Ch. 16, 21, 22 Questions

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:

-2 Station

A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the bestresponse from the triage nurse?

A one time discharge of bloody mucus in the toilet might have been your mucus plug."

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?

Maternal tachycardia and falling BP

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure

When measuring the diagonal conjugate of a woman's pelvis, the distance between which anatomic landmarks would be used?

anterior surface of the sacral prominence and the anterior surface of the symphysis pubis

When the cervix thins and shortens it is known as

effacement

T/F Preterm premature rupture of membranes is the rupture of membranes after 37 weeks gestation

false

True or False The transition phase of labor is the longest stage of labor lasting an average of 12 hours for primigravida and 8 hours for multigravidae

false

A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply.

fetal bradycardia, sinusoidal pattern, recurrent late decelerations

Operative vaginal deliveries include both vacuum assisted deliveries and ____ assisted deliveries

forceps

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurse explains this is probably due to:

lightening

_____ - stained amniotic fluid is associated with increased risk for infection

meconium (fetus has first bowel movement in utero)

_____ variability occurs when there is an amplitude of 6-25 bpm in the FHR

moderate

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

palpate the mother's radial pulse at the same time

Placenta ____ occurs when the placental tissue lies over the internal cervical os

previa

A _____ deceleration lasts longer than 2 minutes but less than 10

prolonged

When assessing FHR patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

Group b strep infection typically appears in the newborn as _____, pneumonia or meningitis

sepsis

T/F The leading cause of death for children under 5 in the US is preterm birth

true

True or False An overall contraction pattern can be described by frequency, duration and intensity of the contraction

true

Ferguson reflex

urge to push during labor

The most common fetal presentation, where the head is flexed with the chin toward the chest is called

vertex

T/F A prolonged latent phase of labor is one that lasts more than 14 hours for a nulliparous women

FALSE

Prior to performing an operative vaginal delivery, the m eternal _____ should be emptied to reduce risk of injury

bladder

An umbilical cord prolapse can often present in the FHR pattern as severe fetal ______

bradycardia

Corticosteroids are given for fetal lung maturity prior to ____ weeks gestation if delivery is a consideration

34

____ disproportion occurs when the fetal head is larger than the size of the maternal pelvis

Cephalopelvic

A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice?

I respect your preference, whether it is to have medication or not

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

clear to straw colored fluid

True or False A normal fetal heart rate baseline is between 100 and 170 bpm

false

T/F An external cephalic version may be attempted to manually turn a fetus in breech position

TRUE

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign?

The presenting part is at the true pelvis and is engaged."

The __ of contractions is timed from the beginning of one contraction the start of the next

frequency

T/F A transverse incision during a C section is associated with less maternal blood loss and better surgical repair

true

T/F Magnesium sulfate is given to provide neuroprotection to neonates in cases of preterm labor between 24-34 weeks gestation

true

T/F Placenta increta is defined as the "penetration of the placenta into the myometrium"

true

The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?

Client priorities and preferences are incorporated into the plan

T/F Performed in the second stage of labor, an episiotomy is considered to be routine practice

FALSE

Fetal ___ testing is performed to assess the likelihood of imminent preterm birth within 10 days

FFN (fibronectin)

True or False A chronic placental abruption is often accompanied by the sudden onset of abdominal pain, vaginal bleeding, and frequent uterine contractions

False

True or False Chorioamnionitis is a rare condition affecting approximately 1-2% of preterm births

False

True or False The majority of births take place in a freestanding birthing center

False

The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply.

False labor contractions are irregular False labor contractions do not increase in duration, frequency and intensity

____ may delay preterm birth for up to 2-7 days

Tocolytics

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priorityafter administering?

assess FHR

At what time is the laboring pt encouraged to push?

When the cervix is fully dilated

A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is

"It is rounded in shape and allows ample room for the neonate to fit through the passageway.

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

occiput

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant