Exam 2 Reveiw Questions
The nurse is preparing the client for the routine lab tests that will be obtained at the first prenatal visit. Which test will the nurse prioritize at this visit? - prolactin level - hepatitis screen - magnesium level - rubeola titer
*hepatitis screen* the woman will undergo tests for hepatitis B, HIV, syphilis, gonorrhea, and chlamydia
A nurse is conducting a class with group of pregnant women who are all in their first trimester of pregnancy. During the class, the women are discussing the various discomforts that they are experiencing. The nurse would expect to hear reports about which discomforts? SATA - nausea - urinary frequency - backache - leg cramps - breast tenderness
*nausea* *urinary frequency* *breast tenderness* common first trimester discomforts include nausea, urinary frequency, and breast tenderness. common second trimester discomforts include backache and leg cramps
The nurse is reviewing the charts of a group of clients. Which client's weight gain should the nurse be concerned about? - the client who gained 15 lbs in the second trimester - the client who gained 8 lbs in the first trimester - the client who gained 4 lbs in the first trimester - the client who gained 25 lbs in the third trimester
*the client who gained 8 lbs in the first trimester* 1.5 lbs per month in first trimester 1 lbs per week in second and thrid trimester 8 lbs in first trimester is excessive.
A woman in her first trimester of pregnancy has noted an increase in thick, whitish vaginal discharge even though she showers daily. The woman shares this information with the clinic nurse, who provides some client education on the topic of leukorrhea. Which interventions should be addressed in this discussion? SATA - wear cotton underwear during the day - a perineal pad to absorb the discharge may help - tampons are the most reliable product to control the flower during the day - it is normal for the discharge to change in color or odor - many women find douching to provide a feeling of cleanliness
*wear cotton underwear during the day* *a perineal pad to absorb the discharge may help* Leukorrhea, a whitish, viscous vaginal discharge or an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen level and the increased blood supply to the vaginal epithelium and cervix in pregnancy. Wearing cotton underpants and sleeping at night without underwear can be helpful. Some women may need to wear a perineal pad to absorb the discharge. Caution women not to use tampons because this could lead to stasis of secretions and subsequent infection. Advise women to contact their OB provider if there is change in the color, odor, or character of this discharge as these suggest infection. Caution women not to douche, douching is contraindicated generally, and especially throughout pregnancy.
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 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.
McKinney 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.
B at their *acme* 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.
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
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.
A nurse is teaching a pregnant woman how to perform fetal kick counts. The nurse determines that the teaching was successful when the client states that she will call her provider if it takes longer than what time frame to reach 10 kicks? - 4 hours - 2 hours - 3 hours - 1 hour
*2 hours* the most common method of kick counting is "Count to 10", where the woman records how long it takes to document 10 movements. if it takes longer than *2 hours*, the woman should contact her provider for further evaulation.
A primigravida client has presented for her first prenatal visit and is concerned about the potential weight gain and the struggle to lose weight after the baby's birth. How much weight should the nurse recommend this client with a normal BMI gain during her pregnancy to ensure a healthy fetus? - 15 to 20 lbs - 20 to 25 lbs - 30 to 35 lbs - 10 to 15 lbs
*30 to 35 lbs* the nurse should convey that weight gain is healthy and that a client with normal BMI should gain 30 to 35 lbs to ensure a healthy fetus.
The nurse is assessing a client at 30 weeks gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? - increasing fluid intake - taking mineral oil - reducing iron supplement - increasing intake of meat
*increasing fluid intake* increasing fluids at least 8 glasses of help relieve constipation. decreasing iron supplement could lead to anemia mineral oil can reduce absorption of fat soluble vitamins should increase fiber (grains, vegetables, fruits) "not meat*
The nurse is caring for a client who is unsure why the provider ordered a sonogram to determine her due date. Which rationale would the nurse provide? - needed to confirm a fetus is present - needed due to irregular periods - needed due to history of past pregnancy - needed for documentation purposes
*needed due to irregular periods* a sonogram is ordered to confirm the client's due date since the client has had irregular periods.
