High-Risk Intrapartum- Davis Practice Q's

After a multiparous woman has been in active labor for 15 hours, an ultrasound is done. The results state that the obstetric conjugate is 10 cm and the suboccipito- bregmatic diameter is 10.5 cm. Which of the following labor findings is related to these results? 1. Full dilation of the cervix. 2. Full effacement of the cervix. 3. Station of 3. 4. Frequency every 5 minutes.

3 A high station is consistent with the data in the scenario. The dimensions noted in the stem are consistent with a diagno- sis of cephalopelvic disproportion since the anterior-posterior diameter of the pelvis (obstetric conjugate) is smaller than the diameter of the baby's head (suboccipitobregmatic). When the fetal head is larger than the maternal pelvis, the baby is unable to descend.

During intubation, the anesthesiologist asks the nurse to apply cricoid pressure. Place an "X" on the location where the nurse should apply the pressure

TEST-TAKING TIP: To locate the cricoid cartilage, the nurse should find the thyroid prominence, which is the largest bulge in the middle of the front of the neck. The nurse should then, while staying in the midline, move the fingers lightly on the skin downward toward the chest until a gully or notch is felt. The next horizontal projection is the cricoid cartilage. With the thumb on one side of the cartilage and the index finger on the other side of the cartilage, the nurse should press firmly toward the client's back and keep pressing until the anes - thesiologist advises him or her to let go. This action presses the cricoid against the esophagus, preventing regurgitation of the stomach contents.

Aclientwithafetaldemiseisadmittedtolaboranddeliveryinthelatentphaseofla- bor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sad. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.

1 1. The nurse would expect the client to be crying and sad. 2. It is unlikely that the client would be talkative and excited. 3. It is unlikely that the client would be quietly doing rapid breathing. 4. It is unlikely that the client would be loudly chanting. TEST-TAKING TIP: A client in the latent phase of labor who is carrying a healthy fetus is likely to be talkative and excited, but a woman whose fetus has died is likely to be crying and sad throughout her labor. Clients in the latent phase usually are performing slow chest breathing.

The nurse is caring for 4 women who are in labor. The nurse is aware that he or she will likely prepare which of the women for cesarean delivery? 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Client is hepatitis B-surface antigen positive. 4. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5 to 1.

1, 3 1 and 3 are correct. 1. The baby in the LSP position is in a breech presentation. Most breech babies are delivered by cesarean section. 2. The placenta usually attaches to the poste- rior portion of the uterine wall. 3. The meningomyelocele sac could easily rupture during a vaginal delivery. When a fetus has been diagnosed with the defect, a cesarean is usually performed. 4. Maternal hepatitis B antigen positive status is not an indication for cesarean delivery. 5. The L/S ratio of 1.5:1 indicates that the baby's lung fields are not yet mature. TEST-TAKING TIP: Although it is recom- mended that cesarean section be per- formed when a mother is affected by two viral illnesses—herpes simplex type 2 (only when active lesions are present) and HIV/AIDS—it is not recommended in the presence of other viral diseases. Hepatitis B is a very serious viral disease, but vertical transmission rates are not significantly different between those babies who are born vaginally and those babies who are born by cesarean section.

A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.

1,4,5 1, 4, and 5 are correct. 1. The client's hepatitis B status should be assessed. 2. The client's rubeola status is not imme- diately important. 3. The client's varicella status is not imme- diately important. 4. The client's group B streptococcus status should be assessed. 5. The client's HIV/AIDS status should be assessed. TEST-TAKING TIP: There are several infectious diseases that affect care given during pregnancy, labor and delivery, postpartum, and in the newborn nursery. The hepatitis B status must be assessed to notify the nursery for care needed by the baby. Group B strep status must be assessed to administer needed antibiotics to the mother during labor and to moni- tor the baby's status in the newborn nursery. The HIV/AIDS status must be assessed to administer needed antiviral medications to the mother in labor and/ or to the baby postdelivery. HIV/AIDS is also an indication for cesarean section delivery.

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has oc- curred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her hips. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2 Flexing the woman's hips sharply toward her shoulders, called McRoberts' maneuver, is appropriate. Flexing the woman's hips sharply toward her shoulders in- creases slightly the diameter of the pelvic outlet which often enables the practi- tioner to successfully deliver the baby. It is especially important to note that fundal pressure is contraindicated be- cause it may actually magnify the prob- lem by wedging the shoulders into the pelvis even more deeply. Suprapubic pressure, on the other hand, is often helpful in assisting with the delivery.

