Exam 2 MATERNITY

10. A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? A. Avoid getting out of bed for another 2 days. B. Walk with the nurse the length of her room. C. Walk the length of the hallway to regain her strength. D. Avoid elevating her feet when she rests in a chair.

B

11. A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum? A. Ask her if she feels any warmth in her legs. B. Assess for calf redness and edema. C. Take her temperature every 4 hours. D. Palpate her feet for tingling or numbness.

B

11. On the first postpartum day, a client who underwent a cesarean birth requests pain medication. Which action should the nurse perform first? A. The medication record should be reviewed to determine when the client was last medicated for pain. B. The location of the pain should be assessed. C. Other nonpharmacologic methods to reduce pain should be introduced to the client. D. The client's vital signs should be assessed.

B

1. How does a woman who feels in control of the situation during labor influence her pain? A. Feelings of control are inversely related to the client's report of pain. B. Decreased feeling of control helps during the third stage. C. There is no association between the two factors. D. Feeling in control shortens the overall length of labor.

A

25. The nurse assists while a pregnant client has an amniotomy. Which action should the nurse take immediately at the conclusion of the procedure? A. Assess the fetal heart rate. B. Adjust the intravenous fluid infusion rate. C. Assist the client to wash the perineum. D. Provide clean gown and linens for the client.

A

3. A primigravida whose baby is presenting breech is scheduled to have a cesarean birth. Which of the following would you prepare her for postoperatively? A. presence of an indwelling catheter B. bed rest for the first 4 days C. insertion of a nasogastric tube D. separation from her infant for 72 hours

A

3. Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? A. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. B. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. C. She says she is extremely thirsty. D. Her perineum is obviously edematous on inspection.

A

4. To assess the frequency of a woman's labor contractions, the nurse would time: A. the beginning of one contraction to the beginning of the next. B. the end of one contraction to the beginning of the next. C. the interval between the acme of two consecutive contractions. D. how many contractions occur in 5 minutes.

A

8. As a woman enters the second stage of labor, which would the nurse expect to assess? A. feelings of being frightened by the change in contractions B. reports of feeling hungry and unsatisfied C. falling asleep from exhaustion D. expressions of satisfaction with her labor progress

A

8. When palpating for fundal height on a postpartum woman, which technique is preferable? A. placing one hand at the base of the uterus, one on the fundus B. placing one hand on the fundus, one on the perineum C. resting both hands on the fundus D. palpating the fundus with only fingertip pressure

A

6. A husband asks if he can view his wife's cesarean birth. Which of the following reflects a modern policy on this subject? A. Surgery is too distressing for fathers to view. B. Viewing the surgery ruins the surprise of the child's sex. C. He can view it if he chooses, especially because his wife will be awake. D. His wife will be in too much pain for him to be comfortable.

C

24. Misoprostol is given to a client experiencing postpartum hemorrhage. The nurse assesses the client for which side effects of this medication? Select all that apply. A. diarrhea B. nausea C. respiratory distress D. urinary retention E. high blood pressure

A, B

26. A breastfeeding mother with endometritis is prescribed an antibiotic. The nurse teaches the mother to observe for what signs in the infant? Select all that apply. A. white plaques in the mouth B. bruising C. elevated temperature D. lethargic sucking E. foul smelling stool

A, B

15. The nurse is instructing a client who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply. A. False labor contractions are irregular. B. True labor contractions disappear when asleep. C. False labor contractions lead to cervical dilation. D. True labor contractions occur in the abdomen and groin. E. False labor contractions do not increase in duration, frequency, and intensity.

A, E

1. Which action would most make the nurse believe that a postpartum woman is accepting a child well? A. She states she has named the child after a well-loved friend. B. She turns her face to meet the infant's eyes when she holds her. C. She comments that her baby has the most hair of any in the nursery. D. She asks the nurse to use her camera to take a photo of the child.

B

27. The nurse is caring for four postpartum clients, monitoring them for postpartum infection. Which client is the priority due to current vital signs suggesting a postpartum infection? A. Client 35 hours postpartum with a temperature of 99.6°F (37.5°C) B. Client 30 hours postpartum with a temperature of 100.4°F (38°C) C. Client 20 hours postpartum with a temperature of 102.4°F (39.1°C) D. Client 25 hours postpartum with a temperature of 99.2°F (37.3°C)

B

1. The fetus of a woman in labor is in a vertex presentation and at a -1 station. The nurse would interpret this to mean that the fetal head is: A. at the ischial spines. B. engaged. C. floating. D. crowning.

