Exam 2

Match each term with the correct definition. 39. Position 40. Fetal lie 41. Presentation a. The fetal part that enters the pelvic inlet first b. The orientation of the long axis of the fetus to the long axis of the woman c. Relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis

39. ANS: C 40. ANS: B 41. ANS: A

The nurse should tell a primigravida that the definitive sign indicating labor has begun is: a. Progressive uterine contractions. b. Lightening. c. Rupture of membranes. d. Passage of the mucus plug.

A Regular, progressive uterine contractions that increase in intensity and frequency are a sign of true labor. Responses B and D are premonitory signs indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself.

The client is admitted in early labor. Her support person tells the nurse that the contractions have the following pattern: started 1232, ended 1233; started 1235, ended 1236; started 1239, ended 1240; started 1243, ended 1244. From this information, the nurse determines that the frequency of the contractions is: a. Every 3 to 4 minutes. b. Every 2 to 3 minutes. c. Lasting a minute. d. Unable to be determined with this information.

A The frequency of a contraction is measured from the beginning of one contraction until the beginning of the next contraction. The contractions started at 1232, 1235, 1239, and 1243. This would put the contractions every 3 to 4 minutes. The duration of the contractions is from the beginning of a contraction until the end of the same contraction. The duration for this pattern would be 1 minute.

The clinic nurse is obtaining a health history on a newly pregnant client. Which is an indication for fetal diagnostic procedures if present in the health history. a. Maternal diabetes b. weight gain of 25 lb c. maternal age older than 30 d. Previous infant weighing more than 3000 g at birth.

A. maternal diabetes rationale: diabetes is a risk factor in pregnancy because of possible impairment of placental perfusion.

Transvaginal ultrasonography is often performed during the first trimester. A 6 week gestation client expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be necessary to determine which of the following. select all. a. Multifetal gestation b. bicornuate uterus c. presence and location of pregnancy d. amniotic fluid volume e. presence of ovarian cysts.

A. multifetal gestation b. bicornuate uterus c. presence and location of pregnancy e. presence of ovarian cysts.

A pregnant clients biophysical profile score is 8. She asks the nurse to explain the results. What is the nurses best response. a. The test results are within normal limits b. Immediate birth by cesarean birth is being considered c. Further testing will be performed to determine the meaning of this score d. An obstetric specialist will evaluate the results of this profile and within the next week will inform you of your options regarding birth.

A. the results are within normal limits. rationale: the normal biophysical score ranges from 8 to 10 pts if the amniotic fluid volume is adequate.

Which maternal factor may inhibit fetal descent? a. A full bladder b. Decreased peristalsis c. Rupture of membranes d. Reduction in internal uterine size

ANS: A A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates: a. lightening. b. breech presentation. c. urinary tract infection. d. onset of Braxton-Hicks contractions.

ANS: A As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

Which clinical findings would be considered to be normal for a preterm fetus during the labor period? a. Baseline tachycardia b. Baseline bradycardia c. Fetal anemia d. Acidosis

ANS: A Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

26. To determine if the client is in true labor, the nurse would assess for changes in: a. cervical dilation. b. amount of bloody show. c. fetal position and station. d. pattern of uterine contractions.

ANS: A Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor.

After birth of the placenta the patient states, "All of a sudden I feel very cold." What is the best nursing action in response to this statement? a. Place a warm blanket over the patient. b. Place the baby on the patient's abdomen. c. Tell the patient that chills are expected after birth. d. "What do you mean by your words 'very cold'?"

ANS: A Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary.

The primary difference between the labor of a nullipara and that of a multipara is: a. total duration of labor. b. level of pain experienced. c. amount of cervical dilation. d. sequence of labor mechanisms.

ANS: A Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors.

A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement? a. The acme b. The interval c. The increment d. The decrement

ANS: A The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.

A client just delivered a baby by the vaginal route. The client asks the nurse why the baby's head is not round, but oval. Which explanation should the nurse give to the client? a. This results from molding. b. This results from lightening. c. This results from the fetal lie. d. This results from the fetal presentation.

ANS: A The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) a. Offer the client a warm blanket. b. Place an ice pack on the perineum. c. Massage the uterus if it is boggy. d. Delay breastfeeding until the client is rested. e. Explain to the client that the lochia will be light pink in color.

ANS: A, B, C The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.) a. Powers b. Passage c. Position d. Passenger e. Psyche

ANS: A, B, D, E · Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis. · Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor. · Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. · Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman's ability to cope. Position is not one of the four Ps.

A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.) a. Ask her if her if she thinks that her membranes have ruptured b. Ask her if she has any evidence of bloody show. c. Have her keep monitoring her contraction pattern and call you back if they become more regular. d. Ask her when her she has her next scheduled visit with her health care provider e. Tell her to come into the hospital for evaluation.

ANS: A, E The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor.

On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time? a. Perform a vaginal exam to denote progress. b. Notify the health care provider. c. Initiate parenteral therapy. d. Apply oxygen via nasal cannula at 8 L/min.

ANS: B A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.

The primipara at 39 weeks' gestation states to the nurse, "I can breathe easier now." What is the nurse's best response? a. "You labor will start any day now since the baby has dropped." b. "That process is called lightening. Do you have to urinate more frequently?" c. "Contact your health care provider when your contractions are every 5 minutes for 1 hour." d. "You will likely not feel you baby's movements as much now, so do not be concerned."

ANS: B As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patient's statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase? a. The client is sociable and excited. b. The client is requesting pain medication. c. The client begins to experience the urge to push. d. The client experiences loss of control and irritability

ANS: B During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Extension b. Engagement c. Internal rotation d. External rotation

ANS: B Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient? a. On her back b. On her left side c. On her right side d. On her hands and knees

ANS: B LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus. Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are present, there is no need to implement this position.

A client whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase b. Active phase c. Second stage d. Third stage

ANS: B The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

The assessment finding which indicates that the client is in the active phase of the first stage of labor is: a. 80% effacement. b. dilation of 5 cm. c. presence of bloody show. d. regular contraction every 3 to 4 minutes.

ANS: B The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined.

Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Station b.Flexion c. Descent d. Engagement

ANS: B The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet.

Which event is the best indicator of true labor? a. Bloody show b. Cervical dilation and effacement c. Fetal descent into the pelvic inlet d. Uterine contractions every 7 minutes

ANS: B The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

A laboring patient states to the nurse, "I have to push!" What is the next nursing action? a. Contact the health care provider. b. Examine the patient's cervix for dilation. c. Review with her how to bear down with contractions. d. Ask her partner to support her head with each push.

ANS: B When the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed.

The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that he's doing now, he could tell her when the contractions are: a. 2 minutes apart. b. at their acme. c. at their increment. d. at their decrement.

ANS: B When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity.

Which assessment finding would cause a concern for a client who had delivered vaginally? a. Estimated blood loss (EBL) of 500 mL during the birth process b. White blood cell count of 28,000 mm3 postbirth c. Client complains of fingers tingling d. Client complains of thirst

ANS: C A client's complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels.

An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is: a. onset of irregular contractions. b. cephalic presentation at 0 station. c. bloody mucus drainage from vagina. d. fetal heart tones (FHTs) present in the lower right quadrant.

ANS: C Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening.

The nurse is assessing the duration of a client's labor contractions. Which action does the nurse implement to assess the duration of labor contractions? a. Assess the strongest intensity of each contraction. b. Assess uterine relaxation between two contractions. c. Assess from the beginning to the end of each contraction. d. Assess from the beginning of one contraction to the beginning of the next.

ANS: C Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction? a. Is not significantly affected b. Increases as blood pressure decreases c. Diminishes as the spiral arteries are compressed d. Continues except when placental functions are reduced

ANS: C During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

The nurse assess a laboring patient's contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern? a. Stage 1, latent phase b. Stage 2, latent phase c. Stage 1, active phase d. Stage 2, active phase

ANS: C In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage 2, latent phase, the woman is resting and preparing to push; she likely has not experienced the Ferguson reflex. She is actively bearing down during the active phase of the second stage.

If a notation on the client's health record states that the fetal position is LSP, this means that the: a. head is in the right posterior quadrant of the pelvis. b. head is in the left anterior quadrant of the pelvis. c. buttocks are in the left posterior quadrant of the pelvis. d. buttocks are in the right upper quadrant of the abdomen.

ANS: C LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT.

client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with: a. more rapid labor. b. a high risk of infection. c. maternal perineal trauma. d. umbilical cord compression.

ANS: D The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth.

The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions? a. Vital signs taken during contractions are not accurate. b. During a contraction, assessing fetal heart rate is the priority. c. Maternal blood flow to the heart is reduced during contractions. d. Maternal circulating blood volume increases temporarily during contractions.

ANS: D During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by: a. promoting blood flow to the cervix. b. contracting the lower uterine segment. c. enlarging the internal size of the uterus. d. pulling the cervix over the fetus and amniotic sac.

ANS: D Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

Uncontrolled maternal hyperventilation during labor results in: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

ANS: D Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long? a. 50 minutes b. hours c. 6 to 7 hours d. 8 to 10 hours

ANS: D The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 minutes for a nullipara. The transition phase lasts hours for a nullipara. A multipara's active phase of labor is 6 to 7 hours.

The nurse notices on the admission record that the fetus is in a cephalic military presentation. The nurse realizes that the fetus: a. Is coming feet first into the birth canal. b. Has the head in the birth canal first, but the head is not flexed. c. Has the head in the birth canal first, and the head is in a flexed presentation. d. Has both feet coming into the birth canal first.

B Cephalic presentation shows that the head is coming into the birth canal first. The military presentation means that the head is in a neutral position, neither flexed nor extended.

Which of the following characteristics is associated with false labor contractions? a. Painless b. Decrease in intensity with ambulation c. Regular pattern of frequency is established d. Progressive in terms of intensity and duration

B False labor contractions decrease with activity, but true labor contractions are enhanced or stimulated with activity such as ambulation. False labor contractions are painful. Responses C and D are characteristics of true labor contractions, which increase in intensity with activities such as ambulation.

A woman is admitted in early labor. The prenatal record states that the fetus is in a transverse lie with a shoulder presentation. The nurse can anticipate a: a. Frequent change of positions for the mother to alter the fetal position. b. Need for early fetal monitoring to assess for fetal heart changes. c. Cesarean birth. d. Prolonged second stage of labor.

C A transverse lie with a shoulder presentation almost always ends with a cesarean birth.

A woman who is about 37 weeks' gestation tells the nurse that for some reason this morning she can breathe easier. The nurse can best explain this as being a: a. Concern, and the fetus needs to be assessed. b. Normal change toward the end of the pregnancy caused by a decreased use of oxygen by the fetus. c. Normal change because of the fetus's dropping down into the pelvis region, relieving the pressure on her diaphragm. d. Normal change caused by the maternal cardiac output increasing as she gets closer to labor.

C Lightening occurs toward the end of the pregnancy as the fetus descends toward the pelvic inlet. When this occurs, the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced.

During contractions the fetus has mechanisms in place to protect it from the decrease in blood flow. Those mechanisms include: a. Fetal hemoglobin levels that are more resistant to oxygen. b. Lower hemoglobin and hematocrit levels. c. A high cardiac output level. d. A higher respiratory level.

C To prepare for labor, the fetus develops hemoglobin levels that readily take on oxygen and release carbon dioxide. The fetal hemoglobin and hematocrit levels are higher to have more oxygen-carrying capacity. The fetus has a higher cardiac output level. The fetus does not breathe yet, so there is no respiratory count.

In preparing a pregnant patient for a nonstress test, the nurse should a. ask the patient if she smokes and when she had her last cigarette b. have the patient drink four glasses of water c. Ask the patient when was the last time she had something to eat or drink d. ask the patient for a urine sample to check for glucose levels

a. ask the patient is she smokes and when she had her last cigarette rationale: For the greatest accuracy of a nonstress test, the woman should not have smoked recently because smoking affects the perception of fetal movement. In addition, smoking causes vasoconstriction, which may alter the results.

