exam 3 practice questions

When caring for a newly delivered woman, what is the best measure for the nurse to implement to prevent abdominal distention after a cesarean birth? a. Rectal suppositories ' b. Early and frequent ambulation c. Tightening and relaxing abdominal muscles d. Carbonated beverages

ANS: B Activity will aid the movement of accumulated gas in the gastrointestinal tract that results in abdominal distention

In recovery, if a woman is asked to either raise her legs (knees extended) off the bed or flex her knees, and then place her feet flat on the bed and raise her buttocks well off the bed, the purpose of this exercise is to assess what? a. Recovery from epidural or spinal anesthesia b. Hidden bleeding underneath her c. Flexibility d. Whether the woman is a candidate to go home after 6 hours

A

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. Which instruction best describes these measures? a. Encouraging the woman to try various upright positions, including squatting and standing b. Telling the woman to start pushing as soon as her cervix is fully dilated c. Continuing an epidural anesthetic so pain is reduced and the woman can relax d. Coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction

A

When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective? a. Dilation of the cervix b. Descent of the fetus to -2 station c. Rupture of the amniotic membranes (ROM) d. Increase in bloody show

ANS: A The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor, indicates that the woman is in true labor

A laboring woman is reclining in the supine position. What is the most appropriate nursing action at this time? a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure d. Determine whether fetal tachycardia is present.

ANS: A The woman's supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental blood flow. Elevating her legs will not relieve the pressure from the inferior vena cava. I

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse? a. Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg b. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg c. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg d. Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg

A An EBL of 1500 ml with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg are normal vital signs except for an increased respiratory rate, which may be secondary to pain from the birth. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg are normal vital signs except for the temperature, which may increase to 38° C during the first 24 hours as a result of the dehydrating effects of labor.

Which component of the physical examination are Leopold's maneuvers unable to determine? a. Gender of the fetus b. Presenting fetal part c. Fetal lie d. Estimated fetal size

A Leopold's maneuvers help identify the size of the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis.

Under which circumstance should the nurse assist the laboring woman into a hands-and-knees position? a. Occiput of the fetus is in a posterior position. b. Fetus is at or above the ischial spines. c. Fetus is in a vertex presentation. d. Membranes have ruptured.

A The hands-and-knees position is effective in helping to rotate the fetus from a posterior to an anterior position not a vertex position.

As the United States and Canada continue to become more culturally diverse, recognizing a wide range of varying cultural beliefs and practices is increasingly important for the nursing staff. A client is from which country if she requests to have the baby's father in attendance? a. Mexico b. China c. Iran d. India

ANS: A Hispanic women routinely have fathers and female relatives in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well.

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. What is the nurse's assessment of the situation? a. The placenta has separated. b. A cervical tear occurred during the birth. c. The woman is beginning to hemorrhage. d. Clots have formed in the upper uterine segmen

ANS: A Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness.

Which breathing pattern should the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple has attended childbirth preparation classes? a. Slow-paced breathing b. Deep abdominal breathing c. Modified-paced breathing d. Patterned-paced breathing

ANS: A Slow-paced breathing is approximately one half the woman's normal breathing rate and is used during the early stages of labor when a woman can no longer walk or talk through her contractions.

Which technique is an adequate means of controlling the birth of the fetal head during delivery in a vertex presentation? a. Ritgen maneuver b. Fundal pressure c. Lithotomy position d. De Lee apparatus

ANS: A The Ritgen maneuver extends the head during the actual birth and protects the perineum. Gentle, steady pressure against the fundus of the uterus facilitates vaginal birth

A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this woman's fundus? a. 1 centimeter above the umbilicus b. 2 centimeters below the umbilicus c. Midway between the umbilicus and the symphysis pubis' d. Nonpalpable abdominally

ANS: A The fundus descends approximately 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus is normally halfway between the symphysis pubis and the umbilicus.

. The nurse should be aware of which information related to a woman's intake and output during labor? a. Traditionally, restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia. b. Intravenous (IV) fluids are usually necessary to ensure that the laboring woman stays hydrated. c. Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. d. When a nulliparous woman experiences the urge to defecate, it often means birth will quickly follow.

ANS: A Women are awake with regional anesthesia and are able to protect their own airway, which reduces the worry over aspiration. Routine IV fluids during labor are unlikely to be beneficial and may be harmful.

Which information regarding the procedures and criteria for admitting a woman to the hospital labor unit is important for the nurse to understand? a. Client is considered in active labor when she arrives at the facility with contractions. b. Client can have only her male partner or predesignated doula with her at assessment. c. Children are not allowed on the labor unit. d. Non-English speaking client must bring someone to translate.

ANS: A According to the Emergency Medical Treatment and Active Labor Act (EMTALA), a woman is entitled to active labor care and is presumed to be in true labor until a qualified health care provider certifies otherwise

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects the application of the gate-control theory? a. Massaging the woman's back. b. Changing the woman's position. c. Giving the prescribed medication. d. Encouraging the woman to rest between contractions.

ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time.

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-, baby Rh+ b. Mother Rh-, baby Rh- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh-

ANS: A An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs.

After delivery, excess hypertrophied tissue in the uterus undergoes a period of self-destruction. What is the correct term for this process? a. Autolysis b. Subinvolution c. Afterpains d. Diastasis

ANS: A Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpains are caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles.

The nurse should be aware of which important information regarding nerve block analgesia and anesthesia? a. Most local agents are chemically related to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. Pudendal nerve block is designed to relieve the pain from uterine contractions. d. Pudendal nerve block, if performed correctly, does not significantly lessen the bearing-down reflex.

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia.

A client is experiencing back labor and reports intense pain in her lower back. Which measure provided by the woman's labor coach would best support this woman in labor? a. Counterpressure against the sacrum b. Pant-blow (breaths and puffs) breathing techniques c. Effleurage d. Conscious relaxation or guided imagery

ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand.

The nurse should be aware of which physiologic effect of labor pain? a. Predominant pain of the first stage of labor is visceral pain that is in the lower portion of the abdomen. b. Referred pain is the extreme discomfort experienced between contractions. c. Somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the pain experienced during the second stage.

ANS: A Predominant pain comes from cervical changes, the distention of the lower uterine segment, and uterine ischemia.

A hospital has several different perineal pads available for use. A nurse is observed soaking several of them and writing down what is observed. What goal is the nurse attempting to achieve by performing this practice? a. To improve the accuracy of blood loss estimation, which usually is a subjective assessment b. To determine which pad is best c. To demonstrate that other nurses usually underestimate blood loss d. To reveal which brand of pad is more absorbent

ANS: A Saturation of perineal pads is a critical indicator of excessive blood loss; anything done to help in the assessment is valuable. The nurse is noting the saturation volumes and soaking appearances.

Which alterations in the perception of pain by a laboring client should the nurse understand? a. Sensory pain for nulliparous women is often greater than for multiparous women during early labor. b. Affective pain for nulliparous women is usually less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple.

What is the most critical nursing action in caring for the newborn immediately after the birth? a. Keeping the airway clear b. Fostering parent-newborn attachment c. Drying the newborn and wrapping the infant in a blanket d. Administering eye drops and vitamin K

ANS: A The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth.

Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant? a. Assessing the infant for signs of trauma b. Administering prophylactic antibiotic agents to the infant c. Applying a cold pack to the infant's scalp d. Measuring the circumference of the infant's head

ANS: A The infant should be assessed for bruising or abrasions at the site of application, facial palsy, and subdural hematoma

The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours earlier. This client is at increased risk for which complication? a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension

ANS: A When the membranes rupture (ROM), microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. ROM is not associated with fetal or maternal bleeding.