A pregnant woman reports her last child was born by cesarean birth. She questions if she will be required to have a cesarean birth for this current pregnancy. What information should be provided? SATA - it is safe for women who have had a cesarean birth to have a vaginal birth if she chooses. - the reason for the previous cesarean birth will aid in determining if a repeated cesarean will be performed - if the cesarean birth was due to pelvic size a repeated cesarean birth is likely - the type of incision into the uterus in the previous cesarean birth will be a factor for consideration - if the previous cesarean birth was due to fetal distress a repeated cesarean birth will be needed
*the reason for the previous cesarean birth will aid in determining if a repeated cesarean birth will be performed* *the type of incision into the uterus in the previous cesarean birth will be a factor for consideration* *if the previous cesarean birth was due to pelvic size a repeated cesarean birth is likely indicated* a woman who gives birth by cesarean may be a candidate for a future birth vaginally. the underlying reason for the cesarean birth has a large impact (small pelvic size, structural deformities or contracture). This is because the problems will still be present in the next pregnancy. If the uterine incision was a classic incision, it places the uterus at high risk for rupture, and a repeated cesarean is indicated. If the cesarean birth was due to fetal distress, the woman may be a candidate for vaginal birth after cesarean birth.
A client at 10 weeks gestation comes to the clinic for a prenatal follow up. The client reports experiencing morning sickness. She states, "It happens at any time of the day. Is there anything I can do?" Which suggestions by the nurse would be most helpful? SATA - limit the number of meals to 2 per day - try eating some dry crackers before you get out of bed in the morning - avoid any strong food odors - limit your intake of fluids when you eat your meals - eat high fat snacks before going to bed at night
*try eating some dry crackers before you get out of bed in the morning* *avoid any strong food odors* *limit your intake of fluids when you eat your meals* to help alleviate nausea and vomiting of pregnancy: - small, frequent meals - bland and low fat - eat dry crackers - avoid strong odors - limit fluid intake during meals - eat *high protein snack* *BEFORE* going to bed
A nurse is assigned to care for a pregnant client as she undergoes a nonstress test. Place the steps involved in conducting the nonstress test in the order. - client consumes a meal - external electronic fetal monitoring device applied - position client in lateral recumbent - client is handed an event marker - fetal monitor strip marked for fetal movement
1. client consumes a meal 2. client placed in left lateral recumbent position 3. external electronic fetal monitoring device applied 4. client is handed an event marker 5. fetal monitor strip marked for fetal movement for a nonstress test, client should have a meal before the procedure then placed in a lateral recumbent position to avoid hypotension syndrome external fetal monitoring device is applied the client is handed an "event marker" with a button that she pushes every time she perceives fetal movement when the button is pushed, the fetal monitor strip is marked to identify that fetal movement has occurred
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 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 pregnant woman experiences frequent leg cramps. Which measure would the nurse include in her teaching plan to provider her with relief? - extend her knee and dorsiflex her foot - elevate her leg on two pillows - bending her knee and dorsiflex her foot - plantarflex her foot and wiggle her toes
*extend her knee and dorsiflex her foot*
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.
At the client's third prenatal visit, a twin gestation pregnancy is diagnosed. The client's pre-pregnancy BMI was 26.5. Given the new diagnosis, the nurse would set the weight gain goal for this client to what weight? - 15 to 25 lbs - 31 to 50 lbs - 11 to 20 lbs - 25 to 35 lbs
*31 to 50 lbs* Based on the BMI this client is overweight and needs to gain 31 to 50 lbs with a multiple gestation pregnancy. the other options are ranges for a single gestation pregnancy
A postpartum client experiences a pulmonary embolism and is treated with IV anticoagulants. The client is being discharged on warfarin. The nurse teaches the client that following a brith-related pulmonary embolism, most women will need to take warfarin for a minimum of how long? - 6 weeks - 3 months - 6 months - 1 year
*6 weeks* 6 weeks coincides with the time for the coagulation changes associated with pregnancy to resolve.
The provider is concerned about a client's fetus having appropriate blood flow through the fetal vessels. Which diagnostic test does the nurse anticipate to confirm diagnosis? - trans-abdominal ultrasound - Doppler study - Amniocentesis - maternal serum alpha-fetoprotein screening
*Doppler study* Doppler study is best for identifying blood flow. transabdominal ultrasound is used to determine gestational age, observe the fetus and diagnose complication of pregnancy amniocentesis is used to identify chromosomal or genetic abnormalities MSAF screening is used to determine neural tube defects
The nurse is caring for a client in her second trimester who requires follow-up genetic testing after a common screening indicated a potential abnormality. What is the nurse's main role at this time? - answering any questions regarding potential abnormalities - allowing the client to vent feelings - facilitate the testing process - witnessing the signature of the genetic testing
*allowing the client to vent feelings* it is a difficult time fo r the client and family. the nurse's role at this time is to support the client and family and allow the client to vent any feelings. the nurse assists with answering questions BUT much of the information comes from the provider. Next, the nurse will facilitate the testing process and witness the signature as testings requires informed consent.