Which one(s) of the following complications may be associated with percutaneous umbilical blood sampling (PUBS) (Select all that apply.) a. fetal bradycardia b. vaginal hemorrhage c. infection d. preterm labor e. umbilical cord prolapse

a. fetal bradycardia c. infection d. preterm labor

The nurse is reviewing maternal serum alpha-fetalprotein (MSAFP) results. Which conditions are associated with elevated levels of MSAFP. select all. a. fetal demise b. neural tube defects. c. abdominal wall defects d. chromosomal trisomies e. gestational trophoblastic disease

a. fetal demise b. neural tube defects c. abdominal wall defects. rationale: elevated levels of AFP may indicate open neural tube defects, abdominal wall defects, or fetal demise.

When is the most accurate time to determine gestational age through ultrasound. a. First trimester b. second trimester c. third trimester d. no difference in accuracy among the trimesters

a. first trimester rationale: gestational age determination by ultrasound is increasingly less accurate the first trimester

The patient has a biophysical profile done. The nurse notes that the NST test was reactive, the fetal breathing movements were absent, there was one gross body movement in 30 minutes, the fetal tone showed fetal extremity extension and return to flexion, and one pocket of amniotic fluid measured 3 cm. The nurse anticipates that next action by the physician will be a. further study because a score of 6 is not normal b. no further study because a score of 9 is normal c. further study because a score of 3 is not normal d. no further study because a score of 10 is perfect.

a. further study because a score of 6 is not normal rationale: The reactive NST gives a score of 2; absent fetal breathing movements is 0; one gross body movement is 0; the fetal tone of extension and flexion is 2; and one pocket of amniotic fluid is 2 points. This gives a total of 6 points, which is not within normal limits, and further studies are indicated.

A newly pregnant patient tells the nurse that she has irregular periods and is unsure of when she got pregnant. Scheduling an ultrasound is a standing prescription for the patients HCP. When is the best time for the nurse to schedule the patients ultrasound. a. Immediately b. in 2 weeks c. in 4 weeks d. in 6 weeks.

a. immediately.

What does a score of 9 on a biophysical profile signify. a. Normal b. abnormal c. equivocal d. non reactive

a. normal rationale: Five parameters of fetal activity - fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume - are used to determine the biophysical profile. The max score is 2 pts for each parameter, so 8 to 10 is considered normal. 4 or less is considered abnormal.

Which conditions are associated with elevated levels of serum alpha-fetoprotein? select all a. Open neural tube defects b. abdominal wall defects c. chromosomal trisomies d. gestational trophoblastic disease e. fetal demise

a. open neural tube defects b. abdominal wall defects e. fetal demise

The nurse notices that during the nonstress test, the fetal heart rate accelerated 20 beats/minute above baseline three times with fetal movement. Each acceleration lasted about 15 seconds before returning to baseline. This result is classified as A. reactive b. non reactive

a. reactive rationale: A reactive (reassuring) nonstress test shows at least two fetal heart accelerations, with or without fetal movement, within a 20-minute period.

On which aspect of fetal diagnostic testing do parents usually place the most importance. a. Safety of the fetus b. duration of the test c. cost of the procedure d. physical discomfort caused by the procedure.

a. safety of the fetus rationale: although all these are considerations, parents are usually most concerned about the safety of the fetus.

The nurse is instructing a client on how to perform kick counts. Which information should the nurse include in the teaching session. select all a. use a clock or timer when performing kick counts b. your bladder should be full before performing kick counts c. notify your health care provider if you have not felt movement in 24 hours. d. protocols can provide a structured timetable for concentrating on fetal movements e. you should lie on your side, place your hands on the largest part of the abdomen, and concentrate on the number of movements.

a. use a clock or timer when performing kick counts. d. protocols can provide a structured timetable for concentrating on fetal movements. e. you should lie on your side, place your hands on the largest part of the abdomen, and concentrate on the number of movements.

For which client would an L/S ration of 2:1 potentially be considered to be abnormal. a. A 38 yr gravida 2, para 1, who is 38 weeks gestation b. A 24 yr old gravida 1, para 0, who has diabetes c. A 44 yr old gravida 6, para 5, who is at term d. An 18 yr old gravida 1, para 0, who is early labor at term.

b. A 24 yr old gravida 1, para 0, who has diabetes rationale: Even though an L/S ratio of 2:1 is typically considered to be a normal finding to validate fetal lung maturity prior to 38 wks gestation, the result may not be accurate in determining fetal lung maturity if a client is diabetic.

Which factor serves as a clinical indicator for a third trimester amniocentesis. a. Sex of the fetus b. Rh isoimmunization c. placenta previa d. placental abruption

b. Rh isoimmunization rationale: Rh isoimmunization is a clinical indicator for a third trimester amniocentesis.

A biophysical profile is performed on a pregnant client. The following assessments are noted: non reactive stress test (NST), three episodes of fetal breathing movements (FBMs), limited gross movements, opening and closing of hang indicating the presence of fetal tone, and adequate amniotic fluid index (AFI) meeting criteria. What would be the correct interpretation of this test result? a. A score of 10 would indicate that the results are equivocal. b. a score of 8 would indicate normal results. c. A score of 6 would indicate that birth should be considered as a possible treatment option d. A score of 9 would indicate reassurance.

b. a score of 8 would indicate normal results.

The nurse is reviewing the procedure for alpha-fetoprotein (AFP) screening with a patient at 16 weeks gestation. The nurse determines that the patient understands the teaching when she mentions that which fluid will be collected for the initial screening. a. Urine b. blood c. saliva d. amniotic.

b. blood rationale: initial screening is completed with blood. AFP can be detected in amniotic fluid, however that procedure is more costly and invasive.

the results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test? a. Repeat the test in 1 week so that results care be trended based on this baseline result. b. contact the HCP to discuss birth options for the client c. Send the client out for a meal and repeat the test to confirm that the results are valid. d. ask the client to perform a fetal kick count assessment for the next 30 mins and then reassess the client.

b. contact the HCP to discuss birth options for the client. rationale: a positive CST test is an abnormal finding, and the physician should be notified so that birth options can be initiated.

Which complication could occur as a result of percutaneous umbilical blood sampling (PUBS) a. postdates pregnancy. b. fetal bradycardia c. placenta previa d. uterine rupture.

b. fetal bradycardia rationale: PUBS is an invasive test whereby a needle is inserted into the umbilical cord to obtain blood as the basis for diagnostic testing with the guidance of ultrasound technology.

The nurses role in diagnostic testing is to provide which of the following. a. Advice to the couple b. information about the tests c. reassurance about fetal safety d. assistance with decision making.

b. information about the tests. rationale: the nurse should provide the couple with all necessary information about a procedure so that the couple can make an informed decision.

An ultrasound is done prior to an amniocentesis to a. determine fetal age b. locate fetal and placental position c. determine maternal blood pressure d. determine amount of fetal movement

b. locate fetal and placental position

What does nursing care after amniocentesis include. a. forcing fluids by mouth b. monitoring uterine activity c. placing the client in a supine position for 2 hours d. applying a pressure dressing to the puncture site.

b. monitoring uterine activity. rationale: A risk with amniocentesis is the onset of spontaneous contractions.

Which analysis of maternal serum may predict chromosomal abnormalities in the fetus. a. biophysical profile b. multiple marker screening c. lecithin to sphingomyelin ratio d. blood type and crossmatch of maternal and fetal serum.

b. multiple marker screening rationale: Maternal serum can be analyzed for abnormal levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), inhibin A, and estriol.

An ultrasound is ordered for a patient who is 8½ months pregnant. It is important for the nurse to a. instruct the patient to drink several glasses of clear fluid 1 hour before the examination and not to void. b. place a wedge under one hip when placing her on the examination table. c. place the patient in the lithotomy position for the examination. d. instruct the patient to bring someone with her to the examination to drive her home

b. place a wedge under one hip when placing her on the examination table.

During a contraction stress test, the nurse notices late decelerations with three of the six contractions. These results are classified as a. negative b. positive c. equivocal d. unsatisfactory

b. positive positive results are when late decelerations accompany at least 50% of the contractions

A pregnant client has received the results of her triple-screen testing and it is positive. She provides you with a copy of the test results that she obtained from the lab. What would the nurse anticipate as being implemented in the clients plan of care. a. No further testing is indicated at this time because results are normal b. Refer to the physician for additional testing c. Validate the results with the lab facility d. repeat the test in 2 weeks and have the client return for her regularly scheduled prenatal visit.

b. refer to the physician for additional testing. rationale: additional genetic testing is indicated to provide the client with treatment options. A positive result on a triple-screen test is considered to be an abnormal finding so the client should be referred to the physician for additional genetic testing.

A woman who is 36 weeks pregnant asks the nurse to explain the vibroacoustic stimulator (VAS) test. Which should the nurse include in the response. select all a. The test is invasive b. the test uses sound to elicit fetal movements c. the test may confirm nonreactive non-stress results. d. the test can only be performed if contractions are present. e. vibroacoustic stimulation can be repeated at 1 min intervals up to three times.

b. the test uses sound to elicit fetal movements c. the test may confirm nonreactive non-stress results e. vibroacoustic stimulation can be repeated at 1 min intervals up to three times.

A patient's maternal serum alpha-fetoprotein (MSAFP) levels are elevated. The nurse can anticipate that the next test done will be a. amniocentesis b. ultrasound c. biophysical profile d. chorionic villus sampling

b. ultrasound rationale: the MSAFP is a screening test, not a diagnostic test. If the levels are elevated, an U/S is offered to determine whether the abnormal concentration results from inaccurate gestational age, multifetal gestation, or fetal demise

When is the earliest that chorionic villus sampling can be performed in pregnancy. a. 4 weeks b. 8 weeks c. 10 weeks d. 12 weeks

c. 10 weeks rationale: fetal villus tissue can be obtained as early as 10 weeks of gestation and can be analyzed directly for chromosomal or genetic abnormalities.

A patient at 36 weeks gestation is undergoing a non-stress test (NST). The nurse observes the fetal heart rate baseline at 135 bpm and four nonepisodic patterns of fetal heart rate reaching 160 bpm for periods of 20 to 25 seconds each. How will the nurse record these findings. a. NST positive, nonreassuring b. NST negative, reassuring. c. NST reactive, reassuring d. NST nonreactive, nonreassuring.

c. NST reactive, reassuring. rationale: the presence of at least three accelerations of at least 15 beats, over at least 15 seconds, over a duration of at least 20 mins, is considered reactive and reassuring. Nonreactive testing reveals no or fewer accelerations over the same or longer period. The NST is not recorded as positive or negative.

A pregnant woman is scheduled to undergo chorionic villus sampling based on genetic family history. Which medication does the nurse anticipate will be administered. a. Magnesium sulfate b. prostaglandin suppository c. RhoGAM if the client is Rh-negative d. Betamethasone.

c. RhoGAM if the client is Rh-negative rationale: CVS can increase the likelihood of Rh sensitization if a woman is Rh-negative.

the primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine whether the fetus has which? a. Hemophilia b. sickle cell anemia c. a neural tube defect d. A normal lecithin-to-sphingomyelin ratio.

c. a neural tube defect. rationale: an open neural tube allows a high level of AFP to seep into the amniotic fluid and enter the maternal serum.

A pregnant patient has a 2-year history of uncontrolled hypertension. The nurse can anticipate that which fetal study to be ordered? a. amniocentesis b. chorionic villus sampling c. doppler ultrasound blood flow assessment

c. doppler ultrasound blood flow assessment rationale: Pregnancies complicated by hypertension may have a Doppler ultrasound assessment of blood flow through the umbilical artery done to identify abnormalities in the diastolic flow

An amniocentesis is ordered for an 8-month-pregnant patient. The nurse is aware that the most common reason for this test at this time is to test for a. fetal demise b. fetal chromosomal abnormalities c. fetal lung maturity d. amniotic fluid amount

c. fetal lung maturity

The nurse is preparing a client for a non-stress test (NST). Which interventions should the nurse plan to implement. select all a. Ensure that the client has a full bladder. b. plan approximately 15 muns for the test c. have the client sit in a recliner with the head elevated 45 degrees d. Apply electronic monitoring equipment to the clients abdomen. e. instruct the client to press an event marker every time she feels fetal movement.

c. have the client sit in a recliner with the head elevated45 degrees d. apply electronic monitoring equipment to the clients abdomen. e. instruct the client to press an event marker every time she feels fetal movement.