What are the complications and risks associated with cesarean births? (Select all that apply.) a. Pulmonary edema b. Wound dehiscence c. Hemorrhage d. Urinary tract infections e. Fetal injuries

ANS: A, B, C, D, E

Emergency conditions during labor that would require immediate nursing intervention can arise with startling speed. Which situations are examples of such an emergency? (Select all that apply.) a. Nonreassuring or abnormal fetal heart rate (FHR) pattern b. Inadequate uterine relaxation c. Vaginal bleeding d. Prolonged second stage e. Prolapse of the cord

ANS: A, B, C, E A nonreassuring or abnormal FHR pattern, inadequate uterine relaxation, vaginal bleeding, infection, and cord prolapse all constitute an emergency during labor that requires immediate nursing intervention

The induction of labor is considered an acceptable obstetric procedure if it is in the best interest to deliver the fetus. The charge nurse on the labor and delivery unit is often asked to schedule clients for this procedure and therefore must be cognizant of the specific conditions appropriate for labor induction. What are appropriate indications for induction? (Select all that apply?) a. Rupture of membranes at or near term b. Convenience of the woman or her physician c. Chorioamnionitis (inflammation of the amniotic sac) d. Postterm pregnaNCY e. fetal death

ANS: A, C, D, E The conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption

What is a maternal indication for the use of forceps-assisted birth? a. Wide pelvic outlet b. Maternal exhaustion c. History of rapid deliveries d. Failure to progress past station 0

ANS: B A mother who is exhausted may be unable to assist with the expulsion of the fetus. The client with a wide pelvic outlet will likely not require forceps extraction. With a rapid delivery, forceps extraction is not necessary.

What is the correct terminology for the nerve block that provides anesthesia to the lower vagina and perineum? a. Epidural b. Pudendal c. Local d. Spinal block

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and the use of low forceps, if needed.

Anxiety is commonly associated with pain during labor. Which statement regarding anxiety is correct? a. Even mild anxiety must be treated. b. Severe anxiety increases tension, increases pain, and then, in turn, increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B Anxiety and pain reinforce each other in a negative cycle that will slow the progress of labor. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances.

Which description of the phases of the first stage of labor is most accurate? a. Latent: mild, regular contractions; no dilation; bloody show b. Active: moderate, regular contractions; 4 to 7 cm dilation c. Lull: no contractions; dilation stable d. Transition: very strong but irregular contractions; 8 to 10 cm dilation

ANS: B The active phase is characterized by moderate and regular contractions, 4 to 7 cm dilation, and duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate and irregular contractions, dilation up to 3 cm, brownish-to-pale pink mucus, and duration of 6 to 8 hours.

Which statement regarding the postpartum uterus is correct? a. At the end of the third stage of labor, the postpartum uterus weighs approximately 500 g. b. After 2 weeks postpartum, it should be abdominally nonpalpable. c. After 2 weeks postpartum, it weighs 100 g. d. Postpartum uterus returns to its pre-pregnancy size by 6 weeks postpartum.

ANS: B The uterus does not return to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. After 2 weeks postpartum, the uterus weighs approximately 350 g.

What information should the nurse understand fully regarding rubella and Rh status? a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination. c. Rh immunoglobulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immunoglobulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

ANS: B Women should understand that they must practice contraception for at least 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. What is the nurse's ideal response? a. "Don't worry about it. You'll do fine." b. "It's normal to be anxious about labor. Let's discuss what makes you afraid." c. "Labor is scary to think about, but the actual experience isn't." d. "You can have an epidural. You won't feel anything

ANS: B "It's normal to be anxious about labor. Let's discuss what makes you afraid" is a statement that allows the woman to share her concerns with the nurse and is a therapeutic communication tool.

Which statement concerninNg the third stage of labor is correct? a. The placenta eventually detaches itself from a flaccid uterus. b. An expectant or active approach to managing this stage of labor reduces the risk of complications. c. It is important that the dark, roughened maternal surface of the placenta appears before the shiny fetal surface. d. The major risk for women during the third stage is a rapid heart rate.

ANS: B Active management facilitates placental separation and expulsion, reducing the risk of complications. The placenta cannot detach itself from a flaccid (relaxed) uterus. Which surface of the placenta comes out first is not clinically important.

A woman who is gravida 3 para 2 arrives on the intrapartum unit. What is the most important nursing assessment initially? a. Contraction pattern, amount of discomfort, and pregnancy history b. Fetal heart rate, maternal vital signs, and the woman's nearness to birth c. Identification of ruptured membranes, woman's gravida and para, and her support person d. Last food intake, when labor began, and cultural practices the couple desires

ANS: B All options describe relevant intrapartum nursing assessments; however, this focused assessment has a priority.