C

18. A client scheduled for a cesarean birth asks, "Will I have any problems with breastfeeding after this type of birth?" Which response by the nurse is appropriate? A. "Breastfeeding really is not recommended after a cesarean birth." B. "It may be hard for you to breastfeed because of your incision." C. "We can work together to find a comfortable position so you can breastfeed your newborn." D. "You will likely have too much pain medicine after so it is not safe to breastfeed."

C

25. A postpartum client is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the client about this medication? Select all that apply. A. This medication has no adverse effects. B. Be sure to engage in activity to aid in intestinal motility. C. One pill should be taken after every meal for the first week. D. This medication works the best when a high-fiber diet is consumed. E. Take each dose of the medication with a full glass of water or juice.

B, D, E

20. A pregnant client in the second stage of labor is being encouraged to push with contractions. Into which position will the nurse assist the client? A. squatting while holding the breath B. lying on side, arms grasped on abdomen C. lying supine with legs in lithotomy stirrups D. semi-Fowler position with legs bent against the abdomen

D

21. Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first? A. Place the client supine. B. Administer an angiotensin-converting enzyme (ACE) inhibitor. C. Ask the client to take deep breaths. D. Raise the client's legs.

D

9. A postpartum woman is placed on an anticoagulant to prevent further clot formation. She asks the nurse if she will be able to continue breastfeeding. The nurse's best response would be that: A. all anticoagulants pass in breast milk, so she will have to stop. B. anticoagulants pass in breast milk, but not in amounts great enough to cause harm. C. the effect of anticoagulants is counteracted by infant gastric juices. D. it depends on the type of anticoagulant she is taking.

D

9. As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? A. Test a sample of amniotic fluid for protein. B. Ask her to bear down with the next contraction. C. Elevate her hips to prevent cord prolapse. D. Assess fetal heart rate for fetal safety.

D

6. Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? A. an absence of lochia B. red-colored lochia for the first 24 hours C. lochia that is the color of menstrual blood D. lochia appearing pinkish-brown on the fourth day

A

1. The nurse is caring for a woman who has had a baby by cesarean birth. Which of the following would be the most important assessment to make? A. whether her abdomen is soft or not B. whether her perineum is edematous C. if her breasts fill by the third day D. if she wants to breastfeed or not

A

27. A client in labor with chronic back pain tells the nurse about taking a dose of hydrocodone/acetaminophen for labor pain prior to coming to the hospital. What should the nurse prepare to do once the fetus is born? Select all that apply. A. Evaluate the neonate for withdrawal symptoms. B. Inform the health care provider so that liver effects can be monitored. C. Suggest that no additional opioid pain medication be provided during labor. D. Coach the client in breathing techniques because other pain medication is contraindicated. E. Request that the health care prescribe the same medication to be used for pain during labor.

A, B

26. The nurse is concerned that a pregnant client will have a complication from a medication after a cesarean birth. For which prescribed medications are complications most likely to occur? Select all that apply. A. insulin B. anticoagulant C. antihypertensive D. antianxiety agent E. beta2-adrenergic blocker

A, B, C, D

24. The provider of a client in labor decides that an emergency cesarean birth is required to safely deliver the fetus. When preparing the operating room suite for this procedure, which medications should the nurse ensure are available for possible use? Select all that apply. A. diazepam B. ephedrine C. acetaminophen D. atropine sulfate E. lactated Ringer's solution

A, B, D

15. After delivery, a client is diagnosed with postpartal gestational hypertension. What care will the nurse provide to this client? Select all that apply. A. Maintain on bed rest. B. Monitor urine output. C. Instruct on the purpose of a fluid restriction. D. Administer magnesium sulfate as prescribed. E. Administer antihypertensive medication as prescribed.

A, B, D, E

19. The nurse caring for pregnant clients is identifying interventions to support the 2030 National Health Goals regarding pain relief during labor. Which interventions support these goals? Select all that apply. A. Encourage pregnant clients to prepare for childbirth by attending classes. B. Discuss the advantages of using epidural or spinal anesthesia during labor. C. Review the various opioid analgesics that can be used to control the pain of labor. D. Review the different breathing techniques that help with pain control during labor. E. Explain the various complementary and alternative therapies to help with pain control.

A, D, E

10. A postpartum client with thrombophlebitis states that her leg is very painful. Which nursing instruction is most appropriate to decrease the pain? A. Massage the calf of her leg. B. Keep covers off the leg. C. Apply ice above the knee. D. Encourage ambulation every two hours.