Which is the major advantage of chorionic villus sampling over amniocentesis. a. It is not an invasive procedure. b. It does not require a hospital setting c. it requires less time to obtain results. d. it has less risk of spontaneous abortion

c. it requires less time to obtain the results. rationale: results from chorionic villus sampling can be known within 24 to 48 hours, whereas results from amniocentesis require 2 to 4 weeks.

In preparing a pregnant client for a non-stress test (NST) which of the following should be included in the plan of care a. Have the client void prior to being placed on the fetal monitor because a full bladder will interfere with the results. b. Maintain NPO status prior to testing c. position the client for comfort, adjusting the tocotransducer belt to locate fetal heart rate d. Have an infusion pump prepared with oxytocin per protocol for evaluation.

c. position the client for comfort, adjusting the tocotransducer belt to locate fetal heart rate rationale: the nurse must adjust the tocotransducer to find the best location to pick up and record the fetal heart rate.

What is the term for a non-stress test in which there are two or more fetal heart rate accelerations of 15 or more bpm with fetal movement in a 20 min period. a. positive b. negative c. reactive d. nonreactive

c. reactive rationale: the non-stress test (NST) is reactive (Normal) when there are two or more fetal heart rate accelerations of at least 15 bpm (each with duration of at least 15 seconds) in a 20 min period.

A 36-year-old primigravida is in the clinic for her first prenatal appointment. The nurse can anticipate that the multiple-marker screening may be done on this patient to screen for a. gestational diabetes b. hypertensive disease of pregnancy c. trisomy disorders d. placental previa

c. trisomy disorders

Which clinical conditions are associated with increased levels of alpha fetoprotein. Select all. a. Down syndrome b. molar pregnancy. c. twin gestation d. incorrect gestational age assessment for a normal fetus - estimation earlier in the pregnancy. e. threatened abortion

c. twin gestation d. incorrect gestational age assessment for a normal fetus - estimation earlier in the pregnancy e. threatened abortion rationale: Elevated AFP levels are seen in multiple gestations, understimation of fetal age, and threatened abortion. Decreased levels are seen in Down sydrome and molar pregnancy.

The physician has ordered a chorionic villus sampling to be done on a patient. The nurse knows to schedule the test to be done between which weeks of gestation? a. 4 and 6 weeks b. 6 and 8 weeks c. 8 and 10 weeks d. 10 and 12 weeks

d. 10 and 12 weeks

What is the purpose of amniocentesis for a client hospitalized at 34 weeks gestation with pregnancy-induced hypertension? a. determine if a metabolic disorder is genetic b. identify the sex of the fetus c. identify abnormal fetal cells d. determine fetal lung maturity.

d. determine fetal lung maturity. rationale: during third trimester, amniocentesis is most often performed to determine fetal lung maturity.

Which nursing intervention is necessary prior to a second trimester transabdominal ultrasound. a. Perform an abdominal prep b. administer a soap suds enema c. ensure the client is NPO for 12 hours d. Instruct the client to drink 1 to 2 quarts of water.

d. instruct the client to drink 1 to 2 quarts of water rationale: when the uterus is still in the pelvis, visualization may be difficult. It is necessary to perform the test when the woman has a full bladder.

Which should be considered a contraindication for transcervical chorionic villus sampling a. Rh-negative mother b. gestation less than 15 weeks c. maternal age younger than 35 yrs d. positive for group B strep.

d. positive for group B strep rationale: maternal infection is a risk with this procedure, and it is contraindicated if the client has an active infection in the cervix, vagina, or pelvic area.

An 8-month-pregnant patient comes to the clinic complaining that she has not felt the baby move for the past 48 hours. Other than checking the fetal heart tones, the nurse can also anticipate which fetal study? a. Amniocentesis b. Multiple-marker study c. Blood flow assessment d. Ultrasonography

d. ultrasonography - used in the last two trimesters to confirm fetal viability.

Which response by the nurse is most appropriate to the statement, "this test isnt my idea, but my husband insists". a. Its your decision b. dont worry, everything will be fine. c. Why dont you want to have this test done d. youre concerned about having this test?

d. youre concerned about having this test. rationale: the nurse should clarify the statement and assist the client in exploring her feelings about the test.

Variability can be reduced by which of the following factors? (Select all that apply). a. Sleep b. Narcotics c. Gestation longer than 39 weeks d. Fetal anomalies that affect the central nervous system

A, B, D

MATCHING a. a test for estimating fetal lung maturity b. a test to assess blood flow to identify abnormalities c. a test to diagnose fetal chromosomal, metabolic, or DNA abnormalities 1. Doppler Ultrasound 2. Lecithin-to-sphingomyelin 3. Chorionic villus sampling.

1. doppler ultrasound - B - to assess blood flow to identify abnormalities 2. lecithin-to-sphingomyelin - A - to estimate fetal lung maturity. 3. chorionic villus sampling - C - to diagnose fetal chromosomal, metabolic, or DNA abnormalities.

A nurse documents that the fetal heart rate variability is marked. This indicates that the range is greater than how many beats per minute? Record your answer as a whole number. _____ bpm

25 There are four categories of fetal heart rate variability: Absent: Amplitude range is undetectable Minimal: detectable to less than or equal to 5 beats/min Moderate (normal): 6 to 25 beats/min Marked: Range >25 beats/min

Mathching: 42. Early decelerations 43. Late decelerations 44. Variable decelerations a. Caused by umbilical cord compression b. Caused by fetal head compression c. Caused by uteroplacental insufficiency

42. B - Fetal head compression briefly increases intracranial pressure, causing the vagus nerve to slow the heart rate. Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency) may result in a pattern of late (delayed) decelerations. Conditions that reduce flow through the umbilical cord may result in variable decelerations. 43. C - Fetal head compression briefly increases intracranial pressure, causing the vagus nerve to slow the heart rate. Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency) may result in a pattern of late (delayed) decelerations. Conditions that reduce flow through the umbilical cord may result in variable decelerations. 44. A - Fetal head compression briefly increases intracranial pressure, causing the vagus nerve to slow the heart rate. Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency) may result in a pattern of late (delayed) decelerations. Conditions that reduce flow through the umbilical cord may result in variable decelerations.

Match each term with the correct definition. a. Pressure applied to specific pressure points using hands, rollers, balls, or other equipment b. Contraction and then release of specific muscle groups until all muscles are relaxed c. Concentrating on something outside the body 43. Focal point 44. Acupressure 45. Progressive relaxation

43. ANS: C PTS: 1 DIF: Cognitive Level: Understanding REF: 291 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: Progressive relaxation is contraction and then release of specific muscle groups until all muscles are relaxed. Acupressure is pressure applied to specific pressure points using hands, rollers, balls, or other equipment. A focal point is concentrating on an object outside the body and away from the pain of contractions. 44. ANS: A PTS: 1 DIF: Cognitive Level: Understanding REF: 291 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: Progressive relaxation is contraction and then release of specific muscle groups until all muscles are relaxed. Acupressure is pressure applied to specific pressure points using hands, rollers, balls, or other equipment. A focal point is concentrating on an object outside the body and away from the pain of contractions. 45. ANS: B PTS: 1 DIF: Cognitive Level: Understanding REF: 283 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: Progressive relaxation is contraction and then release of specific muscle groups until all muscles are relaxed. Acupressure is pressure applied to specific pressure points using hands, rollers, balls, or other equipment. A focal point is concentrating on an object outside the body and away from the pain of contractions. SHORT ANSWER

On review of a fetal monitor tracing, the nurse notes that for several contractions the FHR decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: a. Describe the finding in the notes. b. Reposition the woman onto her side. c. Call the physician for instructions. d. Administer oxygen at 8 to10 L/min with a tight face mask.

A An early deceleration pattern from head compression is described. No action other than documentation of the finding is required because this is an expected reaction to compression of the fetal head as it passes through the cervix. The other responses would be implemented when nonreassuring or ominous changes are noted.

To ensure adequate fetal oxygenation, which of the following are needed? (Select all that apply). a. Normal maternal blood flow and volume to the placenta Correct b. Normal oxygen saturation in maternal blood c. Normal carbon dioxide saturation in the maternal blood d. Adequate exchange of oxygen and carbon dioxide in the placenta e. Normal fetal circulatory and oxygen-carrying functions f. Normal blood glucose levels in the fetal circulation

A, B, D, E

To obtain an accurate blood pressure of a woman in labor, the nurse should assess the blood pressure: a. Between contractions, with the woman lying on her side. b. Between contractions, with the woman lying on her back. c. With a contraction while the woman is lying on her side. d. With a contraction while the woman is lying on her back.

A During uterine contractions, blood flow to the placenta gradually decreases, causing a relative increase in the woman's blood volume. This temporary change increases her blood pressure slightly. If the woman lies on her back, the weight of the fetus, placenta, and fluid may decrease blood flow, causing supine hypotension. Therefore her blood pressure is more accurate when taken between contractions, with her lying on her side.

During active labor, the woman complains about tingling in her hands. The nurse's next action should be to: a. Help the woman slow down her breathing and breathe into her cupped hands. b. Assess vital signs for changes. c. Check cervical dilation. d. Change the woman's position.

A Hyperventilation may occur during active labor as the woman breathes rapidly. She may feel tingling in her hands and feet and dizziness. By having the woman slow her breathing and breathe into her cupped hands, her carbon dioxide levels will return to normal and relieve the symptoms.

During a vaginal exam, the physician stimulates the fetal scalp. The fetal heart rate accelerated from 140 to 155 bpm for about 30 seconds. The nurse should: a. Record this reassuring fetal reaction. b. Notify the physician because this reaction is nonreassuring. c. Assist the woman into a side-lying position. d. Administer oxygen at 8 to 10 L/min.

A It is reassuring for the heart rate to elevate 15 bpm for at least 15 seconds with fetal scalp stimulation. The nurse should record the finding. No other intervention is necessary at this time.

After several mild late decelerations, the physician obtains a fetal scalp blood sample. The fetal pH was 7.32. The nurse is aware that the next action will probably be to: a. Continue to monitor the fetus during the labor. b. Prepare for a cesarean section. c. Prepare for a reassessment of the fetal pH. d. Apply oxygen to the mother at a rate of 10 L/min.

A The normal fetal pH is 7.25 to 7.35. Because this fetal pH is within the normal limits, the nurse can anticipate continuing monitoring of the fetus. Because the pH is within normal limits, it is unlikely that a cesarean section would be performed at this time.

Which of these might cause late decelerations in the fetus? (Select all that apply). a. Maternal hypotension b. Excessive uterine activity c. Maternal hypertension d. Fever e. Maternal overhydration f. Prolapsed cord

A, B, C

Which of the following are considered nonreassuring fetal heart rate patterns? (Select all that apply). a. Tachycardia b. Bradycardia c. Absent variability d. Early decelerations e. Variable decelerations

A, B, C, E

Which of the following should be included in nursing care during labor? (Select all that apply). a. Offer ice chips in small amounts to relieve a dry mouth. b. Monitor for a full bladder because the woman may have a decreased sensation of the urge to void. c. Keep the woman in a side-lying position to prevent supine hypotension. d. Offer small bland meals if the woman is in early labor to help maintain proper blood sugar levels. e. Monitor the fetal heart rate for changes from normal.

A, B, C, E

Which of the following are considered theories about the onset of labor? (Select all that apply). a. Changes in the relative effects of estrogen and progesterone b. An increase in prostaglandins c. Increased secretion of prolactin d. Decreased secretion of oxytocin e. Stretching and irritation of the uterus and cervix

A, B, E

46. The health care provider's prescription reads diphenhydramine (Benadryl), 25 mg IV stat. The medication vial reads diphenhydramine (Benadryl), 50 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Record your answer to one decimal point. _____ mL

ANS: 0.5 mL Desired/available ´ volume = milliliters per dose 25 mg/50 mg ´ 1 mL = 0.5 mL/per dose PTS: 1 DIF: Cognitive Level: Application REF: 283 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

43. The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places. _____ mL

ANS: 0.75 Use the medication calculation formula to calculate the correct dose: Desired/available ´ volume = milliliters per dose (0.3 mg/0.4 mg) ´ 1 mL = 0.75 mL/dose PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

47. The nurse is administering fentanyl (Sublimaze) to a client in labor. The health care provider's prescription reads fentanyl (Sublimaze), 100 mcg IV stat. The medication vial reads fentanyl (Sublimaze), 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Record your answer as a whole number. _____ mL

ANS: 2 mL Desired/available ´ volume = milliliters per dose 100 mcg/50 mcg ´ 1 mL = 2 mL/dose PTS: 1 DIF: Cognitive Level: Application REF: 282 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

34. 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

ANS: A 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 592

9. 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

ANS: A 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 573

16. A client who is 32 weeks pregnant telephones the nurse at her obstetrician's 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."