According to professional standards which action cannot be performed by the non-anesthetist registered nurse who is caring for a woman with epidural anesthesia? a. Monitoring the status of the woman and fetus b. Initiating epidural anesthesia c. Replacing empty infusion bags with the same medication and concentrate d. Stopping the infusion, and initiating emergency measures

ANS: B Only qualified, licensed anesthesia care providers are permitted to insert a catheter, initiate epidural anesthesia, verify catheter placement, inject medication through the catheter, or alter the medication or medications including type, amount, or rate of infusion.

A first-time mother is concerned about the type of medications she will receive during labor. The client is in a fair amount of pain and is nauseated. In addition, she appears to be very anxious. The nurse explains that opioid analgesics are often used along with sedatives. How should the nurse phrase the rationale for this medication combination? a. "The two medications, together, reduce complications." b. "Sedatives enhance the effect of the pain medication." c. "The two medications work better together, enabling you to sleep until you have the baby." d. "This is what your physician has ordered for you."

ANS: B Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractic drugs reduce anxiety and apprehension and potentiate the opioid analgesic affects.

After an emergency birth, the nurse encourages the woman to breastfeed her newborn. What is the primary purpose of this activity? a. To facilitate maternal-newborn interaction b. To stimulate the uterus to contract c. To prevent neonatal hypoglycemia d. To initiate the lactation cycle

ANS: B Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage

Through a vaginal examination, the nurse determines that a woman is 4 cm dilated. The external fetal monitor shows uterine contractions every 3 1/2 to 4 minutes. The nurse reports this as what stage of labor? a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage, latent phase

ANS: B This maternal progress indicates that the woman is in the active phase of the first stage of labor. During the latent phase of the first stage of labor, the expected maternal progress is 0 to 3 cm dilation with contractions every 5 to 30 minutes.

The nurse should be cognizant of which postpartum physiologic alteration? a. Cardiac output, pulse rate, and stroke volume all return to prepregnancy normal values within 48 hours of childbirth. b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth. c. Lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. d. Hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

ANS: B . Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after birth. It gradually decreases over the first 48 hours postpartum. Respirations should decrease to within the woman's normal prepregnancy range soon after childbirth. Leukocytosis increases 10 to 12 days after childbirth, which can obscure the diagnosis of acute infections, producing false-negative test results.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could the nurse use to increase the client's blood pressure? (Select all that apply.) a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase IV fluids. d. Administer oxygen. e. Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until the woman is stable.

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

ANS: C A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement

What is the primary purpose for the use of tocolytic therapy to suppress uterine activity? a. Drugs can be efficaciously administered up to the designated beginning of term at 37 weeks gestation. b. Tocolytic therapy has no important maternal (as opposed to fetal) contraindications . c. The most important function of tocolytic therapy is to provide the opportunity to administer antenatal glucocorticoids. d. If the client develops pulmonary edema while receiving tocolytic therapy, then intravenous (IV) fluids should be given.

ANS: C Buying time for antenatal glucocorticoids to accelerate fetal lung development may be the best reason to use tocolytic therapy

Which statement, related to the reconditioning of the urinary system after childbirth, should the nurse understand? a. Kidney function returns to normal a few days after birth. b. Diastasis recti abdominis is a common condition that alters the voiding reflex. c. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. d. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth.

ANS: C Excess fluid loss through other means besides perspiration and increased urinary output occurs as well.

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen b. Progesterone c. Prolactin d. Human placental lactogen

ANS: C Prolactin levels in the blood progressively increase throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen levels decrease significantly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period

Which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor? a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now."

ANS: C Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. The loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor.