A young couple are concerned that their fetus may be born with sickle cell anemia. The nurse explains that the recessive traits of sickle cell anemia can be determined by using which test? - percutaneous umbilical blood sampling - chorionic villus sampling - amniocentesis - blood typing
*chorionic villus sampling* chorionic villus sampling (CVS) is a procedure for obtaining a sample of the chorionic villi for prenatal evaluation of chromosomal disorders, enzyme deficiencies, fetal gender determination, and identify sex-linked disorders (hemophilia, sickle cell anemia, and Tay-Sachs). amniocentesis is used to evaluated for nueral tube defects, chromosomal disorders, and inborn errors of metabolism. blood typing is performed via blood sample. percutaneous umbilical blood sampling allows for rapid chromosomal analysis.
A client wants to know if she can engage in intercourse during pregnancy. Which information should the nurse confirm to ensure that sexual intercourse or orgasm is not contraindicated in the client? SATA - client does not have breast tenderness - client is not at risk for preterm labor - client does not face a risk for threatened abortion - client has experienced quickening - client does not have dependent edema
*client is not at risk for preterm labor* *client does not face a risk for threatened abortion* to confirm that intercourse or orgasm is not contraindicated in the pregnant client, the nurse should ensure that the client does not have *placenta previa*, and the client is *not at risk for preterm labor* or a *threatened abortion*. breast tenderness and dependent edema are not contraindication for sexual intercourse in a pregnant client. breast tenderness generally occurs in the first trimester. dependent edema is a common vascular problem during pregnancy.
The client at 32 weeks gestation expresses concern regarding lower extremity edema and bulging leg veins. Which suggestion(s) by the nurse is helpful? SATA - complete moderate exercise daily - avoid sudden position changes - wear compression stockings - keep legs below the level of the heart - limit fluid intake to 1 liter daily
*complete moderate exercise* *wear compression stockings* - wear compressions - moderate exercise - frequent rests - leg *elevated* above the heart
The nurse is meeting a client at 28 weeks gestation. To prepare her for the final trimester, which factor should the nurse prioritize in the teaching session? - preventing anemia - decreasing shortness of breath - decreasing bleeding gums - preventing varicosities
*decreasing shortness of breath* as the fetus grows, there is more pressure on the diaphragm and more difficulty breathing, and episodes of dyspnea may occur. this tends to decrease with lightening, when the fetus drops. preventing anemia, decreasing bleeding gums, and preventing varicosities are situations which should be addressed throughout the entire pregnancy.
A client at 29 weeks gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next? - have the primary health care provider see the client - tell the client these are normal findings during pregnancy - ask the client if there is a family history of arthritis - document these findings in the client's chart
*document these findings in the client's chart* the hormone *relaxin* causes smooth muscles, joints, and ligaments of the body to relax. because of the production of relaxin during pregnancy, women often experience aches in the pelvic area. the nurse would explain to the client this is a normal finding of pregnancy and will resolve. the nurse should document this in the chart, but it is not priority over educating the client.
The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks gestation. Which action would be most appropriate? - refer her for cardiac catherterization - ask another nurse to assess the heart - inquire if the client has chest pain - document this and continue to monitor the murmur at future visits
*document this and continue to monitor the murmur at future visits* due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal
A nurse is conducting a class geared toward changes in early pregnancy and self-care items like perineal hygiene. A woman shares that she douches at least once a day since she has "so much discharge" from her vagina. which response by the nurse is *most* appropriate at this time? - douching will definitely keep your vagina clean - if you prepare your own douching solution, be sure to boil the water to kill bacteria - during pregnancy, you should not douche because it can cause fluid to enter the cervix resulting in an infection - let's discuss this with your provider before you continue douching
*during pregnancy, you should not douche because it can cause fluid to enter the cervix resulting in an infection*
A client presents with a positive home pregnancy test. The client has a 7-month old baby and a 2 year old child with her. What is a priority assessment to be completed during this visit? - ultrasound for gestational dating - evaluation of nutrients status - screening for gestational diabetes - antibody screening
*evaluation of nutrient status* clients with pregnancies close together are at risk for entering pregnancy with nutrient deficiencies because there is not adequate time to rebuild nutrient stores.