ANS: A 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. PTS: 1 DIF: Cognitive Level: Application REF: 580

10. After a birth complicated by a shoulder dystocia, the infant's 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 infant's clavicles. b. encourage the parents to hold the infant. c. perform a complete newborn assessment. d. give supplemental oxygen with a small face mask.

ANS: A Because of the shoulder dystocia, the infant's 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 570, 571

7. 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.

ANS: A 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 572

13. 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 nurse's priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the client with her hips slightly elevated.

ANS: A 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. Nonadditive 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. PTS: 1 DIF: Cognitive Level: Application REF: 592

32. 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.

ANS: A 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 589

35. 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 nurse's next action? a. Palpate the patient's 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.

ANS: A 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. PTS: 1 DIF: Cognitive Level: Synthesis REF: 575

Which of the following is the priority intervention for the client in a left side-lying position whose monitor strip shows a deceleration that extends beyond the end of the contraction? a. Administer O2 at 8 to 10 L/min. b. Decrease the IV rate to 100 mL/hr. c. Reposition the ultrasound transducer. d. Perform a vaginal exam to assess for cord prolapse.

ANS: A A deceleration that returns to baseline after the end of the contraction is a late deceleration caused by placental perfusion problems. Administering oxygen will increase the client's blood oxygen saturation, making more oxygen available to the fetus. Decreasing the IV rate, repositioning the ultrasound transducer, and performing a vaginal exam to assess for cord prolapse are not effective interventions to improve fetal oxygenation.

20. Which of the following factors would affect pain perception or tolerance for the laboring client? a. Right occiput posterior fetal position during labor b. Bishop score of 10 prior to the induction of labor c. Gynecoid pelvis d. Absence of Ferguson's reflex

ANS: A A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Ferguson's reflex occurs when a contraction is stimulated as a result of vaginal stimulation. PTS: 1 DIF: Cognitive Level: Analysis REF: 280 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

Which client is a candidate for internal monitoring with an intrauterine pressure catheter? a. Obese client whose contractions are 3 to 6 minutes apart, lasting 20 to 50 seconds b. Gravida 1, para 0, whose contractions are 2 to 3 minutes apart, lasting 60 seconds c. Multigravida whose contractions are 2 minutes apart, lasting 60 to 70 seconds d. Gravida 2, para 1, in latent phase whose contractions are irregular and mild

ANS: A A thick layer of abdominal fat absorbs energy from uterine contractions, reducing their apparent intensity on the monitor strip. Contraction patterns of 2 to 3 minutes lasting 60 seconds and every 2 minutes lasting 60 to 70 seconds indicate accurate measurement of uterine activity. Irregular and mild contractions are common in the latent phase.

3. Which assessment finding could indicate hemorrhage in the postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits. PTS: 1 DIF: Cognitive Level: Analysis REF: 224 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

5. Excessive anxiety during labor heightens the client's sensitivity to pain by increasing: a. muscle tension. b. the pain threshold. c. blood flow to the uterus. d. rest time between contractions.

ANS: A Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman's brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets between contractions. PTS: 1 DIF: Cognitive Level: Understanding REF: 280 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

Which can be determined only by electronic fetal monitoring? a. Variability b. Tachycardia c. Bradycardia d. Fetal response to contractions

ANS: A Beat-to-beat variability cannot be determined by auscultation because auscultation provides only an average fetal heart rate (FHR) as it fluctuates. Tachycardia can be determined by any of the FHR monitoring techniques. Bradycardia can be determined by any of the FHR monitoring techniques. The fetal response to the contractions is usually noted by an increase or decrease in fetal heart rate. These can be determined by any of the FHR monitoring techniques.

25. The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine d. The client's understanding of the event

ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client's understanding of the event would only need to be documented if it presents a problem. PTS: 1 DIF: Cognitive Level: Understanding REF: 222 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should: a. maintain the normal assessment routine. b. administer O2 at 8 to 10 L/min by face mask. c. increase the IV flow rate from 125 to 150 mL/hr. d. assess the maternal blood pressure for a systolic pressure below 100 mm Hg.

ANS: A Decelerations that mirror the contraction are early decelerations caused by fetal head compression. Early decelerations are not associated with fetal compromise and require no intervention. Administering O2, increasing the IV flow rate, and assessing for hypotension are not necessary in early decelerations.

The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel? a. Doppler b. Fetoscope c. Scalp electrode d. Tocodynamometer

ANS: A Doppler is the only listed method involving ultrasonic transmission of fetal heart rates; it requires the use of a gel. The fetoscope does not require gel because ultrasonic transmission is not used. The scalp electrode is attached to the fetal scalp; gel is not necessary. The tocodynamometer does not require gel. This device monitors uterine contractions.

Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by: a. expanding the maternal blood volume. b. maintaining a normal maternal temperature. c. preventing normal maternal hypoglycemia. d. increasing the oxygen-carrying capacity of the maternal blood.

ANS: A Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not add extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

2. Which comfort measure should a nurse use to assist a laboring woman to relax? a. Recommend frequent position changes. b. Palpate her filling bladder every 15 minutes. c. Offer warm wet cloths to use on the client's face and neck. d. Keep the room lights lit so the client and her coach can see everything.

ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights. PTS: 1 DIF: Cognitive Level: Application REF: 236 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

4. Which is an essential part of nursing care for a laboring client? a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Feeling comfortable with the predictable nature of intrapartal care d. Sharing personal experiences regarding labor and birth to decrease her anxiety

ANS: A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority. PTS: 1 DIF: Cognitive Level: Application REF: 220 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

15. A laboring client who imagines her body opening to let the baby out is using a mental technique called: a. imagery. b. effleurage. c. distraction. d. dissociation.

ANS: A Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working. PTS: 1 DIF: Cognitive Level: Understanding REF: 283 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

17. The nurse thoroughly dries the infant immediately after birth primarily to: a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood. PTS: 1 DIF: Cognitive Level: Understanding REF: 248 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.

ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR. PTS: 1 DIF: Cognitive Level: Comprehension REF: 235 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings? a. Late decelerations b. Early decelerations c. Variable decelerations d. Proximal decelerations

ANS: A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. The FHR returns to baseline after the contraction ends. The early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point (nadir) of the deceleration occurring near the contraction's peak. The rate at the lowest point of the deceleration is usually no lower than 30 to 40 bpm from the baseline. Conditions that reduce flow through the umbilical cord may result in variable decelerations. These decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. Proximal decelerations is not a recognized term.

The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a. Administer oxygen with a face mask at 8 to 10 L/min. b. Reposition the fetal monitor ultrasound transducer. c. Assist the client to the bathroom to empty her bladder . d. Continue to monitor the client and fetal heart rate patterns.

ANS: A Late decelerations are similar to early decelerations in the degree of FHR slowing and lowest rate (30 to 40 bpm) but are shifted to the right in relation to the contraction. They often begin after the peak of the contraction. They reflect possible impaired placental exchange (uteroplacental insufficiency). Administration of 100% oxygen through a snug face mask makes more oxygen available for transfer to the fetus. A commonly suggested rate is 8 to 10 L/min. The pattern is nonreassuring so repositioning the fetal ultrasound transducer, assisting the client to the bathroom, or continuing to monitor the pattern will not correct the problem.

2. A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated with opiate-dependent patients? a. Nalbuphine (Nubain) b. Hydroxyzine (Vistaril) c. Promethazine (Phenergan) d. Diphenhydramine (Benadryl)

ANS: A Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics. PTS: 1 DIF: Cognitive Level: Understanding REF: 293 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

10. A client received 25 mg of meperidine (Demerol) intravenously 1 hour before birth. Which drug should the nurse have readily available? a. Naloxone (Narcan) b. Butorphanol (Stadol) c. Nalbuphine (Nubain) d. Promethazine (Phenergan)

ANS: A Naloxone (Narcan) reverses narcotic-induced respiratory depression, which may occur with the administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics given to women in labor. PTS: 1 DIF: Cognitive Level: Application REF: 294 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

3. A client is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or do procedures? a. After the contraction is over b. When it is all right with the coach c. During increment of next contraction d. After administration of analgesic-anesthetic

ANS: A Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in the woman, preventing her from answering questions correctly. PTS: 1 DIF: Cognitive Level: Understanding REF: 297 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability. What is the priority action based on these findings? a. Document the findings. b. Contact the health care provider. c. Increase the rate of the existing IV to 200 mL/hr as per the standing prescription. d. Place oxygen via a rebreather mask at 10 L/min as per the standing prescription.

ANS: A The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors.

32. The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a. 18-gauge b. 20-gauge c. 22-gauge d. 24-gauge

ANS: A The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula. PTS: 1 DIF: Cognitive Level: Understanding REF: 229 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

8. The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a. Latent phase b. Active phase c. Second stage d. Transition phase

ANS: A The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time. PTS: 1 DIF: Cognitive Level: Understanding REF: 282 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

In which situation would a baseline fetal heart rate of 160 to 170 bpm be considered a normal finding? a. The fetus is at 30 weeks of gestation. b. The mother has a history of fast labors. c. The mother has been given an epidural block. d. The mother has mild preeclampsia but is not in labor.

ANS: A The normal preterm fetus may have a baseline rate slightly higher than the term fetus because of an immature parasympathetic nervous system that does not yet exert a slowing effect on the fetal heart rate (FHR). Fast labors should not alter the FHR normally. Any change in the FHR with an epidural is not considered an expected outcome. Preeclampsia should not cause a normal elevation of the FHR.

16. If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to: a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position.

ANS: A The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding. PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

22. When using the second Leopold's maneuver in fetal assessment, the nurse would palpate (the): a. both sides of the maternal abdomen. b. lower abdomen above the symphysis pubis. c. both upper quadrants of the maternal abdomen . d. lower abdomen for flexion of the presenting part.

ANS: A The second Leopold's maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver. PTS: 1 DIF: Cognitive Level: Application REF: 230, 231 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

29. A labor client has brought in with her a picture of her two children and asks the nurse to place it on the wall so that she can look at it during labor contractions. This is an example of: a. focal point. b. distraction. c. effleurage. d. relaxation.

ANS: A The use of a focal point (image and/or point reference in the labor room) is an example of nonpharmacologic pain control during labor. The image of the client's children is not serving as a method of distraction. Effleurage is the use of massage techniques to minimize pain perception. The image of the client's children is not serving as a method of relaxation. PTS: 1 DIF: Cognitive Level: Application REF: 283 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

A patient at 41 weeks' gestation is undergoing an induction of labor with an IV administration of oxytocin (Pitocin). The fetal heart rate starts to demonstrate a recurrent pattern of late decelerations with moderate variability. What is the nurse's priority action? a. Stop the infusion of Pitocin. b. Reposition the patient from her right to her left side. c. Perform a vaginal exam to assess for a prolapsed cord. d. Prepare the patient for an emergency cesarean section.

ANS: A There are multiple reasons for late decelerations. Address the probable cause first, such as uterine hyperstimulation with Pitocin, to alleviate the outcome of late decelerations. Repositioning can increase oxygenation to the fetus but does not address the cause of the problem. Variable decelerations are more often seen with a prolapsed cord. In the presence of moderate variability, the fetus continues to have adequate oxygen reserves. The presence of two or more nonreassuring fetal heart rate patterns increases the level of concern.

Which maternal condition should be considered a contraindication for the application of internal monitoring devices? a. Unruptured membranes b. Cervix dilated to 4 cm c. Fetus has known heart defect d. External monitors currently being used

ANS: A To apply internal monitoring devices, the membranes must be ruptured. Cervical dilation of 4 cm would permit the insertion of fetal scalp electrodes and an intrauterine catheter. A compromised fetus should be monitored with the most accurate monitoring devices. The external monitor can be discontinued after the internal ones are applied.