Which description of the phases of the second stage of labor is most accurate? a. Latent phase: Feeling sleepy; fetal station 2+ to 4+; duration of 30 to 45 minutes b. Active phase: Overwhelmingly strong contractions; Ferguson reflux activated; duration of 5 to 15 minutes c. Descent phase: Significant increase in contractions; Ferguson reflux activated; average duration varies d. Transitional phase: Woman "laboring down"; fetal station 0; duration of 15 minutes

ANS: C The descent phase begins with a significant increase in contractions; the Ferguson reflex is activated, and the duration varies, depending on several factors. The latent phase is the lull or "laboring down" period at the beginning of the second stage and lasts 10 to 30 minutes on average

which documentation on a womens chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochial flow b. Breasts firm and tender c. Fundus below the symphysis and nonpalpable d. Episiotomy slightly red and puffy

ANS: C The fundus descends 1 cm per day; consequently, it is no longer palpable by postpartum day 14. The lochia should be changed by this day to serosa

A woman in labor has just received an epidural block. What is the most important nursing intervention at this time? a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is for the nurse to monitor the maternal blood pressure frequently for signs of hypotension

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. The nurse reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3 . Which factor would contraindicate an epidural for this woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

ANS: C The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia and anesthesia.

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. Which physiologic alteration is the cause for the diaphoresis and diuresis that this client is experiencing a. Elevated temperature caused by postpartum infection b. Increased basal metabolic rate after giving birth c. Loss of increased blood volume associated with pregnancy d. Increased venous pressure in the lower extremities

ANS: C Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy.

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement regarding this procedure is correct? a. The application of nitrous oxide gas is not often used anymore. b. An inhalation of gas is likely to be used in the second stage of labor, not during the first stage. c. An application of nitrous oxide gas is administered for pain relief. d. The application of gas is a prelude to a cesarean birth.

ANS: C A mixture of nitrous oxide with oxygen in a low concentration can be used in combination with other nonpharmacologic and pharmacologic measures for pain relief

. A laboring woman has received meperidine intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a. Fentanyl b. Promethazine c. Naloxone d. Nalbuphine

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid.

Which clinical finding indicates that the client has reached the second stage of labor? a. Amniotic membranes rupture (ROM). b. Cervix cannot be felt during a vaginal examination. c. Woman experiences a strong urge to bear down. d. Presenting part of the fetus is below the ischial spines.

ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. The ROM has no significance in determining the stage of labor.

What should the nurse's next action be if the client's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day? a. Immediately inform the health care provider. b. Have the laboratory draw blood for reanalysis. c. Recognize that this count is an acceptable range at this point postpartum. d. Immediately begin antibiotic therapy.

ANS: C During the first 10 to 12 days after childbirth, WBC values up to 30,000/mm3 are common. Because a WBC count of 25,000/mm3 on her second postpartum day is normal, alerting the health care provider is not warranted nor is reassessment or antibiotics needed; the WBC count is not elevated and so no reanalysis is required

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help their clients. Which clients may initially appear very stoic but then become quite vocal as labor progresses until late in labor, when they become more vocal and request pain relief? a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

ANS: C Hispanic women may be stoic early in labor but more vocal and readier for medications later.

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. Which response by the client alerts the nurse that psychosocial outcomes have not been met? a. The woman excessively discusses her labor and birth experience. b. The woman feels that her baby is more attractive and cleverer than any others. c. The woman refers to the baby as "sweetie" since she has not given the baby a name yet. d. The woman has a partner or family members who react very positively about the baby

ANS: C If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include a refusal to hold or feed the baby, a lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change.

What is the primary rationale for the thorough drying of the infant immediately after birth? a. Stimulates crying and lung expansion b. Removes maternal blood from the skin surface c. Reduces heat loss from evaporation d. Increases blood supply to the hands and feet

ANS: C Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Although rubbing the infant stimulates crying, it is not the main reason for drying the infant

1. In planning for home care of a woman with preterm labor, which concern should the nurse need to address? a. Nursing assessments are different from those performed in the hospital setting. b. Restricted activity and medications are necessary to prevent a recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers are necessary.

ANS: C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance, and prolonged postpartum recovery

The first hour after birth is sometimes referred to as what? a. Bonding period b. Third stage of labor c. Fourth stage of labor d. Early postpartum period

ANS: C The fourth stage of labor begins with the expulsion of the placenta and lasts until the woman is stable in the immediate postpartum period, usually within the first hour after birth. Maternal organs undergo their initial readjustment to a nonpregnant state

Which action is correct when palpation is used to assess the characteristics and pattern of uterine contractions? a. Placing the hand on the abdomen below the umbilicus and palpating uterine tone with the fingertips b. Determining the frequency by timing from the end of one contraction to the end of the next contraction c. Evaluating the intensity by pressing the fingertips into the uterine fundus d. Assessing uterine contractions every 30 minutes throughout the first stage of labor

ANS: C The nurse or primary health care provider may assess uterine activity by palpating the fundal section of the uterus using the fingertips.