In which of the following clinical situations would it be appropriate for an obstetri- cian to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations.

2 It would be appropriate for a health care practitioner to order an amnioin- fusion when a client's amniotic fluid is meconium stained. Amnioinfusion is the instillation of intravenous fluid into the uterine cavity through intravenous tub- ing inserted via the vagina. It may be or- dered if the amniotic fluid is meconium stained. The infusion would dilute the concentration of meconium in order to decrease the potential of the baby aspi- rating large quantities of meconium at birth.

A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilatation and effacement. 4. Maternal pulse rate.

2 Maternal temperature is the highest priority. The test taker must re- member that the uterine cavity is a ster- ile space while the vaginal vault is an un- sterile space. When membranes have ruptured over 24 hours, there is poten- tial for pathogens to ascend into the uterine cavity and infection to result. El- evated temperature is a sign of infection.

An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.

2 The nurse would expect the woman to hemorrhage. A placenta accreta is present when the chorionic villi attach directly to or invade through the myo- metrium of the uterus. There is no way, therefore, for the placenta to separate from the uterine wall. Hemorrhage re- sults. It is not uncommon for a hysterec- tomy to have to be performed in order to save the woman's life.

The labor nurse has just received shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 gm/dL. 2. G2P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2P1001, 39 weeks, Rh negative, today's hematocrit 31%.

3 A placental abruption is a life- threatening situation for the fetus. It has been 15 minutes since the fetal heart was assessed. This is the nurse's priority. In this question, the test taker must discriminate among four situations to discern which is the highest priority. Although a client with placenta previa is at high risk for bleeding, it is very likely that if she did start to bleed spontaneously that she would notify the nurse. The fetus of a client who has a placental abruption, however, is already in a life-threatening situation.

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.

3 The most common difference be- tween placenta previa and placenta abruption is the absence or presence of abdominal pain. Because at least some of the blood from a placental abruption is trapped behind the placenta, women with that complication usually complain of intense, unrelenting pain. But because the blood from a symptomatic placenta previa flows freely through the vagina, the bleeding from that complication is virtually pain free.

A woman being induced with oxytocin (Pitocin) is contracting every 3 min 30 seconds. Suddenly the woman becomes dypsneic, cyanotic, and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.

3 The nurse's priority action is to ad- minister oxygen. This client is exhibiting the classic signs of an amniotic fluid em- bolism. At this point, the baby's health is secondary because the mother is in a life-threatening situation. The nurse must apply oxygen and call a code immediately.

A client, G3P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman? 1. She may need a cesarean delivery. 2. She will be treated with antibiotics during labor. 3. The baby may develop thrush after delivery. 4. The baby will be isolated for at least one day.

3 Thrush is the term given to oral can- didiasis, which the baby may develop after delivery. Candida can be trans- mitted to a baby during delivery as well as postdelivery via the mother's hands. Initially, the baby will develop thrush, but eventually the mother may notice a bright pink diaper rash on the baby. Also, if she is breastfeeding her baby, she may develop a yeast infection of the breast that is very painful. The mother with candidiasis should be advised to wash her hands carefully after toileting

The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? 1. Risk for impaired skin integrity. 2. Risk for body image disturbance. 3. Risk for impaired parenting. 4. Risk for ineffective sexuality pattern.

1 1. The woman is at risk of impaired skin integrity. 2. Risk for impaired body image is not appropriate at this time. 3. Risk for impaired parenting is not appro- priate at this time. 4. Risk for ineffective sexuality pattern is not appropriate at this time. TEST-TAKING TIP: Clients who are delivered by vacuum extraction are at high risk for lacerations. Their skin integrity, therefore, is at risk. The other nursing diagnoses are not applicable.

A client with a complete placenta previa is on the antepartum clinical unit in prepa- ration for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.

1 Because the client will have a ce- sarean section with anesthesia, the woman should be taught coughing and deep breathing exercises for the postoperative period. When a client has a complete placenta previa, the placenta has attached to the uterine lining so that it fully covers the internal cervical os. If the woman were to go through labor, during dilation and effacement the villi of the placenta would incrementally be ex- posed, leading the client to bleed pro- fusely. The baby would exsanguinate and die. The only safe way to deliver the baby, therefore, is via cesarean section.

A physician has notified the labor and delivery suite that four clients will be admit- ted to the unit. The client with which of the following clinical findings would be a candidate for an external version? 1. 3 station. 2. Left sacral posterior position. 3. Flexed attitude. 4. Rupture of membranes for 24 hours.