B

11. The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? A. breast yeast B. mastitis C. plugged milk duct D. engorgement

B

22. During labor, a pregnant client's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective? A. The client is not complaining of leg cramps. B. The client is not requesting pain medication. C. The client is focusing on a painting during contractions. D. The client asks for a cold compress at the end of a contraction.

B

22. While conducting Leopold maneuvers, the nurse determines that the fourth maneuver does not need to be done. What information caused the nurse to make this decision? A. The fetus kicks during the procedure. B. The fetus is not in a cephalic presentation. C. The nurse palpated angular bumps and nodules. D. The nurse palpated a round and hard mass that moves freely.

B

23. A client in labor who is dilated 8 cm tells the nurse, "My opioid pain medication given 3 hours ago has worn off. I would like another dose." Which response by the nurse is appropriate? A. "I will check with your provider to see if you can have something." B. "Where you are in your labor progress would make it unsafe to give you another dose." C. "You can only have the medication every 4 hours, so you will have to wait another hour." D. "Let me check, but since 3 hours have passed, you should be able to have another dose."

B

24. The nurse has been given a basin containing a newly delivered placenta. Which action will the nurse complete next? A. Place in a bag and store in the refrigerator. B. Analyze for fragments. C. Send to the laboratory for testing. D. Remove all blood from the placenta.

B

4. Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths? A. Sitz baths cause perineal vasoconstriction and decreased bleeding. B. The longer a sitz bath is continued, the more therapeutic it becomes. C. Sitz baths increase the blood supply to the perineal area. D. Sitz baths may lead to increased postpartum infection.

C

4. Why should a woman be cautioned against taking acetylsalicylic acid (aspirin) to relieve pain in labor? A. Competition with bilirubin-binding sites in fetal circulation increases the risk of acute bilirubin encephalopathy (kernicterus). B. development of respiratory depression in the newborn C. interference with blood coagulation with increased risk of bleeding in the mother or infant D. interference with the ability to concentrate on contractions

C

5. A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her? A. Lie supine so the tracing does not show a shadow. B. Avoid flexing her knees so her abdomen is not tense. C. Lie on her side so she is comfortable. D. Avoid using her call bell to reduce interference.

C

5. Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution? A. Her uterus is 2 cm above the symphysis pubis. B. Her uterus is three finger widths under the umbilicus. C. Her uterus is at the level of the umbilicus. D. She experiences "pulling" pain while breastfeeding.

C

7. A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? A. "An injury is unlikely because of expert professional care given." B. "I have never read or heard of this happening." C. "The injection is given in the space outside the spinal cord." D. "The injection is given at the third or fourth thoracic vertebrae so paralysis is not a problem."

C

7. Following a cesarean birth, a woman has 3000 ml of intravenous fluid ordered. The nurse anticipates in the plan of care that she will be kept NPO except for minimal ice chips until which time? A. until 24 hours post-procedure B. until 48 hours post-procedure C. until bowel sounds have returned D. until her bladder tone has returned

C

8. A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response? A. "The anesthesiologist will do her best to avoid this." B. "The pain relief offered will compensate for the discomfort afterward." C. "Spinal headache is not a usual complication of epidural blocks." D. "Your health care provider knows what is best for you."

C

3. A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A. The flow contains large clots. B. The flow is over 500 mL. C. Her uterus is soft to your touch. D. The color of the flow is red.

D

3. Which of the following supports why a preterm fetus usually is more affected by medication given at birth than a full-term fetus? A. affinity of the preterm fetus to drugs that are fat-soluble B. affinity of the preterm fetus to drugs that are strongly bound to protein C. inability of the preterm fetus to use drugs with a molecular weight over 1000 D. inability of the immature liver to metabolize or inactivate drugs

D

23. A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation? A. Massage the fundus. B. Take a blood pressure. C. Call the provider. D. Encourage the client to void.

A

21. A postpartum client is diagnosed with a vaginal laceration. What intervention will the nurse provide to the client at this time? A. Monitor vital signs every 30 minutes. B. Insert an indwelling urinary catheter. C. Provide stool softeners as prescribed. D. Weigh vaginal packing to estimate blood loss.

B

16. The nurse assesses a postpartum client's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? A. lochia alba B. lochia rubra C. lochia serosa D. lochia normalia

B

5. The injection of a local anesthetic to block specific nerve pathways is referred to as: A. amnesic medication. B. gas administration. C. natural anesthesia. D. pudendal block.

