrain from sexual activity prior to testing. Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.

A pregnant client with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicate a potential infection? a. Fetal heart rate, 150 beats/min b. Maternal temperature, 99 F c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates

c. Cloudy amniotic fluid, with strong odor Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/min is often the first sign of intrauterine infection. A temperature of 100.4 F or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patients chart.

c. Contact the health care provider. The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a. Decrease IV fluid rate. b. Document the finding. c. Encourage the use of an incentive spirometer. d. Ambulate the client around the nurses station.

c. Encourage the use of an incentive spirometer. Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses station should not be done at this time.

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38 C (100.4 F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

c. Firm fundus, but excessive lochia Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38 C (100.4 F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/min. b. Stop the Pitocin infusion. c. Position the client in the knee-chest position. d. Increase the main line infusion to 150 mL/hr.

c. Position the client in the knee-chest position. A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.

Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of 3 d. Meconium-stained amniotic fluid

c. Presenting part at a station of 3 Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the client at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the client at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.

A postpartum client asks, Will these stretch marks go away? Which is the nurses best response? a. No, never. b. Yes, eventually. c. They will fade to silvery lines but wont disappear completely. d. They will continue to fade and should be gone by your 6-week checkup.

c. They will fade to silvery lines but wont disappear completely. Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.

A postpartum client overhears the nurse tell the health care provider that she has a positive Homans sign and asks what it means. Which is the nurses best response? a. You have pitting edema in your ankles. b. You have deep tendon reflexes rated 2+. c. You have calf pain when the nurse flexes your foot. d. You have a fleshy odor to your vaginal drainage.

c. You have calf pain when the nurse flexes your foot. Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul odor, is within normal limits.

Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous client with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous client at 39 weeks of gestation who is expecting twins

d. A multiparous client at 39 weeks of gestation who is expecting twins Over distention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this clients uterus is over distended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an over distended uterus.

Vaginal exam findings reveal a slit-like opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history? a. Client has not been pregnant. b. Client has had a C section as a method of birth. c. Client has been treated for an STD with resultant scarring of the cervix. d. Client has a history of pregnancy.

d. Client has a history of pregnancy. With pregnancy, the cervix becomes slit-like in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth. Treatment of STD is not associated with cervical changes.

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patients chart.

d. Document the finding in the patients chart. The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed.

If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included? a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection

d. Explanation of the risks of becoming pregnant within 28 days following injection Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.

Which is (are) the priority nursing assessment(s) for the client having tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure

d. Fetal heart rate, maternal pulse, and blood pressure All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured, but these are not relevant to the medication.

Which documentation in the clients chart on the 14th postpartum day indicates a normal involution process? a. Breasts firm and tender b. Episiotomy slightly red and puffy c. Moderate bright red lochial flow d. Fundus below the symphysis and not palpable

d. Fundus below the symphysis and not palpable The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa.

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

d. Gently palpate, applying the same technique used for vaginal deliveries. Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.

A laboring client in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger. b. Let me take off the monitor belts and help you get into a more comfortable position. c. You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain. d. I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.

d. I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps. Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the client cope with the situation, no matter at what stage. It is important to get her into a more comfortable position, but fetal monitoring should continue. Breathing will not decrease the pain.

Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

d. Lochial color changes from rubra to alba For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

d. Postpartum hemorrhage and urinary tract infection Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.

Which intervention should be incorporated in a plan of care for a labor client who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the client for epidural administration as ordered by the physician

d. Preparing the client for epidural administration as ordered by the physician The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore, augmentation would not be advised as this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.

Which finding by the nurse on a vaginal exam would be a concern if a spontaneous rupture of the membranes occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d. Presenting part at 3 station

d. Presenting part at 3 station If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.

Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.

d. Reposition the mother with her hips higher than her head. The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority.

An obstetric client has been identified as being high risk and so has had activities restrictions (placed on bed rest) placed on her until the end of the pregnancy. Currently, she is at 32 weeks gestation and has two other children at home, ages 3 and 6. The clients husband works at home. A nursing diagnosis of Impaired home maintenance is noted. Which statement potentially identifies a long-term goal? a. The client and husband will be able to adapt their schedules accordingly to meet activities of daily living until the clients next scheduled antepartum visit the following week. b. The client and husband will hire a nanny to act as an additional caregiver for the next month. c. The client will continue to take care of her children at home, taking frequent rest periods. d. The client and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy.

d. The client and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy. A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified time frame. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the client to take care of her children at home with rest period because the client will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

d. Uterine fundus 2 cm above the umbilicus By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client.

A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after birth because of: a. increased estrogen. b. increased progesterone. c. decreased human placental lactogen. d. decreased melanocyte-stimulating hormone.

d. decreased melanocyte-stimulating hormone. Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.

When increasing the IV infusion rate of terbutaline (Brethine) 0.01 mg/min every 30 minutes, the nurse knows to stop increasing the rate when the: a. maximum dose of 0.1 mg/min is reached. b. systolic blood pressure falls below 110 mm Hg. c. contractions are less than two in a 10-minute period. d. maternal heart rate remains over 120 beats/min.

d. maternal heart rate remains over 120 beats/min. The infusion rate is not increased or may be decreased if the maternal pulse rate remains over 120 beats/min (bpm). A maximum dose of 0.1 mg is above the recommended maximum rate, systolic blood pressure below 110 mm Hg may be a normal finding for this client, and the medication should continue to be increased until the maximum level is reached or contractions stop.