2 1. A fetus in +3 station is well below engage- ment. An external version would not be advisable. 2. LSP position is a breech presentation. It may be appropriate for a physician to perform an external version prior to this delivery. 3. There is no indication that the baby in the flexed attitude is in a malpresentation. 4. Prolonged rupture of membranes is not an indication for an external version. TEST-TAKING TIP: If a baby is in the breech presentation, the version would have to be performed before the baby had engaged. Once the baby is well established in the true pelvis, it is at high risk for the baby to be moved.

A preterm labor client, 30 weeks' gestation who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."

3 1. Decadron is not a tocolytic. 2. Decadron is not an anti-infective. 3. Decadron is a steroid that hastens the maturation of the fetal lung fields. 4. Decadron is not an analgesic. TEST-TAKING TIP: Steroids (either IM betamethasone or IM dexamethasone) are given over a 2-day period to mothers in preterm labor. The medications have been shown to hasten the development of surfactant in the lung fields of fetuses. Babies whose mothers have received one of the medications experience fewer respiratory complications.

A woman with severe preeclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 120 seconds. 4. Fetal heart rate 156 with early decelerations.

3 1. Oxytocin is safe to administer if a client has preeclampsia. 2. The frequency is within normal limits. 3. The duration of the contractions is prolonged. The baby will be deprived of oxygen. 4. The FH is within normal limits. TEST-TAKING TIP: The test taker should consider that not only is this client receiv- ing oxytocin, but she is also preeclamptic. Preeclampsia is a vasoconstrictive disease state. The likelihood of poor placental perfusion is already high. When the contraction duration is also prolonged, the fetus is at high risk of becoming hypoxic.

Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 120 with variable decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta.

3 The drop in fetal heart rate with vari- able decelerations indicates that the cord has likely prolapsed. The test taker must re- member that variable decelerations are caused by cord compression. The fact that variables are seen in the scenario as well as a precipitous drop in the fetal heart baseline is an indirect indication that the cord is being compressed, result- ing in decreased oxygenation to the fetus.

A client is on magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of 3. 2. Urinary output of 30 cc/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 gm/dL.

4 1. Hyperreflexia is seen with severe preeclamp- sia. The magnesium sulfate is being ad- ministered to depress the hyperreflexia. 2. 30 mL/hr is an acceptable urinary output. 3. A respiratory rate of 16 rpm is within normal limits. 4. A serum magnesium level of 9 g/dL is dangerously high. The health care practitioner should be notified. TEST-TAKING TIP: When magnesium sulfate is being administered, the nurse should monitor the client for adverse side effects including respiratory depression, oliguria, and depressed reflexes. When the magne- sium level is above 7 g/dL, toxic effects can be seen.

Which of the following situations is considered a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4 Shoulder dystocia is an obstetric emergency. Dystocia means difficult delivery. A shoulder dystocia, therefore, refers to difficulty in delivering a baby's shoulders. This is an obstetric emer- gency since the dystocia occurs in the middle of the delivery when the head has been delivered but the shoulders remain wedged in the pelvis. The most common complications are related to nerve palsies from traction placed on the baby's head in attempts to deliver the shoulder. In addition, the baby's life is threatened since the baby is unable to breathe and umbilical cord flow is often dramatically reduced during this phase of the delivery.

A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. LMA (left mentum anterior). 2. LSP (left sacral posterior). 3. RScT (right scapular transverse). 4. ROP (right occiput posterior).

1 1. LMA position is consistent with that information. 2. In the LSP position, the sacrum is present- ing, not the vertex. 3. In the RScT position, the fetus is in the transverse lie. 4. In the ROP position, the occiput is presenting so the fetal attitude is flexed. TEST-TAKING TIP: To conceptualize the relationship between attitude, presenta- tion, and position, the test taker must first thoroughly understand the three concepts. The vertex presentation is a head-down presentation; both occipital and mentum presentations are vertex presentations. When the attitude is extended in a head-down presentation, the front of the head or the face is the presenting part, whereas when the head is flexed, the back of the head, or occiput, is presenting. When the scapula is presenting, the baby is lying sideways in utero, called transverse lie.

A woman in active labor received Nubain (nalbuphine hydrochloride) 14 mg IV for pain relief. One-half hour later her respirations are 8 rpm. The nurse reports the respiratory rate to the physician. Which of the following medications would be appropriate for the physician to order at this time? 1. Narcan (naloxone). 2. Reglan (declopramide). 3. Benadryl (diphenhydramine). 4. Vistaril (hydroxyzine).