27. Which of the following clients could be a candidate for a vaginal birth after cesarean section (VBAC)? a. A 32-year-old gravida 2, para 1, who had a primary cesarean section for fetal distress b. A 23-year-old gravida 3, para 2, who had two cesarean sections with classic incisions c. An 18-year-old gravida 3, para 2, who had cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively d. A 25-year-old gravida 1, para 0, who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth

ANS: A VBAC can be done if the need for the primary cesarean section was based on factors other than cephalopelvic disproportion (CPD) and macrosomia. A client who has had a prior classic incision into the uterus is not a candidate for this type of procedure. Based on the presented history of a cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively, this client is at risk for uterine rupture and for delivering another macrosomic infant because she has already had two cesarean sections for the same indications. A client who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth is not a candidate for a VBAC because she does not meet the clinical criteria. PTS: 1 DIF: Cognitive Level: Analysis REF: 281 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

13. During labor a vaginal examination should be performed only when necessary because of the risk of: a. infection. b. fetal injury. c. discomfort. d. perineal trauma.

ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma. PTS: 1 DIF: Cognitive Level: Understanding REF: 231, 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

35. The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's priority action for this patient? a. Ask the patient's labor coach if this is a usual expression of pain for her. b. Refer to the patient's chart to determine any orders for pain medication. c. Tell the patient that she is disturbing the other laboring patients on the unit. d. Encourage the patient to try to suppress her noisiness during contractions.

ANS: A Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a woman's personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others. PTS: 1 DIF: Cognitive Level: Application REF: 280 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

In which of the following situations would fetal oxygenation be compromised? a. The mother has been taking Tylenol for mild headaches 2 days prior to the onset of labor. b. The mother regularly sleeps on her left side. c. The mother routinely uses cocaine. d. The mother drinks one caffeine drink a day.

C Cocaine use produces maternal hypertension. Hypertension in the mother reduces blood flow to the placenta and decreases the fetal oxygenation.

37. A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.) a. Less maternal fatigue b. Less birth canal injuries c. Decreased pushing time d. Faster descent of the fetus e. An increase in frequency of contractions

ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her body's signals. A brief slowing of contractions often occurs at the beginning of the second stage. PTS: 1 DIF: Cognitive Level: Analysis REF: 238 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

40. Which interventions are required following an amniotomy procedure? (Select all that apply.) a. Notation related to amount of fluid expelled b. Color and consistency of fluid c. Fetal heart rate d. Maternal blood pressure e. Maternal heart rate

ANS: A, B, C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required. PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

Which medications could potentially cause hyperstimulation of the uterus during labor? (Select all that apply.) a. Oxytocin (Pitocin) b. Misoprostol (Cytotec) c. Dinoprostone (Cervidil) d. Methylergonovine maleate (Methergine)

ANS: A, B, C, D Oxytocin, misoprostol, and dinoprostone fall under the general category of uterine stimulants. Cytotec and Cervidil are prostaglandins. Methergine is an ergot alkaloid.

40. While developing an intrapartum care plan for the client in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include which of the following? (Select all that apply.) a. Culture b. Anxiety and fear c. Support systems d. Preparation for childbirth e. Previous experiences with pain

ANS: A, B, C, D, E · Culture: A woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). · Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. · Support systems: An anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and birth. · Preparation for childbirth: This does not ensure a pain-free labor. Preparation does reduce anxiety and fear. It also allows a woman to rehearse for labor. · Previous experiences with pain: Fear and withdrawal are natural responses to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. PTS: 1 DIF: Cognitive Level: Application REF: 280, 281 OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity

36. 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

ANS: A, B, C, E 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 591

When evaluating the client's progress, the nurse knows that four of the five fetal factors that interact to regulate the heart rate are (select all that apply): a. baroreceptors. b. adrenal glands. c. chemoreceptors. d. uterine activity. e. autonomic nervous system.

ANS: A, B, C, E The sympathetic and parasympathetic branches of the autonomic nervous system are balanced forces that regulate FHR. Sympathetic stimulation increases the heart rate, whereas parasympathetic responses, through stimulation of the vagus nerve, reduce the FHR and maintain variability. The baroreceptors stimulate the vagus nerve to slow the FHR and decrease the blood pressure. These are located in the carotid arch and major arteries. The chemoreceptors are cells that respond to changes in oxygen, carbon dioxide, and pH. They are found in the medulla oblongata and aortic and carotid bodies. The adrenal medulla secretes epinephrine and norepinephrine in response to stress, causing accelerations in FHR. Hypertonic uterine activity can reduce the time available for the exchange of oxygen and waste products; however, this is a maternal factor. The fifth fetal factor is the central nervous system. The fetal cerebral cortex causes the heart rate to increase during fetal movement and decrease when the fetus sleeps.

Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) a. A gush of blood appears. b. The uterus rises upward in the abdomen. c. The fundus descends below the umbilicus. d. The cord descends further from the vagina. e. The uterus becomes boggy and soft, with an elongated shape.

ANS: A, B, D Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected.

42. The nurse is preparing a client for a cesarean section scheduled to be done under general anesthesia. Which should the nurse plan to administer, if ordered by the health care provider, to prevent aspiration of gastric contents?(Select all that apply.) a. Citric acid (Bicitra) b. Ranitidine (Zantac) c. Hydroxyzine (Vistaril) d. Glycopyrrolate (Robinul) e. Promethazine (Phenergan)

ANS: A, B, D To prevent aspiration of gastric contents during general anesthesia administration of medications to raise the gastric pH and make secretions less acidic, such as citric acid (Bicitra) and ranitidine (Zantac) may be prescribed. In addition, medications to reduce secretions, such as glycopyrrolate (Robinul) may be prescribed. Hydroxyzine (Vistaril) and promethazine (Phenergan) are used to prevent and relieve nausea often associated with opioids. PTS: 1 DIF: Cognitive Level: Analysis REF: 296 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity MATCHING

The nurse is preparing supplies for an amnioinfusion on a client with intact membranes. Which supplies should the nurse gather? (Select all that apply.) a. Extra underpads b. Solution of 3% normal saline c. Amniotic hook to perform an amniotomy d. Solid intrauterine pressure catheter with a pressure transducer on its tip

ANS: A, C Amnioinfusion is performed with lactated Ringer's solution or normal saline, not 3%. Normal saline is infused into the uterus through an intrauterine pressure catheter (IUPC). The underpads must be changed regularly because fluid leaks out constantly. The membranes need to be ruptured before an amnioinfusion can be initiated so an amniotic hook will be needed. The IUPC must have a double lumen to run the infusion through.

42. The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a. Soft boggy uterus b. Maternal temperature of 99° F c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics e. Half of a lochia pad saturated in the first hour after birth

ANS: A, C, D Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts. PTS: 1 DIF: Cognitive Level: Analysis REF: 249 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity SHORT ANSWER

41. The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.) a. Maternal hypotension b. Fetal heart rate of 140 to 150 bpm c. Meconium-stained amniotic fluid d. Maternal fever—38° C (100.4° F) or higher e. Complete uterine relaxation of more than 30 seconds between contractions

ANS: A, C, D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38° C [100.4° F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding. PTS: 1 DIF: Cognitive Level: Analysis REF: 234 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.) a. In true labor, the cervix begins to dilate. b. In true labor, the contractions are felt in the abdomen and groin. c. In true labor, contractions often resemble menstrual cramps during early labor. d. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages. e. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

ANS: A, C, E In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking. False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in frequency, duration, and intensity.

26. 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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Application REF: 569

5. 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.

ANS: B 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. PTS: 1 DIF: Cognitive Level: Application REF: 591

15. 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.

ANS: B After the fetal legs and trunk emerge from the client's 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 590

24. 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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 593

2. 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

ANS: B 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.

20. 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.

ANS: B 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 570, 571

33. 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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 593

6. 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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Application REF: 572

30. 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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 584

4. 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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Application REF: 585

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

ANS: B 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 574

25. 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 client's 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 client's 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 physician's directions.

ANS: B 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 590

4. Childbirth pain is different from other types of pain in that it is: a. less intense. b. associated with a physiologic process. c. more responsive to pharmacologic management. d. designed to make one withdraw from the stimulus.

ANS: B Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during labor may affect the course and length of labor. The pain with childbirth is a normal process; it is not caused by the type of injury as when withdrawal from the stimulus occurs. PTS: 1 DIF: Cognitive Level: Understanding REF: 278 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

12. Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth? a. Bloody mucous discharge increases. b. The vulva bulges and encircles the fetal head. c. The membranes rupture during a contraction. d. The fetal head is felt at 0 station during the vaginal examination.

ANS: B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. PTS: 1 DIF: Cognitive Level: Analysis REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

20. Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor? a. Length of second-stage labor is 2 hours. b. Client has received an epidural for pain control during the labor process. c. Client is using breathing techniques during contractions to maximize pain relief. d. Client is receiving parenteral fluids during the course of labor to maintain hydration.

ANS: B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit. PTS: 1 DIF: Cognitive Level: Application REF: 244 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Safe and Effective Care Environment/Management of Care

36. A multipara's labor plan includes the use of jet hydrotherapy during the active phase of labor. What is the priority patient assessment prior to assisting the patient with this request? a. Maternal pulse b. Maternal temperature c. Maternal blood pressure d. Maternal blood glucose level

ANS: B A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several studies have shown benefits of water therapy during labor, including immersion in a tub or whirlpool (jet hydrotherapy, or Jacuzzi). The major concern about immersion therapy has been newborn and postpartum maternal infections caused by microorganisms in the water. Infections can be caused by the woman's own ascending vaginal bacteria or by preexisting organisms in an improperly cleaned tub. However, several studies have not found a significant association between newborn or postpartum maternal infections and the use of immersion hydrotherapy with proper cleaning. PTS: 1 DIF: Cognitive Level: Application REF: 283 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

33. The priority intervention for a client with epidural anesthesia whose blood pressure is 80/50 mm Hg is: a. reposition to supine position. b. administer ephedrine, 5 mg IV push. c. maintain IV infusion rate at 150 mL/hr. d. Notify anesthesia about maternal hypotension.

ANS: B A significant blood pressure decrease is a drop to 100 mm Hg or lower systolic. If hypotension is significant, ephedrine is ordered to increase the blood pressure to normal values. The supine position will further decrease maternal blood pressure by compressing the major vessels. Maintaining the IV infusion rate will not return blood pressure to normal values as quickly as needed; immediate action needs to be taken, and notifying anesthesia would be time-consuming. PTS: 1 DIF: Cognitive Level: Application REF: 301 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

35. The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the baby's head? a. Expulsion b. Restitution c. Internal rotation d. External rotation

ANS: B After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head. PTS: 1 DIF: Cognitive Level: Understanding REF: 247 OBJ: Nursing Process Step: Planning MSC: Client needs: Health Promotion and Maintenance

31. Your laboring client has asked that you help her to use a cutaneous stimulation strategy for pain management, you would then: a. assist her into the shower. b. apply a heat pack to lower back. c. help her to create a relaxing mental scene. d. encourage cleansing breaths and slow-paced breathing.

ANS: B Cutaneous stimulation includes self-massage, massage by others, counterpressure, touch, thermal stimulation, and acupressure. A shower, tub, or whirlpool are forms of hydrotherapy; creating a relaxed mental scene is mental stimulation. The use of cleansing breaths and patterned breathing is part of breathing techniques for labor. PTS: 1 DIF: Cognitive Level: Application REF: 282 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

7. A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are: a. contraction pattern, amount of discomfort, and pregnancy history. b. fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. last food intake, when labor began, and cultural practices the couple desires. d. identification of ruptured membranes, the woman's gravida and para, and her support person.

ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits. PTS: 1 DIF: Cognitive Level: Application REF: 222 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

The physician has ordered an amnioinfusion for the laboring client. What data supports the use of this therapeutic procedure? a. Presenting part not engaged b. +4 meconium-stained amniotic fluid on artificial rupture of membranes (AROM) c. Breech position of fetus d. Twin gestation

ANS: B Amnioinfusion is a procedure used during labor when cord compression or the detection of gross meconium staining is found in the amniotic fluid. A saline solution is used as an irrigation method through the IUPC (intrauterine pressure catheter).