D

13. A woman who underwent a primary cesarean birth for a breech presentation states that her neonate seems to have so much more mucus than her first baby. Concerned, she asks why this has happened. How should the nurse respond? A. "Babies born by cesarean section have more respiratory complications because they do not have the benefit of having the mucus in their lungs removed by the pressure experienced in the birth canal." B. "There is no scientific reason for this occurrence." C. "All babies are different so it is unwise to make comparisons." D. "The pain medication given during the surgery may have contributed to the mucus build up."

A

13. The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client? A. weak and rapid pulse B. warm and flushed skin C. elevated blood pressure D. decreased respiratory rate

A

24. After learning about the need for a cesarean birth, the pregnant client begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the client needs at this time? A. fear related to impending surgery B. risk for infection related to a surgical incision C. powerlessness related to medical need for cesarean birth D. risk for impaired parent/infant attachment related to unplanned method of birth

A

25. Eight days after birth, the woman notices a return to red lochia. What condition does the nurse anticipate this client is experiencing? A. retained placental fragments B. perineal hematoma rupture C. genital tract infection D. disseminate intravascular coagulopathy

A

12. A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? A. Assess vital signs. B. Assess the fundus. C. Notify the health care provider. D. Begin an IV infusion of Ringer's lactate solution.

B

21. A postpartum client is experiencing painful hemorrhoids. After teaching the client about ways to obtain relief and comfort, the nurse determines that the teaching was successful based on which client statement? A. "I need to avoid using any type of stool softeners for bowel movements." B. "I should lie on my left side with my right hip and knee bent several times a day." C. "I should rub the area vigorously after each time after using the bathroom." D. "I need to keep my fiber intake low so I do not irritate the hemorrhoids."

B

21. After assessment, the nurse determines that a pregnant client's fetus has a face presentation that is pointing to the client's left side with transverse pointing. How should the nurse document this assessment finding? A. LCT B. LMT C. LOT D. ROA

B

23. A client is scheduled for a cesarean birth. The nurse is discussing with the client the different types of incisions that may be used. Which statement would the nurse likely include in the teaching about a low-segment incision? A. The incision will be made vertically. B. Vaginal births are possible with future pregnancies. C. The incision is prone to leaving a wide scar. D. Birth is quick because the incision is made in a very active area of the uterus.

B

24. An immediate postpartum parent asks if it is possible to have rooming-in with the newborn. How should the nurse respond to this client's request? A. "It all depends on whether you are planning to breastfeed." B. "Rooming-in is helpful in allowing you to have more contact with your newborn." C. "It is not such a good idea to put all this responsibility on you as a first-time parent." D. "It would be better for you to rest for the first 3 days so you will be ready when you go home."

B

4. The nurse is administering methylergonovine 0.2 mg to a postpartum client with uterine subinvolution. Which assessment will the nurse need to make prior to administering the medication? A. if urine output is higher than 50 ml/h B. if blood pressure is lower than 140/90 mm Hg C. if the client can walk without experiencing dizziness D. if hematocrit level is higher than 45%

B

5. A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? A. Avoid using soap for any perineal care. B. Wash her perineum with her daily shower. C. Use an alcohol wipe to wash her episiotomy line. D. Refrain from washing lochia from the suture line.

B

6. When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection? A. in the milk ducts B. in the reproductive tract C. in the urinary bladder D. within the blood stream

B

10. A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice? A. "That's wonderful. Medication during labor is not good for the baby." B. "Your health care provider is a man and has never been in labor; he may be underestimating the pain you will have." C. "I respect your preference, whether it is to have medication or not." D. "Let me get you something for relaxation if you don't want anything for pain."

C

11. A client who is in the transition phase reports her pain medication last given 3 hours ago has worn off. She asks if she can have another dose of the narcotic. How should the nurse respond to the request? A. "Since it has been over 3 hours, you should be able to have more of the medication." B. "It is too early as the medication should be given only every 4 hours." C. "Your phase of labor makes giving another dose unsafe." D. "I will get permission from your health care provider."

C

11. To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? A. lying supine with legs in lithotomy stirrups B. squatting while holding her breath C. head elevated, grasping knees, breathing out D. lying on side, arms grasped on abdomen

C

20. The nurse is assessing the fundus of a client on postpartum day 1. What should the nurse expect when palpating the fundus? A. fundus 4 cm above symphysis pubis and firm B. fundus height 4 cm below umbilicus and midline C. fundus one fingerbreadth below umbilicus and firm D. fundus two fingerbreadths above symphysis pubis and hard

C

22. The nurse provides discharge instructions to a postpartum client. Which client statement indicates that teaching has been effective? A. "I should limit stair climbing to four times a day." B. "I can have coitus at any time after returning home." C. "I should plan to return to my full-time job after 6 weeks." D. "I should notify the physician if my discharge decreases in amount."