1 1. The nurse would expect to administer Narcan to the client. 2. There is no indication for the adminis- tration of Reglan (antiemetic agent) at this time. 3. There is no indication for the adminis- tration of Benadryl (antihistamine) at this time. 4. There is no indication for the administra- tion of Vistaril (antihistamine) at this time. TEST-TAKING TIP: Nubain is an opioid analgesia. It has markedly depressed the client's respiratory response. Narcan is an opioid antagonist. It is likely that the physician will order Narcan to be admin- istered at this time.

The nurse is admitting four full term primigravid clients to the labor and delivery unit. The nurse requests pre-cesarean section orders from the health care practi- tioner for which of the clients? The client who has: 1. cervical cerclage. 2. FH 156 with beat-to-beat variability. 3. Maternal blood pressure of 90/60. 4. Full effacement.

1, 5 1 and 5 are correct. 1. Cervical cerclage, a stitch encircling the cervix, is incompatible with vaginal delivery. 2. This FH is well within normal limits. 3. This BP is well within normal limits. 4. A fully effaced cervix is essential for a vaginal delivery. It is not an indication for a cesarean section. 5. Active herpes simplex 2 is an absolute indi- cator for a cesarean delivery. TEST-TAKING TIP: The test taker must be able to differentiate in which circumstances a full- term, otherwise healthy woman, would be unable to deliver vaginally. There are a few absolute indicators for cesarean section: mater- nal infection with active herpes simplex 2 and HIV/AIDS (http://www.cdc.gov/hiv/topics/ perinatal/overview_partner.htm#_strategies); malpresentation—for example, horizontal lie and breech; previous maternal surgery—e.g., myomectomy; a vertical cesarean scar; some congenital anomalies—e.g., hydrocephalus and meningomyelocele; and other physical conditions, including cervical cerclage in place, obstructive lesions in the lower gynecological system, and complete placenta previa. The test taker should become familiar with each of these.

The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section: Risk for ineffective individual coping related to emer- gency procedure. Which of the following nursing interventions would be appropri- ate in relation to this diagnosis? 1. Apply antiembolic boots bilaterally. 2. Explain all procedures slowly and carefully. 3. Administer an antacid per MD orders. 4. Monitor the FH and maternal vital signs.

2 1. Antiembolic stockings (sometimes called antiembolic boots) are often applied during and post-cesarean section. Their applica- tion is unrelated to the nursing diagnosis, however. 2. The nurse should explain all procedures slowly and carefully. 3. Antacid administration is warranted in this situation but is unrelated to the nursing diagnosis. 4. The fetal heart and maternal vital signs should be carefully monitored, but they are unrelated to the nursing diagnosis. TEST-TAKING TIP: Whenever a question is asked, the test taker must attend to the content of the question. All of the responses are appropriate in relation to cesarean deliveries, but only response 2 is related to the diagnosis of risk for ineffective individual coping.

A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1. Contraction pattern is every 3 min 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90.

2 1. This is a normal contraction pattern. It is not a contraindication to analgesic administration. 2. Late decelerations are indicative of uteroplacental insufficiency and indi- cate fetal distress. It is inappropriate to administer a central nervous system (CNS) depressant to the mother at this time. 3. Sleeping between contractions is a normal phenomenon. It is not a contraindication to analgesic administration. 4. Hypertension is not a contraindication to analgesic administration. TEST-TAKING TIP: Analgesics are central nervous system (CNS) depressants. They not only depress the CNS of the mother, reducing her pain, but also depress the CNS of the baby. It is inappropriate to ad- minister a depressant to a mother whose fetus is already exhibiting signs of distress. First, the variability of the baseline would be diminished, preventing the nurse from assessing that very important indicator of fetal well-being. And if the baby were to be delivered via cesarean section, the baby would likely be depressed and in need of resuscitation.

The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.

2 Green amniotic fluid in the presence of late decelerations is indicative of fetal distress. Late decelerations are related to poor uteroplacental blood flow. As a result of the poor blood flow, the fetus is being poorly oxygenated and nourished. Amniotic fluid becomes green- tinged in the presence of meconium. Meconium is expelled in utero when the fetal anal sphincter relaxes. Sphincters relax when the body is hypoxic. The nurse, therefore, must conclude that the fetus is at high risk for injury related to intrauterine hypoxia.

A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.