28. The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation. PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

21. A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority intervention should be done by the nurse to help evaluate clinical response to treatment? a. Obtain a pain scale response from the client based on a 0 to 10 scale. b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. c. Document intake and output on the electronic health record (EHR). d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.

ANS: B Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this client's situation. Increasing the flow rate of parenteral fluids requires a physician's order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess. PTS: 1 DIF: Cognitive Level: Analysis REF: 285 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

23. A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration? a. Oxytocin (Pitocin) b. Naloxone (Narcan) c. Bromocriptine (Parlodel) d. Oxygen

ANS: B Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression. PTS: 1 DIF: Cognitive Level: Analysis REF: 291 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

21. A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, -1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time? a. Performing more frequent vaginal exams will not make the labor go any quicker. b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c. Tell the client that she will check every 30 minutes. d. Medicate the client as needed for anxiety so that the labor can progress.

ANS: B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client's anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 231, 233 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

11. The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate? a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour

ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications. PTS: 1 DIF: Cognitive Level: Application REF: 231 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

13. Which client will most likely have increased anxiety and tension during labor? a. Gravida 2 who refused any medication b. Gravida 2 who delivered a stillborn baby last year c. Gravida 1 who did not attend prepared childbirth classes d. Gravida 3 who has two children younger than 3 years

ANS: B If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect. PTS: 1 DIF: Cognitive Level: Analysis REF: 280 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

6. Which fetal position may cause the laboring client more back discomfort? a. Left occiput anterior b. Left occiput posterior c. Right occiput anterior d. Right occiput transverse

ANS: B In the left occiput posterior position, each contraction pushes the fetal head against the mother's sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position. PTS: 1 DIF: Cognitive Level: Understanding REF: 280 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

16. When giving a narcotic to a laboring client, which statement explains why the nurse should inject the medication at the beginning of a contraction? a. The medication will be rapidly circulated. b. Less medication will be transferred to the fetus. c. The maternal vital signs will not be adversely affected. d. Full benefit of the medication is received during that contraction.

ANS: B Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus. PTS: 1 DIF: Cognitive Level: Application REF: 293, 294 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

Which is the most appropriate method of intrapartum fetal monitoring when a woman has a history of hypertension during pregnancy? a. Continuous auscultation with a fetoscope b.Continuous electronic fetal monitoring c. Intermittent assessment with a Doppler transducer d. Intermittent electronic fetal monitoring for 15 minutes each hour

ANS: B Maternal hypertension may reduce placental blood flow through vasospasm of the spiral arteries. Reduced placental perfusion is best assessed with continuous electronic fetal monitoring to identify patterns associated with this condition. It is not practical to provide continuous auscultation with a fetoscope. This fetus needs continuous monitoring because it is at high risk for complications.

Which statement correctly describes the nurse's responsibility related to electronic monitoring? a. Report abnormal findings to the physician before initiating corrective actions. b. Teach the woman and her support person about the monitoring equipment and discuss any of their questions. c. Document the frequency, duration, and intensity of contractions measured by the external device. d. Inform the support person that the nurse will be responsible for all comfort measures when the electronic equipment is in place.

ANS: B Teaching is an essential part of the nurse's role. Corrective actions should be initiated first to correct abnormal findings as quickly as possible. Electronic monitoring will record the contractions and FHR response. The support person should still be encouraged to assist with the comfort measures.

26. At 5 minutes after birth, the nurse assesses that the neonate's heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a. 7 b. 8 c. 9 d. 10

ANS: B The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8. PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

The health care provider for a laboring patient makes the following entry into the patient's record: 3/50%/-1. What instruction will the nurse implement with the patient? a. "You will need to remain in bed attached to the electronic fetal monitor." b. "Breathe with me slowly, in through your nose and out through your mouth." c. "I will begin the administration of 1000 mL of IV fluid so you can have an epidural." d. "Your partner will need to change into scrub attire to attend the imminent birth."

ANS: B This client is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the stem that the membranes are ruptured, which may prohibit the patient from ambulating. Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at -1 station. Epidural placement during early labor may slow down the labor process. There is no indication that birth is imminent because the patient is 3 cm dilated.

33. The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a. Place the catheter as quickly as possible. b. Place a small pillow under the patient's left hip. c. Omit the use of a cleansing agent, such as Betadine. d. Set up the catheter tray before positioning the patient.

ANS: B To promote placental function, the nurse can place a small pillow or rolled blanket under the patient's left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care. PTS: 1 DIF: Cognitive Level: Analysis REF: 235 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

What is the most likely cause for this fetal heart rate pattern? a. Administration of an epidural for pain relief during labor b. Cord compression c. Breech position of fetus d. Administration of meperidine (Demerol) for pain relief during labor

ANS: B Variable deceleration patterns are seen in response to head compression or cord compression. A breech presentation would not be likely to cause this fetal heart rate pattern. Similarly, administration of medication and/or an epidural would not cause this fetal heart rate pattern.

23. A nursing priority during admission of a laboring client who has not had prenatal care is: a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care.

ANS: B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed. PTS: 1 DIF: Cognitive Level: Analysis REF: 223 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern? a. Early decelerations b. Variable decelerations c. Nonperiodic accelerations d. Increase in baseline variability

ANS: B When the membranes rupture, amniotic fluid may carry the umbilical cord to a position where it will be compressed between the maternal pelvis and the fetal presenting part, resulting in a variable deceleration pattern. Early declarations are considered reassuring; they are not a concern after rupture of membranes. Accelerations are considered reassuring; they are not a concern after rupture of membranes. Increase in baseline variability is not an expected occurrence after the rupture of membranes.

39. You are preparing a client for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.) a. Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement. b. Have ephedrine available at bedside during catheter placement. c. Monitor blood pressure of client frequently during catheter insertion and for the first 15 minutes of epidural administration. d. Insert a Foley catheter prior to epidural catheter placement. e. Monitor the client for hypertension in response to epidural insertion.

ANS: B, C A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is. PTS: 1 DIF: Cognitive Level: Application REF: 300 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.) a. Progesterone levels become higher than estrogen levels. b. Natural oxytocin in conjunction with other substances plays a role. c. Stretching, pressure, and irritation of the uterus and cervix increase. d. The secretion of prostaglandins from the fetal membranes decreases.

ANS: B, C Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labor's initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

11. The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n): a. local. b. epidural. c. pudendal. d. spinal block.

ANS: C A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs. PTS: 1 DIF: Cognitive Level: Understanding REF: 295 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

39. When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.) a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor.

ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 229 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

37. 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

ANS: B, C, E 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. PTS: 1 DIF: Cognitive Level: Application REF: 569

The nurse recognizes that fetal scalp stimulation may be prescribed to evaluate the response of the fetus to tactile stimulation. Which conditions contraindicate the use of fetal scalp stimulation? (Select all that apply.) a. Post-term fetus b. Maternal fever c. Placenta previa d. Induction of labor e. Prolonged rupture of membranes

ANS: B, C, E Fetal scalp stimulation is not done when there is maternal fever (possibility of introducing microorganisms into the uterus), placenta previa (placenta overlies the cervix, and hemorrhage is likely), or prolonged rupture of membranes (risk of infection). Fetal scalp stimulation may be used to evaluate a post-term fetus' response to stimulation. It is also used to evaluate a fetus when labor is being induced.

38. Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed.

ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period. PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

28. 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.

ANS: C 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. PTS: 1 DIF: Cognitive Level: Application REF: 591

3. 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

ANS: C 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 576

14. 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

ANS: C 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 590

21. 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.

ANS: C 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. PTS: 1 DIF: Cognitive Level: Application REF: 581

31. 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.

ANS: C 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. PTS: 1 DIF: Cognitive Level: Application REF: 586

23. 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

ANS: C The presence of CPD is a contraindication for vaginal birth. To prevent further complications, the client should be prepped for a cesarean section. PTS: 1 DIF: Cognitive Level: Analysis REF: 570

5. A client at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences: a. fetal movement. b. irregular contractions for 1 hour. c. a trickle of fluid from the vagina. d. thick pink or dark red vaginal mucus.

ANS: C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced. PTS: 1 DIF: Cognitive Level: Application REF: 221 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

31. The health care provider has asked the nurse to prepare for an amniotomy. What is the nurse's priority action with this procedure? a. Perform Leopold's maneuvers. b. Determine the color of the amniotic fluid. c. Assess the fetal heart rate immediately after the procedure. d. Prepare the patient for a change in her pain level after the procedure.

ANS: C An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopold's maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 229 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

28. A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes. The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment? a. Use contact anesthesia for an epidural and prepare the client per protocol. b. Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop. c. Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. d. Call the physician for admitting orders.

ANS: C By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the client's needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the client's concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician. PTS: 1 DIF: Cognitive Level: Analysis REF: 287 OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment

32. To relieve a mild postdural puncture headache, the nurse should encourage the intake of: a. milk. b. orange juice. c. tea or coffee. d. beef or chicken bouillon.

ANS: C Caffeine is an oral therapy that is beneficial in relieving postdural puncture headache. Milk, juices, and bouillon will add oral hydration but lack the added benefit of the caffeine. PTS: 1 DIF: Cognitive Level: Application REF: 292 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

Which of the following is the priority intervention for a supine client whose monitor strip shows decelerations that begin after the peak of the contraction and return to the baseline after the contraction ends? a. Increase IV infusion. b. Elevate lower extremities. c. Reposition to left side-lying position. d. Administer oxygen per face mask at 4 to 6 L/min.

ANS: C Decelerations that begin at the peak of the contractions and recover after the contractions end are caused by uteroplacental insufficiency. When the client is in the supine position, the weight of the uterus partially occludes the vena cava and descending aorta, resulting in hypotension and decreased placental perfusion. Increasing the IV infusion, elevating the lower extremities, and administering O2 will not be effective as long as the client is in a supine position.

19. Which clinical effect can occur in the presence of increased maternal pain perception during labor? a. Increase in uterine contractions in response to catecholamine secretion b. Decrease in blood pressure in response to alpha receptors c. Decreased perfusion to the placenta in response to catecholamine secretion d. Increased uterine blood flow, causing increase in maternal blood pressure

ANS: C Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

The nurse admits a laboring patient at term. On review of the prenatal record, the patient's pregnancy has been unremarkable and she is considered low risk. In planning the patient's care, at what interval will the nurse intermittently auscultate (IA) the fetal heart rate during the first stage of labor? a. Every 10 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes

ANS: C Evaluate the fetal monitoring strip systematically for the elements noted. The following are recommended assessment and documentation intervals for IA and EFM (although facility policies may be different): low-risk women, every 30 minutes during the active phase and every 15 minutes during the second stage.

To clarify the fetal condition when baseline variability is absent, the nurse should first: a. monitor fetal oxygen saturation using fetal pulse oximetry. b. notify the physician so that a fetal scalp blood sample can be obtained. c. apply pressure to the fetal scalp with a glove finger using a circular motion. d. increase the rate of nonadditive IV fluid to expand the mother's blood volume.

ANS: C Fetal scalp stimulation helps identify whether the fetus responds to gentle massage. An acceleration in response to the massage suggests that the fetus is in normal oxygen and acid-base balance. Monitoring fetal oxygen saturation using fetal pulse oximetry is no longer available in the United States. Obtaining a fetal scalp blood sample is invasive and the results are not immediately available. Increasing the rate of nonadditive IV fluid would not clarify the fetal condition.

Which of the following therapeutic applications provides the most accurate information related to uterine contraction strength? a. External fetal monitoring (EFM) b. Internal fetal monitoring c. Intrauterine pressure catheter (IUPC) d. Maternal comments based on perception

ANS: C IUPC is a clinical tool that provides an accurate assessment of uterine contraction strength. EFM provides evidence of contraction pattern and fetal heart rate but only estimates uterine contraction strength. Internal fetal monitoring provides direct evidence of fetal heart rate and contraction pattern. It only estimates uterine contraction strength. Maternal comments related to pain may not be related to uterine contraction strength and thus are influenced by the client's own pain perception.