A 25-year-old gravida 3, para 2 client gave birth to a 9-pound, 7-ounce boy, 4 hours ago after augmentation of labor with oxytocin. She presses her call light, and asks for her nurse right away, stating "I'm bleeding a lot." What is the most likely cause of postpartum hemorrhaging in this client? a. Retained placental fragments b. Unrepaired vaginal lacerations c. Uterine atony d. Puerperal infection

ANS: C This woman gave birth to a macrosomic infant after oxytocin augmentation. Combined with these risk factors, uterine atony is the most likely cause of bleeding 4 hours after delivery.

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia does the nurse expect to find when evaluating this client? a. Lochia rubra b. Lochia sangra c. Lochia alba d. Lochia serosa

ANS: D Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris

. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurse's highest priority? a. Beginning an intravenous (IV) infusion of Ringer's lactate solution b. Assessing the woman's vital signs c. Calling the woman's primary health care provider d. Massaging the woman's fundus

ANS: D The nurse should first assess the uterus for atony by massaging the woman's fundus. Uterine tone must be established to prevent excessive blood loss.

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath three times daily, and a stool softener. Which information regarding the client's condition is most closely correlated with these orders? a. Woman is a gravida 2, para 2. b. Woman had a vacuum-assisted birth. c. Woman received epidural anesthesia. d. Woman has an episiotomy.

ANS: D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is approximately twice the normal adult breathing rate. She starts to report feeling lightheaded and dizzy and states that her fingers are tingling. Which intervention should the nurse immediately initiate? a. Contact the woman's health care provider . b. Tell the woman to slow her pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag

ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis and enable her to rebreathe carbon dioxide and replace the bicarbonate ion.

Which characteristic of a uterine contraction is not routinely documented? a. Frequency: how often contractions occur b. Intensity: strength of the contraction at its peak c. Resting tone: tension in the uterine muscle d. Appearance: shape and height

ANS: D Uterine contractions are described in terms of frequency, intensity, duration, and resting tone. Appearance is not routinely charted.

The obstetric nurse is preparing the client for an emergency cesarean birth, with no time to administer spinal anesthesia, general anesthesia will be used. What is the greatest risk of administering general anesthesia to the client.? a. Respiratory depression b. Uterine relaxation c. Inadequate muscle relaxation d. Aspiration of stomach contents

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia.

The nurse is providing instruction to the newly delivered client regarding postbirth uterine and vaginal discharge, called lochia. Which statement is the most appropriate? a. Lochia is similar to a light menstrual period for the first 6 to 12 hours. b. It is usually greater after cesarean births. c. Lochia will usually decrease with ambulation and breastfeeding. d. It should smell like normal menstrual flow unless an infection is present.

ANS: D An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease.

When a nulliparous woman telephones the hospital to report that she is in labor, what intervention should the nurse prioritize? a. Instructing the woman to stay home until her membranes rupture . b. Emphasizing that food and fluid intake should stop. c. Arranging for the woman to come to the hospital for labor evaluation. d. Asking the woman to describe why she believes she is in labor.

ANS: D Assessment begins at the first contact with the woman, whether by telephone or in person. By asking the woman to describe her signs and symptoms, the nurse can begin her assessment and gather data.

A client is concerned that her breasts are engorged and uncomfortable. What is the nurse's explanation for this physiologic change? a. Overproduction of colostrum b. Accumulation of milk in the lactiferous ducts and glands c. Hyperplasia of mammary tissue d. Congestion of veins and lymphatic vessels

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatic vessels. An overproduction of colostrum, an accumulation of milk in the lactiferous ducts and glands, and hyperplasia of mammary tissue do not cause breast engorgement.

A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide initially? a. Notify the woman's health care provider. b. Administer the prescribed narcotic analgesic. c. Assure her that her labor will be over soon. d. Assist her with simple breathing and relaxation instructions.