2 Sinusoidal patterns are related to Rh isoimmunization, fetal anemia, severe fetal hypoxia, or a chronic fetal bleed. They also may occur transiently as a result of Demerol (meperidine) or Stadol (butorphanol) administration. Since this client has just been admit- ted, medication administration is not a likely cause. The health care practi- tioner should be notified. Sinusoidal fetal heart patterns exhibit no variability and have a uniform wave-like pattern (see below). The nurse would note no periods when the heart rate appears normal. The fetus is in imminent danger. The practitioner must be notified as soon as possible so that he or she can determine the appro- priate intervention.

A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.

2 The nurse's goal at this point must be the delivery of a healthy baby. Nursing goals may change repeatedly during a client's labor. The nurse must assess the woman's progress in relation to the health and well-being of the fetus. As long as the baby is responding well, the nurse's focus should relate to maternal comfort and care. Once fetal compromise is noted, however, nursing actions often shift.

A full-term client, contracting every 15 min 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.

2 Vaginal examination is contraindi- cated. The client in this sce- nario is at risk of an ascending infection from the vagina to the uterine body because she has prolonged rupture of membranes. Any time a vaginal examina- tion is performed, the chance of infection rises. Nipple stimulation is appropriate since endogenous oxytocin will be re- leased which would augment the client's weak labor pattern.

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? 1. 3 pitting edema and pulmonary edema. 2. Epigastric pain and systemic jaundice. 3. 4 deep tendon reflexes and clonus. 4. Oliguria and elevated specific gravity.

2, 3 2 and 3 are correct. 1. A client with severe preeclampsia could exhibit symptoms of +3 pitting edema without the addition of HELLP syndrome. 2. Petechiae may develop when a client is thrombocytopenic, one of the signs of HELLP syndrome. 3. Hyperbilirubinemia develops when red blood cells hemolyze, one of the changes that may develop as a result of liver necrosis. Jaundice is a manifesta- tion of hyperbilirubinemia. 4. +4 reflexes are consistent with a diagnosis of severe preeclampsia and may be present without the addition of HELLP syndrome. 5. Elevated specific gravity is consistent with a diagnosis of severe preeclampsia and may be present without the addition of HELLP syndrome. TEST-TAKING TIP: The test taker must be able to discriminate between symptoms of severe preeclampsia and HELLP syn- drome. If the nurse remembers what each of the letters in HELLP stands for, he or she can determine which of the responses is correct.

A woman has been in the second stage of labor for 21⁄2 hours. The fetal head is at 4 station and the fetal heart is showing mild late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the fol- lowing actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the woman to push between contractions. 3. Assess the fetal heart rate after each contraction. 4. Advise the woman to refuse the use of forceps.

3 1. A consent for the use of forceps is not required. The general consent for vaginal delivery covers this possibility. 2. Even when forceps are applied, the woman should push only during contractions. 3. The FH should always be assessed after each contraction during stage 2. Plus, this baby is especially at risk because the stage is prolonged and the physician is using forceps for delivery. 4. It is inappropriate for the nurse to advise the client to refuse the use of forceps. TEST-TAKING TIP: This is an excellent ex- ample of a medically indicated use of for- ceps. The woman is likely fatigued from pushing for over 2 hours, the presenting part is at the pelvic floor, and the baby is showing signs of fetal distress. It would be advisable to deliver this baby in a timely fashion. The use of forceps should result in a speedy delivery.

A client with an internal fetal monitor catheter in place has just received IV butor- phanol (Stadol) for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Diminished short- and long-term variability. 4. Accelerations after contractions.

3 1. Early decelerations are related to head compression. They would not be expected as a result of Stadol administration. 2. Late decelerations are related to uteropla- cental insufficiency. They would not be ex- pected as a result of Stadol administration. 3. Absent variability would be expected as a result of Stadol administration. 4. Postcontraction accelerations are seen in a well and fully alert fetus. The nurse would expect the incidence of accelerations to di- minish as a result of Stadol administration. TEST-TAKING TIP: Variability is an indicator of fetal well-being. It reflects the competi- tion between the sympathetic and the parasympathetic nervous systems' effects on the fetal heart rate. When the CNS is depressed from the administration of a narcotic analgesic, therefore, the nurse should expect to see diminished variability.

A client had an epidural inserted 2 hours ago. It is functioning well, the client is he- modynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Ausculate lungs.