A pregnant client reports frequent urination and tells the health care provider that she has stopped drinking water during the day since she cannot take many breaks during work. Which statement by the nurse is *most* appropriate at this time? - fluids are necessary so your blood volume can double, which is normal in pregnancy. - maybe it would be better to stop drinking caffeinated beverages/coffee instead of water - just wait until late pregnancy when the baby's head is settled into the inlet of the pelvis - I can write you a note to your supervisor if that will help relieve some stress
*fluids are necessary so your blood volume can double, which is normal in pregnancy* women should not restrict their fluid intake to diminish frequency of urination because fluids are necessary to allow blood volume to double. decreasing daily caffeine intake because of the risks caffeine poses for *lower birth weight* may have the added benefit of reducing urinary frequency. women need to understand that voiding more frequently is a normal pregnancy finding. the sensation of frequency will probably return after lightening (the settling of the fetal head into the inlet of the pelvis at pregnancy's end) a note for the supervisor is inappropriate in the workplace
The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client? - risk for Down Syndrome - risk for neural tube defects - tests needs to be repeated - further testing is required
*further testing is required* maternal serum alpha-fetoprotein (MSAFP) measures alpha-fetoprotein levels, which are proteins made by the fetus. *done between *16 to 20 weeks* *abnormal levels mean additional testing is needed* *higher levels MSAFP* means (multiple fetuses, death of fetus, neural tube defect, or Down Syndrome)
When discussing infection prevention with a group of prenatal women, which interventions should the nurse emphasize to prevent toxoplasmosis in this population? SATA - have a significant other change the litter box - avoid crowds of young children at day care facilities - cook meat thoroughly before eating - apply bug spray to exposed skin every time one goes outside - use condoms regularly when having sex with different partners
*have significant other change the litter box* *cook meat thoroughly before eating* toxoplasmosis, a protozoan infection, is spread most commonly through contact with *uncooked meat*, although it may also be contracted through *handling cat stool in soil or cat litter*. avoiding crowds of young children can prevent the exposure to CMV.
The nurse is completing the initial assessment at the prenatal visit of a pregnant client. Which question should the nurse prioritize when completing the review of systems? - have you ever had a heart attack? - have you had any urinary tract infection? - do you have a peptic ulcer? - have you had any neurologic diseases?
*have you had any urinary tract infections?* current infections can have adverse effects in the pregnancy any conditions the woman has had in the past may recur or be worsen during pregnancy urine culture may be required to ensure the woman does not have a current infection UTIs can lead to premature labor
During a postpartum hemorrhage, the nurse anticipated administering which medication to cause vasoconstriction of the uterine vessels? - fentanyl - misoprostol - magnesium sulfate - methylergonovine
*methylergonovine* oxytocin, methylergonovine, and misoprostol all stimulate the uterine muscle to contract. methylergonovine is the only medication that also stimulates vasoconstriction of the uterine blood vessels, thereby decreasing bleeding. Fentanyl is a pain medication. Magnesium sulfate is smooth muscle relaxant.
A nurse is educating a pregnant client about physical changes that can occur during pregnancy. Which conditions are associated with physical changes in pregnancy? SATA - persistent cough - kussmaul respirations - nasal stuffiness and sinus problems - thoracic breathing instead of abdominal breathing - swollen and tender gums
*nasal stuffiness and sinus problems* *thoracic breathing instead of abdominal breathing* *swollen and tender gums* during pregnancy, the respiratory system changes to increase lung volume for the fetus. This change can increase estrogen and cause nasal congestion and sensitive gums. When the fetus is growing, the thoracic muscles and cartilage relax more, and breathing becomes thoracic as the chest broadens. persistent cough and Kussmaul respirations are not related to pregnancy.