ANS: D By reducing tension and stress, both focusing, and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and is often successful.

An 18-year-old pregnant woman, gravida 1, para 0, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The client states, "My contractions are so strong, I don't know what to do." What should the nurse's first action be? a. Assess for fetal well-being . b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized

ANS: D Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth.

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches

ANS: D Headaches are common in the first postpartum week; they are usually bilateral and frontal in location.

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions experience more pain. d. Levels of pain-mitigating beta-endorphins are higher during a spontaneous, natural childbirth.

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains.

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman spontaneously empty her bladder as soon as possible. If all else fails, what tactic might the nurse use? a. Pouring water from a squeeze bottle over the woman's perineum b. Placing oil of peppermint in a bedpan under the woman c. Asking the healthcare provider to prescribe analgesic agents d. Inserting a sterile catheter

ANS: D Invasive procedures are usually the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills). Pouring water over the perineum may stimulate voiding

Which collection of risk factors will most likely result in damaging lacerations, including episiotomies? a. Dark-skinned woman who has had more than one pregnancy, who is going through prolonged second-stage labor, and who is attended by a midwife b. Reddish-haired mother of two who is going through a breech birth c. Dark-skinned first-time mother who is going through a long labor d. First-time mother with reddish hair whose rapid labor was overseen by an obstetrician

ANS: D Reddish-haired women have tissue that is less distensible than darker-skinned women and therefore may have less efficient healing. First-time mothers are also at greater risk, especially with breech births, long second-stage labors, or rapid labors during which the time for the perineum to stretch is insufficient.

What are the most common causes for subinvolution of the uterus? a. Postpartum hemorrhage and infection b. Multiple gestation and POSTPARTUM HEMORRHAGE c. Uterine tetany and overproduction of oxytocin d. Retained placental fragments and infection

ANS: D Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection. Subinvolution may be caused by an infection and result in hemorrhage.

The Valsalva maneuver can be described as the process of making a forceful bearing-down attempt while holding one's breath with a closed glottis and a tightening of the abdominal muscles. When is it appropriate to instruct the client to use this maneuver? a. During the second stage to enhance the movement of the fetus b. During the third stage to help expel the placenta c. During the fourth stage to expel blood clots d. During no stage of labor

ANS: D The client should not be instructed to use this maneuver. This process stimulates the parasympathetic division of the autonomic nervous system and produces a vagal response (decrease in heart rate and blood pressure.)

Which explanation concerning postpartum ovary function is most accurate? a. Almost 75% of women who do not breastfeed resume menstruating within 1 month after birth. b. Ovulation occurs slightly earlier for breastfeeding women. c. Because of menstruation and ovulation schedules, contraception considerations can be postponed until after the puerperium. d. The first menstrual flow after childbirth usually is heavier than normal.

ANS: D The first flow is heavier, but within three or four cycles, the flow is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns in approximately 3 months

The nurse performs a vaginal examination to assess a client's labor progress. Which action should the nurse take next? a. Perform an examination at least once every hour during the active phase of labor. b. Perform the examination with the woman in the supine position. c. Wear two clean gloves for each examination. d. Discuss the findings with the woman and her partner.

ANS: D The nurse should discuss the findings of the vaginal examination with the woman and her partner, as well as report the findings to the primary care provider

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse's highest priority in this situation? a. Prepare the woman for imminent birth. b. Notify the woman's primary health care provider. c. Document the characteristics of the fluid. d. Assess the fetal heart rate (FHR) and pattern.

ANS: D The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the rupture of membranes (ROM) to ascertain fetal well-being, and the findings should be documented.

A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural "no matter what!" What is the nurse's best response? a. "I'll make sure you get your epidural." b. "You may only have an epidural if your physician allows it." c. "You may only have an epidural if you are going to deliver vaginally." d. "The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth."

ANS: D To avoid suppressing the progress of labor, pharmacologic measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm

Maternity nurses often must answer questions about the many, sometimes unusual, ways people have tried to make the birthing experience more comfortable. Which information regarding nonpharmacologic pain relief is accurate? a. Music supplied by the support person must be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital.