3 1. The client is hemodynamically stable. Her blood pressure needs to be assessed about every 1 hour at this time. 2. The client is hemodynamically stable. Her pulse needs to be assessed about every 4 hours at this time. 3. The client's bladder should be palpated. 4. There is nothing in the scenario that implies that the client's lung fields need to be assessed. TEST-TAKING TIP: There are three very im- portant reasons the client's bladder should be assessed. First, clients receive at least 1 liter of fluid immediately before the insertion of an epidural. Within a 2-hour period, it is likely that the woman's bladder has become full. Second, clients are unable to feel when they need to urinate with an epidural in place. Third, a full bladder can impede fetal descent.

There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3P0020, in active labor. 2. Age 22, G1P0000, eclampsia. 3. Age 25, G4P3003, last delivery by cesarean section. 4. Age 32, G2P0100, first baby died during labor.

3 A woman, no matter what age, who has had a previous cesarean section is at risk for uterine rupture. When babies are birthed via cesarean section, the surgeon must create an incision through the uter- ine body. The muscles of the uterus have, therefore, been ligated and a scar has formed at the incision site. Scars are not elastic and do not contract and relax the way muscle tissue does. A vaginal birth after cesarean (VBAC) section can only be performed if the woman had a low flap (Pfannenstiel) incision in the uterus during her previous cesarean section.

The results from a fetal blood sampling test are reported as pH 7.22. The nurse in- terprets the results as: 1. The baby is severely acidotic. 2. The baby must be delivered as soon as possible. 3. The results are equivocal warranting further sampling. 4. The results are within normal limits.

3 Further testing is indicated. Some practitioners per- form fetal scalp sampling when there is a decrease in fetal heart variability. A nor- mal fetal pH is defined as 7.25 to 7.35. An acidotic fetus has a pH that is less than 7.20. When the pH is between 7.20 to 7.25, the value is considered to be equivocal with a need for further testing. Usually interventions are instituted— oxygen applied, position changed, IV fluid increased—and another sampling is done in 10 to 15 minutes.

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta.

3 Placental abruption is associated with maternal illicit drug use. Crack cocaine is a powerful vasoconstrictive agent. The chorionic villi atrophy as a result of the vasoconstrictive effects of the drug. Placental abruption, when the placenta detaches from the decidual lining of the uterus, is therefore of particular concern.

Given the fetal heart rate pattern shown below, which of the following interven- tions should the nurse perform first? 1. Increase the intravenous drip rate. 2. Apply oxygen by face mask. 3. Turn the woman on her side. 4. Report the tracing to the obstetrician.

3 Repositioning the woman is the first action that should be taken. To answer this ques- tion, the test taker must fully understand the etiology of the decelerations. Vari- able decelerations occur as a result of umbilical cord compression. It is possi- ble, therefore, that if the mother is posi- tioned differently, the pressure will be shifted and the decelerations will resolve. If the first position change does not re- solve the problem, the nurse should try additional position changes. It is also im- portant for the nurse to do all that he or she can to resolve the problem—by ad- ministering oxygen and increasing the IV drip rate—before calling the physician. To do otherwise could constitute patient abandonment.

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a con- traction while another occurred 10 seconds after the contraction and a third oc- curred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.

3 The contractions described in the scenario result from cord compression (variable decelerations) First, the test taker should be able to interpret fetal heart tracings both visually and verbally. This includes baseline data as well as accelera- tion and deceleration changes. Second, the test taker should know the etiology of each of the tracings. Third, the test taker should know the appropriate nurs- ing intervention related to each tracing.

A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days, "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman's bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman's uterus and monitor for ballottement.

3 The fluid should be assessed with nitrazine paper. Nitrazine paper is an- other name for litmus paper. It detects the pH of fluid. Amniotic fluid is alkaline while urine is acidic. If the paper turns a dark blue, the nurse can conclude that the membranes have ruptured and that the woman is leaking amniotic fluid.

A woman, 40 2⁄7 weeks' gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units oxytocin (Pitocin) to be di- luted in 1000 mL D51⁄2 NS. The order reads: administer oxytocin IV at 0.5 milliunits per min. Calculate the drip rate for the infusion pump to be programmed. __________ mL/hr.