C

23. A postpartum client has a history of thrombophlebitis. The nurse suspects that the client isn developing this condition based on which finding? A. Legs are warm to touch. B. Temperature is elevated to 99.4°F (37.4°C). C. Calf is red and swollen. D. Client reports tingling but no numbness.

C

23. After delivery of the placenta, a client's uterus is sluggish to contract. What should the nurse prepare to do to assist the client at this time? A. Administer intravenous fluids. B. Measure blood pressure every 15 minutes. C. Administer oxytocin (pitocin) as prescribed. D. Prepare to administer blood products as prescribed.

C

25. A pregnant client planning for labor is asking questions about pain control options. What should the nurse explain about pain control during labor? A. The physician will decide how much pain relief is needed during labor. B. Pain medication should be started immediately when contractions are thought to begin. C. Any medication should have maximum effect for the client and minimal effect on the fetus. D. Any medication will interfere with the ability of the uterus to contract during labor and delivery.

C

25. During active labor, the nurse observes the client crying during contractions and not using breathing techniques learned during prenatal classes. Which client concern is the priority for the nurse to address at this time? A. ineffective airway clearance B. anxiety C. ineffective breathing pattern D. powerlessness

C

26. A pregnant client received an opioid analgesic 2 hours before birth. The newborn is lethargic and difficult to arouse. What should the nurse prepare to do to help this newborn? A. Administer intravenous fluids. B. Apply oxygen and place in a heated bassinet. C. Administer naloxone hydrochloride. D. Provide tactile stimulation to encourage crying.

C

3. Dilation (dilatation) follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement? A. 3 to 4 cm B. 7 to 8 cm C. 8 to 10 cm D. 12 to 14 cm

C

4. A woman is scheduled to have epidural anesthesia for a cesarean birth. Which of the following would the nurse anticipate including in the preoperative plan of care while she waits for the anesthetic? A. encouraging her to ambulate B. administering an oral antacid C. administering morphine sulfate IM D. keeping her turned on her side

D

1. A postpartum woman has a fourth-degree perineal laceration. Which prescription will the nurse question? A. urging the client to drink all the milk on the tray B. administration of acetaminophen and codeine for pain C. administration of a sitz bath D. administration of an enema

D

10. A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. What would be the nurse's best response? A. "You will like cesarean birth so much that you will want repeat cesarean births in the future." B. "There is no way to predict that; it will depend on your individual uterine anatomy." C. "Yes. 'Once a cesarean always a cesarean' is a well-known rule." D. "Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth."

D

10. During the second stage of labor, a woman is generally: A. very aware of activities immediately around her. B. anxious to have people around her. C. no longer in need of a support person. D. turning inward to concentrate on body sensations.

D

13. A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period? A. She sits and rocks her infant for long intervals. B. She is eager to talk about her birth experience. C. She has not asked for anything for pain all day. D. She did her perineal care independently.

D

5. A woman asks you if she will have any difficulty breastfeeding following a cesarean birth. What would be the nurse's best response? A. It's no recommended that she try to breastfeed following a cesarean birth. B. Although she can try, it is hard to find a comfortable position to hold a newborn to breastfeed. C. She will need too much analgesia postoperatively to make breastfeeding safe. D. You will help her find a comfortable position for breastfeeding her infant.

D

6. If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? A. a shallow deceleration occurring with the beginning of contractions B. variable decelerations, too unpredictable to count C. fetal baseline rate increasing at least 5 mm Hg with contractions D. fetal heart rate declining late with contractions and remaining depressed

D

6. Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? A. The father's coaching role may be disrupted at times. B. The infant may show increased drowsiness. C. The mother may have continued memory loss postpartum. D. The mother may have difficulty working effectively with contractions.

D

7. A postpartum woman is prescribed an antibiotic because of endometritis. Her breastfed infant should be observed particularly for which of the following? A. decreased sleep levels and increased appetite B. jaundice that does not respond to phototherapy C. irritability and loss of appetite D. signs of oral candidiasis (thrush) and easy bruising

D

7. When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel? A. fundus height 4 cm below umbilicus and midline B. fundus two fingerbreadths above symphysis pubis and hard C. fundus 4 cm above symphysis pubis and firm D. fundus two fingerbreadths below umbilicus and firm

D

9. Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. The nurse's first action would be to: A. raise her head off the bed. B. ask her to inhale deeply at least five times. C. administer oxygen by facemask. D. turn her on her left side or raise her legs.