If the position of a fetus in a cephalic presentation is right occiput anterior, the nurse should assess the fetal heart rate in which quadrant of the maternal abdomen? a. Right upper b. Left upper c. Right lower d. Left lower

ANS: C If the fetus is in a right occiput anterior position, the fetal spine will be on the mother's right side. The best location to hear the fetal heart rate is through the fetal shoulder, which would be in the right lower quadrant. The right upper, left upper, and left lower areas are not the best locations for assessing the fetal heart rate in this case.

Client is at 38 weeks' gestation, gravida 1, para 0, vaginal exam—4 cm, 100% effaced, +1 station vertex. What is the most likely intervention for this fetal heart rate pattern? a. Continue oxytocin (Pitocin) infusion. b. Contact the anesthesia department for epidural administration. c. Change maternal position. d. Administer Narcan to client and prepare for immediate vaginal delivery.

ANS: C Late decelerations indicate fetal compromise (uteroplacental insufficiency) and are considered to be a significant event requiring immediate assessment and intervention. Of all the options listed, changing maternal position may increase placental perfusion. In the presence of late decelerations, Pitocin infusion should be stopped. Contacting anesthesia for epidural administration will not solve the existing problem of late decelerations. There are no data to support the administration of Narcan and because client is still in early labor, birth is not imminent.

1. The nurse is preparing to perform Leopold's maneuvers. Why are Leopold's maneuvers used by practitioners? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position

ANS: C Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination. PTS: 1 DIF: Cognitive Level: Application REF: 227 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

17. The method of anesthesia in labor that is considered the safest for the fetus is: a. epidural block. b. pudendal block. c. local infiltration. d. spinal (subarachnoid) block.

ANS: C Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension. PTS: 1 DIF: Cognitive Level: Understanding REF: 295 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior. d. Determine whether the mother is too fatigued to interact normally with her infant.

ANS: C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner. PTS: 1 DIF: Cognitive Level: Analysis REF: 251 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

30. A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a. Obtain a fetal heart rate. b. Determine the estimated due date. c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat.

ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and pain—location, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed. PTS: 1 DIF: Cognitive Level: Analysis REF: 227 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

When a nonreassuring pattern of the fetal heart rate is noted and the client is lying on her left side, which nursing action is indicated? a. Lower the head of the bed. b. Place a wedge under the left hip. c. Change her position to the right side. d. Place the mother in Trendelenburg position.

ANS: C Repositioning on the opposite side may relieve compression on the umbilical cord and improve blood flow to the placenta. Lowering the head of the bed would not be the first position change choice. The woman is already on her left side, so a wedge on that side would not be an appropriate choice. Repositioning to the opposite side is the first intervention. If unsuccessful with improving the FHR pattern, further changes in position can be attempted; the Trendelenburg position might be the choice.

15. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue. The Apgar score for this infant is: a. 7. b. 8. c. 9. d. 10.

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet. PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

34. Which client will be most receptive to teaching about nonpharmacologic pain control methods? a. Gravida 1, para 0, in transition b. Gravida 2, para 1, admitted at 8 cm c. Gravida 1, para 0, dilated 2 cm, 80% effaced d. Gravida 3, para 2, complaining of intense perineal pressure

ANS: C The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Clients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a client whose birth is imminent. PTS: 1 DIF: Cognitive Level: Analysis REF: 282 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

36. The nurse is performing Leopold's maneuvers on a client. Which figure depicts the Leopold's maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis. Refer to Figures a to d. a. b. c. d.

ANS: C The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is done by palpating the suprapubic area. Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, the grasping movement of the fingers moves it upward in the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus. Palpating the uterine fundus distinguishes between a cephalic and breech presentation. Holding the left hand steady on one side of the uterus while palpating the opposite side of the uterus determines on which side of the uterus is the fetal back and on which side are the fetal arms and legs. Placing your hands on each side of the uterus with fingers pointed toward the inlet determines whether the head is flexed (vertex) or extended (face). PTS: 1 DIF: Cognitive Level: Analysis REF: 230 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

24. Which statement is true with regard to the type of pain associated with childbirth experience? a. Pain is constant throughout the labor experience. b. Labor pain during childbirth is considered to be an abnormal response. c. Pain associated with childbirth is self-limiting. d. Pain associated with childbirth does not allow for adequate preparation.

ANS: C The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a normal response during childbirth. Pregnant woman can prepare for the expected pain of childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 278 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated? a. Reposition the client. b. Apply a fetal scalp electrode. c. Record this reassuring pattern. d. Administer oxygen by nasal cannula.

ANS: C The periodic pattern described is early deceleration that is not associated with fetal compromise and requires no intervention. It is a reassuring pattern. Repositioning the client, applying a fetal scalp electrode, or administering oxygen would be interventions done for nonreassuring patterns.

29. The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time? a. To apply internal monitoring electrodes b. To assess for Goodell's sign c. To determine cervical dilation and effacement d. To determine strength of contractions

ANS: C The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodell's sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions. PTS: 1 DIF: Cognitive Level: Knowledge REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

38. Meperidine (Demerol), 50 mg IV, has been ordered for a laboring patient. The patient is contracting every 3 minutes, with a duration of 45 to 60 seconds. What is the nurse's best plan for administering the IV medication? a. Inject the medication between two contractions. b. Inject the medication during and after a single contraction. c. Inject the medication at the start of the next two contractions. d. Inject the medication throughout the duration of a single contraction.

ANS: C The suggested administration of IV Demerol is 25 mg/min and therefore will need to be administered over the course of two contractions. Opioid analgesics are given in small frequent doses by the IV route during labor to provide a rapid onset of analgesia and predictable duration of action. The woman will benefit from rapid pain control, with less likelihood of neonatal respiratory depression. Starting the injection at the beginning of the contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. When placental blood flow resumes, more of the drug is in maternal tissues. PTS: 1 DIF: Cognitive Level: Analysis REF: 293 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE

Proper placement of the tocotransducer for electronic fetal monitoring is: a. inside the uterus. b. on the fetal scalp. c. over the uterine fundus. d. over the mother's lower abdomen.

ANS: C The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use. The tocotransducer monitors uterine contractions. The most intensive uterine contractions occur at the fundus; this is the best placement area.

30. A pregnant woman in labor is quite anxious and has been breathing rapidly during contractions. She now complains of a tingling sensation in her fingers. What is the priority nursing intervention? a. Perform a vaginal exam to denote progress. b. Reposition the client to a side lying position. c. Instruct the client to breathe into her cupped hands. d. Notify the physician about current findings.

ANS: C This client is exhibiting signs of hyperventilation associated with a rapid breathing pattern, which can occur during the labor process. The nurse should instruct the client to breathe into her cupped hands to retain carbon dioxide that is being lost from the hyperventilation process. A vaginal exam is not indicated because there is no evidence of fetal distress and/or change in labor progress. Repositioning the client may be an option but is not the priority intervention at this time. Notifying the physician is not appropriate at this time because the RN should attend to actions that are readily available to her based on her scope of practice and standard of care. The physician may have to be notified once the intervention has been performed. PTS: 1 DIF: Cognitive Level: Analysis REF: 285 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

26. A client in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with: a. visceral pain. b. tissue ischemia. c. somatic pain. d. cervical dilation.

ANS: C This is an example of somatic pain experienced as a result of distention of the vagina and perineum during the second stage of labor. Visceral pain occurs in response to pressure on pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the uterus. The pain of cervical dilation is a major pain source during labor but, during the second stage of labor, the client is already fully dilated so this would not be a factor. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

22. The process of labor places significant metabolic demands on the obstetric client. Which physiologic findings would be expected? a. Decreased maternal blood pressure as a result of stimulation of alpha receptors b. Uterine vasoconstriction as a result of stimulation of beta receptors c. Increased maternal demand for oxygen d. Increased blood flow to placenta because of catecholamine release

ANS: C With regard to labor, one would expect to see an increase in maternal blood pressure because of stimulation of alpha receptors. Uterine vasoconstriction would occur in response to stimulation of alpha receptors. One would expect to see a decrease in blood flow to the placenta. The maternal metabolic rate is increased during labor, along with an increase in maternal demand for oxygen. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have: a. a higher hematocrit. b. increased leukocytes. c. increased blood volume. d. a lower fibrinogen level.

ANS: C Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

41. The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) a. Encourage the client to drink fluids. b. Place the client in a Trendelenburg position. c. Administer a normal saline bolus as prescribed. d. Administer oxygen at 8 to 10 L/min per face mask. e. Administer IV ephedrine in 5- to 10-mg increments as prescribed.

ANS: C, D, E If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client. PTS: 1 DIF: Cognitive Level: Application REF: 289 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

18. 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.

ANS: D 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. PTS: 1 DIF: Cognitive Level: Understanding REF: 582

22. 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 client's 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 client's 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.

ANS: D 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 580

17. 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

ANS: D 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. PTS: 1 DIF: Cognitive Level: Application REF: 576

27. 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

ANS: D 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 590

11. 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."

ANS: D 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. PTS: 1 DIF: Cognitive Level: Application REF: 570

8. 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

ANS: D Overdistention 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 client's uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus. PTS: 1 DIF: Cognitive Level: Analysis REF: 569

19. 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 exam—3 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

ANS: D 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. PTS: 1 DIF: Cognitive Level: Analysis REF: 570

29. 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.

ANS: D 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. PTS: 1 DIF: Cognitive Level: Application REF: 584

12. 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.

ANS: D 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. PTS: 1 DIF: Cognitive Level: Application REF: 591

The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation? a. This pattern reflects variable decelerations. No interventions are necessary at this time. b. Document this reassuring fetal heart rate pattern but decrease the rate of the intravenous (IV) fluid. c. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. d. This deceleration pattern is associated with uteroplacental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply.

ANS: D A pattern similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction, describes a late deceleration. Oxygen should be given via a snug face mask. Position the client on her left side to increase placental blood flow. Variable decelerations are caused by cord compression. A vaginal examination should be performed to identify this potential emergency. This is not a reassuring pattern, so the IV rate should be increased to increase the mother's blood volume. These are late decelerations, not early; therefore, interventions are necessary.

19. Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours? a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 244 OBJ: Nursing Process Step: Nursing Diagnosis MSC: Client Needs: Psychosocial Integrity

27. The gynecologist performs an amniotomy. What will the nurse's role include immediately following the procedure? a. Assessing for ballottement b. Conducting a pH and/or fern test c. Labeling of specimens for chromosomal analysis d. Recording the character and amount of amniotic fluid

ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis. PTS: 1 DIF: Cognitive Level: Understanding REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

9. The primary side effect of maternal narcotic analgesia in the newborn is: a. tachypnea. b. bradycardia. c. acrocyanosis. d. respiratory depression.

ANS: D An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. PTS: 1 DIF: Cognitive Level: Understanding REF: 293 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

24. The nurse has given the newborn an Apgar score of 5. She should then: a. begin ventilation and compressions. b. do nothing except place the infant under a radiant warmer. c. observe the infant and recheck the score after 10 minutes. d. gently stimulate by rubbing the infant's back while administering O2.

ANS: D An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation. An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborn's transition to extrauterine life. PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is concerned that a client's uterine activity is too intense and that her obesity is preventing accurate assessment of the actual intrauterine pressure. Based on this information, which action should the nurse take? a. Reposition the tocotransducer. b. Reposition the Doppler transducer. c. Obtain an order from the health care provider for a spiral electrode. d. Obtain an order from the health care provider for an intrauterine pressure catheter.

ANS: D An intrauterine pressure catheter can measure actual intrauterine pressure. The tocotransducer measures the uterine pressure externally; this would not be accurate with an obese client, even with repositioning. A Doppler auscultates the FHR. A scalp electrode (or spiral electrode) measures the fetal heart rate (FHR).

7. A major advantage of nonpharmacologic pain management is that: a. a more rapid labor is likely. b. more complete pain relief is possible. c. the woman remains fully alert at all times. d. there are no side effects or risks to the fetus.

ANS: D Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at a quicker pace. The woman's alertness is not altered by medication, but the increase in pain will decrease alertness. PTS: 1 DIF: Cognitive Level: Understanding REF: 281 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

When a pattern of variable decelerations occur, the nurse should: a. administer O2 at 8 to 10 L/min. b. place a wedge under the right hip. c. increase the IV fluids to 150 mL/hr. d. position client in a knee-chest position.