3 mL/hr. The nurse must do a number of calculations to determine the pump drip rate in this client. First, the nurse must determine how many milliunits are in 1000 mL of fluid: 10 units in 1000 mL 10,000 milliunits in 1000 mL Next, the nurse must determine how many milliunits are to be infused per hour (since pumps are always calibrated mL/hour): 0.5 millliunits per minute 30 milliunits per 60 minutes Finally, the nurse must do a ratio and pro- portion to determine the mL per hour: 10,000 milliunits/1000 mL =30 milliunits/x mL x 3 mL/hr

Which of the following situations in a fully dilated client would warrant the need for a forceps delivery? 1. Maternal history of asthma. 2. Right mentum posterior position and -1 station. 3. Transverse fetal lie. 4. Fetal heart rate of 60 beats per minute.

3, 4 3 and 4 are correct. 1. Asthmatic clients, although needing careful monitoring, are able to deliver vaginally. 2. It would be appropriate to deliver a baby whose position and station are ROP and +4 via forceps. 3. A baby in transverse lie is physically in- capable of delivering vaginally. 4. It is not appropriate to deliver a baby vaginally who is at -1 station. The baby has yet to engage. This baby would likely be delivered by cesarean section for prolonged fetal distress. 5. Clients with cerebral palsy may be deliv- ered with forceps. TEST-TAKING TIP: It is unsafe to use forceps to deliver a baby when the baby's station is above +2. When the baby is above that sta- tion, it is unknown whether or not there is sufficient room in the pelvis for the baby to pass. If there should be too little space, very serious fetal complications could arise, including fractured skull and subdural hematoma.

A nurse is caring for a gravid client who is G1P0000, 35 weeks' gestation. Which of the following would warrant the nurse to notify the woman's health care practi- tioner that the client is in preterm labor? 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Contraction duration of 30 seconds.

3, 4 3 and 4 are correct. 1. The presence of contractions without cer- vical change is not diagnostic of preterm labor. 2. Preterm labor is defined as cervical ef- facement of greater than 80%. Although the client has effaced slightly, a diagnosis of preterm labor cannot as yet be made. 3. The dilation of 3 cm is indicative of preterm labor. 4. A cervical length of 2 cm is indicative of preterm labor. 5. The presence of 30-second-duration contractions is not diagnostic of preterm labor. TEST-TAKING TIP: Preterm labor is defined as labor before 38 weeks' gestation with 3 or more contractions occurring within a 30-minute period PLUS cervical change of one of the following: cervical effacement greater than 80%, cervical dilation greater than 1 cm, or cervical length of less than 2.5 cm. The change in cervical length is diagnosed by transvaginal ultrasound.

An anesthesiologist informs the nurse that a woman for cesarean section will have the procedure under general anesthesia with postoperative patient-controlled anal- gesia rather than under continuous epidural infusion. Which of the following would warrant this decision? 1. The woman has a history of drug addiction. 2. The woman is allergic to morphine sulfate. 3. The woman is a thirteen-year-old adolescent. 4. The woman has had surgery for scoliosis.

4 1. A history of drug addiction is not a contraindication for epidural anesthesia. 2. An allergy to morphine is not a contraindi- cation for epidural anesthesia. 3. Adolescence is not a contraindication for epidural anesthesia. 4. A history of scoliosis surgery is a con- traindication for epidural anesthesia. TEST-TAKING TIP: Scoliosis is a defect in the growth of the thoracic and lumbar spine. The surgery is, therefore, performed on the vertebrae of the spinal column. Any spinal surgery is a contraindication to the administration of regional anesthesia.

A pregnant woman, G3P2002, had her two other children by cesarean section. Which of the following situations would mandate that this delivery also be by cesarean? 1. The woman refuses to have a regional anesthesia. 2. The woman is postdates with intact membranes. 3. The baby is in the occiput posterior position. 4. The previous uterine incisions were vertical.

4 1. A vaginal delivery can be performed with no anesthesia. 2. A postdates pregnancy is not an absolute indication for a cesarean delivery. 3. An occiput posterior position is not an indication for a cesarean delivery. 4. The presence of vertical incisions in the uterine wall is an absolute indication for a cesarean delivery. TEST-TAKING TIP: The muscle tissue that contracts during labor is located in the fundal region of the uterus. A vertical inci- sion into the uterus ligates fundal tissue. The scar that forms from the incision is nonelastic, putting the client at risk of uterine rupture. Having had a previous vertical uterine incision, therefore, is an absolute indicator for future cesarean delivery. In addition, some physicians also encourage clients who have had low-flap (Pfannenstiel) incisions into the uterus to have all subsequent children delivered via cesarean section. (It is important to note that the type of incision that the surgeon used to open the skin is not necessarily the type of incision used to open the uterus.)

A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station 2. 2. 38 weeks' gestation. 3. Reactive NST. 4. Previous cesarean section.