D

2. The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? A. lochia rubra B. lochia serosa C. lochia normalia D. lochia alba

A

20. A postpartal client is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the client about breastfeeding during this time? A. Breastfeeding can continue. B. The baby will need weekly blood work. C. The effect of anticoagulants is counteracted by infant gastric juices. D. All anticoagulants pass in breast milk so breastfeeding will have to stop.

A

14. When the membranes of a pregnant client rupture during labor, the nurse determines that the client and fetus are in danger. What did the nurse assess at the time of membrane rupture? A. meconium-stained amniotic fluid B. fetus presenting in an LOA position C. maternal pulse of 90 to 95 beats/min D. blood-tinged vaginal discharge at full dilation

A

15. A client in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method? A. Counterirritation stimulation blocks pain from traveling to the spinal cord. B. Needles are inserted along meridians to release endorphins and control pain. C. A machine is used to measure the client's ability to relax during contractions. D. Small injections of sterile saline reduce are used to reduce the amount of back pain.

A

16. A client is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2030 National Health Goals during the postpartum period? A. Encourage to continue breastfeeding. B. Suggest breastfeeding be discontinued. C. Instruct on supplementing feedings with formula. D. Explain how breastfeeding will weaken the client's condition.

A

17. The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective? A. "If the drainage changes from clear to bright red, I am to call the doctor." B. "I will have large amount of vaginal drainage for at least several months." C. "An elevated temperature is normal during the first few weeks after delivery." D. "My drainage will fluctuate between bright red and dark red for several weeks."

A

17. While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time? A. health-seeking behaviors related to care of newborn B. ineffective coping related to expectation to provide newborn care C. risk for altered family coping related to an additional family member D. risk for impaired parenting related to disappointment in the sex of the child

A

18. A postpartum client has a swollen area of purplish discoloration in the vuvlar area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this client? A. acute pain B. risk for injury C. risk for infection D. ineffective peripheral tissue perfusion

A

18. The nurse is evaluating the effectiveness of teaching on perineal care provided to a postpartum client. Which outcome indicates that teaching has been effective? A. The client performs perineal care independently with every morning shower. B. The client explains the purpose of performing perineal care at least once a day. C. The client flushes the commode before standing when performing perineal care. D. The client washes the perineum from back to front when performing perineal care.

A

18. The nurse is teaching a pregnant client the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor? A. The fetal head bends forward onto the chest. B. The fetal head rotates into a transverse position. C. The head extends so that the face and chin are born. D. The shoulders move into an anteroposterior position.

A

19. The nurse is concerned that a new parent is developing a postpartum complication. What did the nurse most likely assess in this client? A. lochia that has an offensive odor B. red-colored lochia for the first 24 hours C. lochia that is the color of menstrual blood D. lochia appearing pinkish-brown on the fourth day

A

22. The client has a nursing diagnosis of deficient fluid volume related to blood loss. Which nursing actions would the nurse include in this client's plan of care? A. Encourage intake of oral fluids. B. Administer medications to decrease blood loss. C. Start a pad count for 24 hours. D. Place the client on strict intake and output. E. Administer a liter of hypertonic IV fluid over 30 minutes.

A

12. Which of the following women most likely will not be a candidate to attempt a vaginal birth after having had a previous cesarean section? A. a woman who had a cesarean birth because of placenta previa B. a woman who had a cesarean birth because of cephalopelvic disproportion C. a woman who has a gynecoid shaped pelvis D. a woman who had a cesarean birth because of a breech presentation

B

13. The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? A. This would cause fetal depression in utero. B. This may prolong labor and increase complications. C. The effects would wear off before birth. D. This can lead to maternal hypertension.

B

15. A client in labor tells the nurse, "My health care provider has mentioned that a cesarean birth might be needed." When discussing this topic with the client, which response by the nurse reflects the 2030 National Health Goals regarding cesarean births? A. "If you have one cesarean, then all future births must be done through cesarean." B. "Being more mobile during labor can help reduce your need for a cesarean birth." C. "Your health care provider will let you know what kind of birth you can have." D. "Most clients prefer cesarean births because they are quicker and cause less pain."