Which occupation may expose a fetus to environmental hazards? SATA - nurse anesthetist working in a busy oral surgeon's office - accountant - short-order cook for a busy deli - nurse working for a pulmonologist who administers inhalation ribavirin routinely to the client population - carpenter
*nurse anesthetist working in a busy oral surgeon's office* *nurse working for a pulmonologist who administers inhalation ribavirin routinely to the client population* *short order cook for a busy deli*
The nurse is conducting an assessment of a pregnant client at a routine second trimester prenatal visit. Which lower extremity assessment should the nurse prioritize? - diameter of the calf muscle - presence of varicosities - lateral movement of the kneecap - blanching and refilling of toenails
*presence of varicosities* during pregnancy, women are prone to develop varicosities because of uterine pressure on lower extremity veins. evaluating the diameter of the calf would be important if a deep vein thrombosis was suspected. capillary refill of the toenails would be a routine evaluation. lateral movement of the kneecap would not be priority
To prevent exposure to hepatitis A, the nurse teaches the pregnant client to avoid which food? - raw fish - raw eggs - undercooked chicken - grilled tuna
*raw fish* hepatitis A virus is found in raw fish salmonella is found in raw eggs and undercooked chicken mercury is found in swordfish
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? - split S1S2 - premature ventricular contractions - S4 (atrial gallop) - soft systolic murmur
*soft systolic murmur* A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by nurse.
A primigravida client has come to the clinic for prenatal checkup. What teaching topics would help to promote a healthy pregnancy for this client? - douching is recommended to decrease the risk of vaginal infections - more frequent tooth brushing is recommended to prevent caries related to ptyalism - applying lanolin ointment to the breasts is recommended to prevent cracked nipples - swimming in a pool is a recommended exercise during pregnancy
*swimming in a pool is recommended exercise during pregnancy* swimming in a pool is good exercise for a pregnant woman. However, swimming in a lake can be harmful because of the danger of infection, especially in the latter months. douching can increase the risk of vaginal infections. increased salivation or ptyalism, seen in some women during pregnancy, does not cause tooth decay and necessitate more frequent brushing. lanolin ointments may damage the areola and nipple and have not been shown to be effective in preventing sore and cracked nipples.
In which situation is the nurse correct to document a reactive nonstress test? SATA - the mother noting fetal movement and/or fetal kicks - variability noted in the fetal monitor strip - deceleration in the fetal heart rate every 15 minutes - at least 2 accelerations of the fetal heart rate - a lack of fetal movement over a 20 minute period
*the mother noting fetal movement and/or fetal kicks* *at least 2 accelerations of the fetal heart rate* *variability noted in the fetal monitor strip* it is a normal factor to have a reactive nonstress test. a reactive test shows at least 2 accelerations of the fetal heart rate, variability of the fetal heart rate in the monitor strip, and the mother notes fetal movement and/or kicking. decelerations and lack of fetal movement are abnormal and will need to have further follow-up.
A pregnant woman in her second trimester comes to the clinic for a follow-up. During the visit, the woman reports discomfort related to hemorrhoids. Which suggestion(s) would be appropriate for the nurse to include when teaching the woman about relief measures. SATA - be sure to drink at least 2 L of fluid each day - try using some cold compresses on the area - take a sitz bath using cool or cold water - raise your feet on a stool when having a bowel movement - avoid exercising when you are having discomfort
*try using some cold compresses on the area* *raise your feet on a stool when having a bowel movement* *be sure to drink at least 2 L of fluids each day* for hemorrhoid relief, instruct the client to *avoid constipation* by *increasing fiber*, *increasing fluid* at least 2L per day. also teach client about *warm sitz baths*, *witch hazel compresses*, or *cold compresses*. *avoid straining* while defecating by *elevating feet on stool*, and *avoid prolonged sitting or standing*. exercising helps reduce risks for constipation which would lead to straining.
A petite pregnant client is concerned that she will be unable to deliver vaginally due to her small size. Which procedure should the nurse point out will help to confirm the manual measurements of her pelvis and provide information that will help determine the best method of delivery for her? - vaginal exam - ultrasonography - pap smear - measurement of her height and weight
*ultrasound* manual measurement of the pelvis are usually obtained within the first few months of pregnancy to determine the adequacy of the pelvis ultrasound helps to obtain pelvimetry vaginal exam is not an actaul measurement
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.
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.
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.
The primipara at 39 weeks gestation states to the nurse, I can breathe easier now. What is the nurses 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 babys 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 patients 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 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.
The health care provider for a laboring patient makes the following entry into the patients 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.
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 patients 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 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.
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.
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.
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.
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 assess a laboring patients 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 clients 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.
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 clients 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
The nurse is assessing the duration of a clients 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.
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.
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 mothers 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.