ANS: D Variable decelerations are caused by conditions that reduce flow through the umbilical cord. The client should be repositioned when the FHR pattern is associated with cord compression. The knee-chest position uses gravity to shift the fetus out of the pelvis to relieve cord compression. Administering oxygen will not be effective until cord compression is relieved. Increasing the IV fluids and placing a wedge under the right hip are not effective interventions for cord compression.

Which client has the priority need for fetal monitoring? a. Primigravida at 38 weeks with spontaneous ROM b. Multigravida at 40 weeks with history of 10-hour labors c. Multigravida admitted for repeat elective cesarean section d. Primigravida at 39 weeks with meconium-stained amniotic fluid

ANS: D Meconium-stained amniotic fluid indicates a potential risk factor during labor. Primigravida at 38 weeks with spontaneous ROM, multigravida with a history of 10-hour labors, and multigravida admitted for repeat elective cesarean section do not have potential maternal or fetal risk factors.

6. Which client at term should go to the hospital or birth center the soonest after labor begins? a. Gravida 2, para 1, who lives 10 minutes away b. Gravida 1, para 0, who lives 40 minutes away c. Gravida 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours

ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours. PTS: 1 DIF: Cognitive Level: Analysis REF: 221 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment

14. Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? a. Narcotics b. Spinal block c. Epidural anesthesia d. Breathing and relaxation techniques

ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn. PTS: 1 DIF: Cognitive Level: Application REF: 297 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

1. Childbirth preparation can be considered successful if the outcome is described as which of the following? a. Labor was pain-free. b. The birth experiences of friends and families were ignored. c. Only nonpharmacologic methods for pain control were used. d. The client rehearsed labor and practiced skills to master pain.

ANS: D Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realistic information about labor pain. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone. PTS: 1 DIF: Cognitive Level: Analysis REF: 281 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

37. A patient in active labor requests an epidural for pain management. What is the nurse's priority action for this patient? a. Assess the fetal heart rate pattern over the next 30 minutes. b. Take the patient's blood pressure every 5 minutes for 15 minutes. c. Determine the patient's contraction pattern for the next 30 minutes. d. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hr over 30 minutes.

ANS: D Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringer's or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation. PTS: 1 DIF: Cognitive Level: Analysis REF: 289 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

25. A pregnant woman is in the second stage of labor and is actively pushing. What type of pain would she be most likely to experience? a. Deep, poorly localized pain b. Visceral pain c. Slow, dull, aching pain d. Somatic pain

ANS: D Somatic pain is quick, sharp, and precisely localized and is seen during the second stage of labor. Deep, poorly localized pain is associated with visceral pain, which predominates during the first stage of labor. Visceral pain is slow, deep, dull, aching, and poorly localized. Slow, dull, aching pain is characteristic of visceral pain. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

34. The nurse examines a primipara's cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurse's priority action? a. Palpate her bladder for fullness. b. Assess the frequency and duration of her contractions. c. Determine who will stay with the patient for the birth. d. Encourage the patient to exhale in short breaths with contractions.

ANS: D Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patient's urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push. PTS: 1 DIF: Cognitive Level: Analysis REF: 237 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be: a. discharged home with a sedative. b. admitted for extended observation. c. admitted and prepared for a cesarean birth. d. discharged home to await the onset of true labor.

ANS: D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated. PTS: 1 DIF: Cognitive Level: Application REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

In which situation would it be appropriate to obtain a fetal scalp blood sample to establish fetal well-being? a. The fetus has developed tachycardia related to maternal fever. b. The mother has vaginal bleeding, and the baseline fetal heart rate is decreasing. c. The fetal heart tracing on a preterm fetus shows decreased baseline variability. d. The fetal heart tracing shows a persistent pattern of late decelerations, with normal baseline variability.

ANS: D The tracing is nonreassuring, and additional assessment is needed regarding the acid-base status of the fetus. Fetal scalp blood sampling is contraindicated with vaginal bleeding, maternal fever, and a preterm fetus.

14. A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely: a. abnormal labor. b. a sign that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis. PTS: 1 DIF: Cognitive Level: Application REF: 223 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

Why is continuous electronic fetal monitoring generally used when oxytocin is administered? a. Fetal chemoreceptors are stimulated. b. The mother may become hypotensive. c. Maternal fluid volume deficit may occur. d. Uteroplacental exchange may be compromised.

ANS: D The uterus may contract more firmly and the resting tone may be increased with oxytocin use. This response reduces the entrance of freshly oxygenated maternal blood into the intervillous spaces, depleting fetal oxygen reserves. Oxytocin affects the uterine muscles. Hypotension is not a common side effect of oxytocin. All laboring women are at risk for fluid volume deficit; oxytocin administration does not increase the risk.

18. To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should: a. give the woman oxygen. b. turn the woman to the right side. c. decrease the intravenous infusion rate. d. place a wedge under the woman's right hip.

ANS: D Tilting the woman's pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. However, placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension. PTS: 1 DIF: Cognitive Level: Application REF: 286 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is monitoring a client in labor and notes this fetal heart rate pattern on the electronic fetal monitoring strip (see figure). Which is the most appropriate nursing action? a. Decrease the rate of the IV fluids. b. Document the fetal heart rate pattern. c. Explain to the client that the pattern is reassuring. d. Perform a vaginal exam to detect a prolapsed cord.

ANS: D Variable decelerations do not have the uniform appearance of early and late decelerations. Their shape, duration, and degree of fall below baseline rate vary. They fall and rise abruptly (within 30 seconds) with the onset and relief of cord compression, unlike the gradual fall and rise of early and late decelerations. A vaginal examination may identify a prolapsed cord, which may cause variable decelerations, bradycardia, or both as it is compressed. A vaginal examination also evaluates the woman's labor status, which helps the birth attendant decide if labor should continue. This is a nonreassuring pattern so the IV rate should be increased and an intervention needs to be done, not just documentation.

12. A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session? a. It usually results in a more rapid labor. b. It has no effect on the outcome of labor. c. It is considered to be a normal occurrence. d. It may result in decreased placental perfusion.

ANS: D When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed. PTS: 1 DIF: Cognitive Level: Application REF: 279 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

10. Which should the nurse recognize as being associated with fetal compromise? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. PTS: 1 DIF: Cognitive Level: Application REF: 235 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

As the nurse is admitting a woman in labor, she notices that the woman is happy and excited that she is in labor. The contractions are 5 minutes apart, lasting 30 to 35 seconds. The nurse can anticipate that the client is in which phase of labor? a. Second b. Latent c. Active d. Transition

B During the latent phase of the first stage of labor, the woman is usually sociable, excited, and cooperative. The contractions are about 5 minutes apart.

In caring for a low-risk woman in the active phase of labor, the nurse realizes the assessment of fetal well-being should occur: a. Every 15 minutes. b. Every 30 minutes. c. Every 5 minutes. d. Every hour.

B For low-risk women, the nurse should evaluate the fetal monitoring strip or assessment fetal well-being at least every 30 minutes during the active phase of labor and every 15 minutes during the second stage. For the high-risk woman, monitoring should occur every 15 minutes during the active phase and every 5 minutes during the second stage.

The nurse is preparing to auscultate the fetal heart rate using a Doppler transducer. When performing the Leopold maneuver, the nurse felt the buttocks near the fundus and the back along the left side of the mother. The best position for the Doppler would be in the mother's: a. Left upper quadrant. b. Left lower quadrant. c. Right upper quadrant. d. Right lower quadrant.

B The fetal heart is best heard through the fetus's upper back. Because this fetus is in a cephalic position, with the back toward the mother's left side, the Doppler should be placed in the left lower quadrant of the mother's abdomen.

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of oxytocin (Pitocin). The woman is in a side-lying position and her vital signs are stable, falling within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's immediate action would be to: a. Change the woman's position. b. Stop the oxytocin. c. Elevate the woman's legs. d. Administer oxygen via a tight mask at 8 to 10 L/min.

B The late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the oxytocin infusion because oxytocin stimulates the uterus to contract. The woman is already in an appropriate position for uteroplacental perfusion. Elevating her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.

The midwife has just examined a labor client and states that she is 10 cm dilated. The nurse is aware that this client is in which stage of labor? a. First b. Second c. Third d. Fourth

B The second stage begins with complete dilation (10 cm) and ends with the birth of the baby.

A fetal pulse oximetry is applied to a fetus. The reading shows an oxygen saturation of 45%. The nurse realizes that this means: a. A low reading; normal should be above 95%. b. A high reading; normal should be between 20% and 30%. c. A normal reading. d. This is not conclusive.

C A normal fetal pulse oximetry reading is 30% to 70%. A normal reading for an adult is between 95% and 100%. The lower reading is considered normal because of the high hemoglobin and hematocrit levels in the fetus compared with those of an adult.

A primigravida is in the latent phase of labor and is at low risk for complications of labor. She asks the nurse if she may walk for a few minutes. The nurse is aware that this is (is not) possible because: a. Continuous fetal monitoring is required. b. Continuous monitoring of the contractions is necessary at this stage of labor. c. Intermittent auscultation of fetal heart rate is appropriate for her. d. There is no need to assess fetal heart rate at this early stage of labor.

C Continuous fetal and uterine monitoring are not necessary for the latent phase of labor in women who are at low risk for complications.

After birth, the woman complains of chills. The first intervention by the nurse should be to: a. Monitor the maternal temperature. b. Monitor the maternal blood pressure. c. Place a warm blanket on the woman. d. Explain to the woman this is caused by the excitement of birth and will stop in about 30 minutes.

C Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket may help shorten the chill.

Firm contractions that occur every 3 minutes and last 100 seconds may reduce fetal oxygen supply because they: a. Cause fetal bradycardia and reduce oxygen concentration. b. Activate the fetal sympathetic nervous system. c. Limit the time for oxygen exchange in the placenta. d. Suppress the normal variability of the fetal heart.

C The resting time between these contractions is about 80 seconds, which reduces the time available for exchange of oxygen and waste products in the placenta. This will reduce the fetal oxygen supply. The other choices can all be results of the decreased oxygen supply.

When doing a vaginal exam, the nurse notes a triangular-shaped depression toward the mother's left side and pointing up toward her abdomen. The nurse can record the fetal position as: a. LOP. b. ROP. c. LOA. d. ROP.

C The triangular shape is the posterior fontanel, which makes the positioning part the occiput. The posterior fontanel is toward the mother's left side and anterior. This makes the position left occiput anterior (LOA).

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe which of the following? a. Weight gain of 1 to 3 pounds b. Quickening c. Fatigue and lethargy d. Bloody show

D Premonitory signs of labor (prodromal labor) include weight loss of 1 to 3 pounds, a burst of energy or the nesting instinct, and passage of the mucus plug (also termed pink or bloody show) as the cervix ripens. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks' gestation.

Which of the following findings meets the criteria of a reassuring FHR pattern? a. The FHR does not change as a result of fetal activity. b. The average baseline rate ranges between 90 and 110 bpm. c. Mild late deceleration patterns occur with some contractions. d. Variability averages between 6 and 25 bpm.

D Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. The FHR should accelerate with fetal movement. Baseline range for the FHR is from 110 to 160 bpm. Late deceleration patterns are never reassuring.

Fluctuations in the baseline FHR that cause the printed line to have an irregular rather than a smooth appearance is termed ___________________.

Variability

A patient comes to the clinic requesting an ultrasound to confirm pregnancy. Her last menstrual period was 15 days ago. The nurses best response would be to a. Make an appointment b. Ask the reason for needing a confirmation this soon in the pregnancy c. inform her that an ultrasound cannot confirm a pregnancy this early d. refer her to a specialist who is trained in confirming early pregnancies

c. inform her that an ultrasound cannot confirm a pregnancy this early

what is the purpose of initiating contractions in a contraction stress test (CST). a. increase placental blood flow b. identify fetal acceleration patterns c. determine the degree of fetal activity d. apply a stressful stimulus to the fetus.

d. apply a stressful stimulus to the fetus rationale: The CST involves recording the response of the fetal heart rate to stress induced by uterine contractions.

As full term nears, the cervix softens because of the effects of the hormone relaxin and increased water content. This cervical change is termed ____________________.

ripening

A patient is to have an ultrasound to do a general survey of the fetus, placenta, and amniotic fluid. This type of ultrasound level is termed ______________.

standard or basic.