B

16. The health care provider is reluctant to provide pain medication to a client delivering a preterm fetus. What should the nurse explain to the client as the reason for the preterm fetus being more affected by medication? A. affinity of the preterm fetus to fat-soluble drugs B. inability of the immature liver to metabolize or inactivate drugs C. affinity of the preterm fetus to drugs that are strongly bound to protein D. inability of the preterm fetus to use drugs with a molecular weight over 1,000

B

19. A client is in the active stage of labor when the membranes spontaneously rupture. What action is appropriate for the nurse to do first when this occurs? A. Turn the client onto the left side. B. Assess fetal heart rate for fetal safety. C. Test a sample of amniotic fluid for protein. D. Instruct to bear down with the next contraction.

B

2. When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? A. warm and flushed skin B. weak and rapid pulse C. elevated blood pressure D. decreased respiratory rate

B

2. Which of the following would be a danger signal for a woman in labor? A. blood-tinged vaginal discharge at full dilation (dilatation) B. meconium-stained amniotic fluid C. maternal pulse of 90 to 95 beats per minute D. fetus presenting in an LOA position

B

20. A pregnant client nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the client during the delivery process? A. The client requests pain medication throughout the labor process. B. The client uses breathing techniques to control anxiety and pain during labor. C. The client tolerates the use of sanitary napkins to absorb vaginal secretions during labor. D. The client refuses complementary and alternative techniques to control pain during labor.

B

7. If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? A. Help the woman to sit up in a semi-Fowler's position. B. Turn her or ask her to turn to her side. C. Administer oxygen at 3 to 4 L by nasal cannula. D. Ask her to pant with the next contraction.

B

8. To prevent thrombophlebitis following a cesarean birth, which of the following would be most important to implement? A. Urge the woman to cough and take deep breaths. B. Encourage the woman to ambulate. C. Urge the woman not to dislodge the IV fluid line. D. Instruct the woman to press inward on her abdomen periodically.

B

9. A woman having a cesarean birth will have a low transverse incision ("bikini cut"). Which of the following would the nurse cite as an advantage? A. The uterine incision will be vertical. B. The skin incision will be just above her pubic hair. C. Because the cervix is cut, the operation proceeds rapidly. D. Because the fundus of the uterus is cut, the infant can be resuscitated rapidly.

B

9. A woman who is two days postpartum has painful hemorrhoids. Which position would the nurse suggest she use for resting? A. spine with uterus pressed to the side B. Sims position C. knee-chest position D. Trendelenburg position

B

12. A postpartum woman (gravida 1, para 1) asks immediately after delivery if she should request rooming-in with her infant. The nurse's best response would be that: A. this puts too much responsibility on a first-time mother. B. it depends on whether she will breastfeed or not. C. rooming-in allows increased maternal-newborn contact. D. resting for the first 3 days postpartum will be better for her.

C

12. A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural? A. Review the woman's medical history and laboratory results, and interview her to confirm all information is accurate and up to date. B. Place the woman in the fetal position on the table, and keep her steady so that she won't move during the procedure. C. Administer a fluid bolus through the IV line to reduce the risk of hypotension. D. Prepare a sterile field with the supplies and medications that will be needed.

C

12. The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's plan of care? A. A woman should be left entirely alone during this period. B. A woman will rarely speak or laugh during this period. C. A woman may spend time thinking about what is happening to her. D. No nursing care is needed to be done during this time.

C

13. Assessment reveals that the fetus of a client in labor is in a vertex presentation and at +4 station. The nurse interprets the fetal head at which location? A. floating B. engaged C. crowning D. above the ischial spines

C

14. The nurse is caring for a client recovering from a cesarean birth. Which assessment should the nurse make a priority for this client? A. breast filling B. plan to breastfeed C. abdominal texture D. perineum for edema

C

14. The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior? A. disappointment with the child's sex B. difficulty accepting the role changes C. reacting normally to accepting a new child D. cultural customs do not include kissing children

C

14. When entering the second phase of labor, a client tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the client at this time? A. pain related to labor contractions B. powerlessness related to the duration and intensity of labor C. decisional conflict related to the use of analgesia during labor D. anxiety related to lack of knowledge about normal labor processes

C

15. While documenting client care, the nurse notes that a postpartum client is accepting the birth of the child well. What did the nurse most likely observe to come to this conclusion? A. names the child after a well-loved friend B. asks the nurse to take a photo of the child C. turns the face to meet the infant's eyes when holding the baby D. comments that the baby has the most hair of any in the nursery

C

16. A cesarean birth is scheduled for a pregnant client with a breech presentation. When developing the client's postoperative plan of care, which intervention will the nurse include? A. bed rest for the first 4 days B. insertion of a nasogastric tube C. maintenance of an indwelling catheter D. separation from the newborn for 72 hours

C

17. The fetal heart rate tracing of a woman in the early stage of labor shows early decelerations. Which action by the nurse would be appropriate to do first? A. Continue to monitor the fetal heart rate. B. Prepare for an imminent birth. C. Notify the health care provider D. Have the woman turn on her side.