Under which circumstance would it be unnecessary for the nurse to perform a vaginal examination? a. Admission to the hospital at the start of labor b. When accelerations of the fetal heart rate (FHR) are noted c. On maternal perception of perineal pressure or the urge to bear down d. When membranes rupture

B

Which client is most likely to experience strong and uncomfortable afterpains? a. A woman who experienced oligohydramnios b. A woman who is a gravida 4, para 4-0-0-4 c. A woman who is bottle-feeding her infant d. A woman whose infant weighed 5 pounds, 3 ounces

B Afterpains are more common in multiparous women. In a woman who experienced polyhydramnios, afterpains are more noticeable because the uterus was greatly distended. Breastfeeding may cause the afterpains to intensify

4. What is the rationale for the administration of an oxytocic after expulsion of the placenta? a. To relieve pain b. To stimulate uterine contraction c. To prevent infection d. To facilitate rest and relaxation

B Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor.

A woman who has a history of sexual abuse may have several traumatic memories triggered during labor. She may fight the labor process and react with pain or anger. The nurse can implement appropriate care measures to help her client view the childbirth experience in a positive manner. Which intervention is key for the nurse to use while providing care? a. Tell the client to relax and that it won't hurt much . b. Limit the number of procedures that invade her body. c. Reassure the client that, as the nurse, you know what is best. d. Allow unlimited care providers to be with the client.

B The number of invasive procedures such as vaginal examinations, internal monitoring, and IV therapy should be limited as much as possible.

Where is the point of maximal intensity (PMI) of the fetal heart tone (FHR) located? a. Usually directly over the fetal abdomen b. In a vertex position, heard above the mother's umbilicus c. Directly over the fetal back d. In a breech position, heard below the mother's umbilicus

C Nurses should be prepared for the shift. The PMI of the FHR is usually directly over the fetal back.

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. They are becoming more regular and are moderate to strong. Based on this information, what would a prudent nurse do next? a. Immediately notify the woman's primary health care provider. b. Prepare to administer an oxytocic to stimulate uterine activity . c. Document the findings because they reflect the expected contraction pattern for the active phase of labor. d. Prepare the woman for the onset of the second stage of labor

C The nurse is responsible for monitoring the uterine contractions to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta.

A nulliparous woman has just begun the latent phase of the second stage of her labor. The nurse should anticipate which behavior? a. A nulliparous woman will experience a strong urge to bear down. b. Perineal bulging will show. c. A nulliparous woman will remain quiet with her eyes closed between contractions. d. The amount of bright red bloody show will increase.

C The woman is able to relax and close her eyes between contractions as the fetus passively descends. The woman may be very quiet during this phase

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. What amount of blood loss does the postpartum nurse anticipate? (Select all that apply.) a. 100 ml b. 250 ml or less c. 300 to 500 ml d. 500 to 1000 ml e. 1500 ml or greater

C, D

Parents who have not already done so need to make time for newborn follow-up of the discharge. According to the American Academy of Pediatrics (AAP), when should a breastfeeding infant first need to be seen for a follow-up examination? a. 2 weeks of age b. 7 to 10 days after childbirth c. 4 to 5 days after hospital discharge d. 48 to 72 hours after hospital discharge

D

When would an internal version be indicated to manipulate the fetus into a vertex position? a. Fetus from a breech to a cephalic presentation before labor begins b. Fetus from a transverse lie to a longitudinal lie before a cesarean birth c. Second twin from an oblique lie to a transverse lie before labor begins d. Second twin from a transverse lie to a breech presentation during a vaginal birth

D

Which term best describes the interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state? a. Involutionary period because of changes to the uterus b. Lochia period because of the nature of the vaginal discharge c. Mini-tri period because it lasts only 3 to 6 weeks d. Puerperium, or fourth trimester of pregnancy

D

Several delivery changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed? a. Nail brittleness b. Darker pigmentation of the areolae and linea nigra c. Striae gravidarum on the breasts, abdomen, and thighs d. Spider nev

a

Which statement by a newly delivered woman indicates that she knows what to expect regarding her menstrual activity after childbirth? a. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." b. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." c. "I will not have a menstrual cycle for 6 months after childbirth." d. "My first menstrual cycle will be heavier than normal and then will be light for several months after."

b