C

17. When teaching the pregnant client about self-medicating for pain during labor, why did the nurse instruct the client to avoid taking acetylsalicylic acid (aspirin)? A. development of respiratory depression in the newborn B. interference with the ability to concentrate on contractions C. interference with blood coagulation with increased risk of bleeding in mother or infant D. Competition with bilirubin-binding sites in fetal circulation increases the risk of kernicterus.

C

18. The nurse is preparing materials to instruct a pregnant client about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the client? A. general anesthesia B. pressure anesthesia C. regional anesthesia D. pudendal nerve block

C

19. A client preparing for patient-controlled analgesia for pain relief after a cesarean birth asks if this is an effective way to control pain. How should the nurse respond to the client? A. "It is effective, but the amount of analgesic used will preclude breastfeeding." B. "Every woman reacts differently to pain, so it would be impossible to predict." C. "Not only is it effective but it also will reduce the amount of opioid analgesic needed." D. "Most women do not feel well enough after surgery to want control of their own pain relief."

C

19. The nurse instructs a client on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective? A. The client complains of fatigue. B. The client appears disheveled and listless. C. The client is chatting on the telephone with a friend. D. The client is cleaning the kitchen while the baby naps.

C

2. On the second day postpartum following a cesarean birth, at which of the following locations would you expect to palpate the woman's fundus? A. two fingers above the umbilicus B. at the umbilicus C. two fingers below the umbilicus D. four fingers below the umbilicus

C

2. Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms? A. Efferent fibers are blocked by continuously applied high-intensity stimulation. B. Pain is prevented from traveling from the uterus to spinal cord synapses. C. Electrical impulses are created that interfere with nerve transmission. D. TENS reduces apprehension and thereby complements opioid action.

C

20. A client who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the client's fluid status during the procedure? A. Provide a clear liquid tray. B. Encourage intake with ice chips. C. Initiate intravenous fluid therapy. D. Administer an antiemetic as prescribed.

C

14. The nurse is planning interventions to prevent the onset of urinary retention in a postpartum client. Why are these interventions needed? A. Frequent partial voiding never relieves the bladder pressure. B. Catheterization at the time of delivery reduces bladder tonicity. C. Mild dehydration causes a concentrated urine volume in the bladder. D. Decreased bladder sensation results from edema because of the pressure of birth.

D

16. The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions? A. number of contractions that occur in 5 minutes B. the end of one contraction to the beginning of the next C. the interval between the acmes of two consecutive contractions D. the interval between the beginning and the end of one contraction

D

17. A pregnant client is to receive epidural anesthesia for a cesarean birth. When reviewing this procedure with the client, the nurse reinforced the need to remain in which position? A. supine B. prone C. sitting upright D. side-lying

D

21. A client who has had a cesarean birth is receiving intravenous fluids. The client asks the nurse, "When will I be able to eat something?" Which response by the nurse is appropriate? A. "You have to wait at least 24 hours after the procedure." B. "It depends but it is usually about 48 hours afterwards." C. "You can eat as soon as you are urinating at least every 2 hours." D. "When I hear noises in your abdomen, then it is safe to eat."

D

22. The nurse encourages a client recovering from a cesarean birth to begin early ambulation. For which outcome would this action be indicated? A. The client will tolerate clear liquids. B. The client will have no evidence of wound infection. C. The client will successfully begin breastfeeding the infant. D. The client will not develop manifestations of thrombophlebitis.

D

26. The nurse is caring for a client entering the active phase of labor. Which outcome is most appropriate at this time? A. Client will develop an irresistible urge to push. B. Client will combat feelings of nausea to prevent vomiting. C. Client will verbalize positive statements about the labor process. D. Client will adjust body to attain the most comfortable position.

D

27. The nurse is caring for a woman who has entered the second stage of labor. Which action by the woman would the nurse correct? A. crying during uterine contractions B. verbalizing anger toward the support person C. pushing with the uterine contractions D. holding breath during pushing

D

8. A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? A. Bend her knee, and palpate her calf for pain. B. Ask her to raise her foot and draw a circle. C. Blanch a toe, and count the seconds it takes to color again. D. Assess for pedal edema.

D