4 1. Station -2 is not a contraindication for external version. 2. Preterm gestational age is not a contraindi- cation for external version. 3. Reactive NST is not a contraindication for external version. 4. Previous cesarean section is a con- traindication for external version. TEST-TAKING TIP: During external version, the health care practitioner moves the fetus from a malpresentation—usually breech— to a vertex presentation. To accomplish the movement, the physician manually palpates the fetus externally through the mother's abdominal and uterine walls. Because significant stress is placed on the uterine body, the presence of a cesarean scar is a contraindication to the procedure.

A 40-week-gestation client has an admitting platelet count of 90,000 mm3 and a hematocrit of 29%. Her lab values 1 week earlier were platelet count 200,000 mm3 and hematocrit 37%. Which additional abnormal lab value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).

4 1. The nurse would expect to see an elevated serum creatinine level, not a decreased level. 2. The nurse would expect to see a low RBC count, not an elevated one. 3. The nurse would expect to see an ele- vated alkaline phosphatase level, not a decreased one. 4. The nurse would expect to see an elevated ALT. TEST-TAKING TIP: This is a difficult, criti- cal thinking question. This client is ex- hibiting signs of HELLP syndrome (low platelets and hemolysis). Even though severe preeclampsia is not a part of the HELLP constellation, a client in severe preeclampsia would have poor renal function (elevated serum creatinine level). With hemolysis, the nurse would expect to see a drop in the RBC count, and with a damaged liver, an elevated alkaline phosphatase level as well as an elevated ALT level.

A woman, G3P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop her infusion. 2. Give her oxygen. 3. Change her position. 4. Monitor her labor.

4 It is appropriate to monitor the woman's labor Even if the test taker were unfamiliar with a normal contrac- tion pattern—as seen in the stem of the question—if he or she knew that the fetal heart pattern is normal, he or she could deduce the correct answer. Three of the responses infer that the nurse should take action because of a complication. Only "4" indicates that the nurse should continue monitoring the labor. In this situation, the one response that is different from the others is the correct answer.

A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses should the nurse make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual smell." 3. "Your labor should start pretty soon." 4. "Have you felt the baby move since the membranes broke?"

4 The most important information is the health and well-being of the fetus. Fetal movement indicates that the baby is alive. There are two concerns in this scenario: the fact that the mem- branes just ruptured and the smell of the fluid. The nurse should, therefore, con- sider two possible problems: possible prolapsed cord, which may occur as a result of the rupture of the amniotic sac, and possible infection, which may be in- dicated by the smell. Normal fetal move- ment will give the nurse some confidence that the cord is not prolapsed. This is the first question that should be asked. Then, the client should be encouraged to go to the hospital to be assessed for pos- sible infection and signs of labor.

A primigravid client received Prepidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place woman on her side. 4. Monitor for onset of labor.

4 The nurse should monitor this client for the onset of labor. The Bishop score indi- cates the inducibility of the cervix of a client. Five signs are assessed—cervical position, cervical dilation, cervical efface- ment, cervical station, and cervical con- sistency. A total score is calculated. A primigravid cervix is considered in- ducible when the Bishop score is 9 or higher. A multigravid cervix is considered inducible when the Bishop score is 5 or higher.

To reduce possible side effects from a cesarean section under general anesthesia, clients are routinely given which of the following medications? 1. Antacids. 2. Tranquilizers. 3. Antihypertensives. 4. Anticonvulsants.

1 1. Antacids are routinely administered presurgically to cesarean section clients. 2. Tranquilizers are not routinely administered presurgically to cesarean section clients. 3. Antihypertensives are not routinely administered presurgically to cesarean section clients. 4. Anticonvulsants are not routinely adminis- tered presurgically to cesarean section clients. TEST-TAKING TIP: Progesterone is a mus- cle relaxant. Because pregnant women have elevated levels of progesterone, their cardiac sphincters are relaxed. They are at especially high risk, therefore, for 3809_Ch09_279-318 14/02/13 4:49 PM Page 310 vomiting during surgery. To decrease the acidity of the vomitus in case of aspi- ration, gravid women are routinely given antacids presurgically. 74. An "X" will be placed

A woman has received Prepidil (dinoprostone gel) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.

1 A common side effect of Prepidil is diarrhea and labor contractions are often first felt in the back. Prepidil (dinoprostone) is a prostaglandin medication used to ripen the cervix for induction. Gastroin- testinal side effects are commonly seen when prostaglandin is used since the gastrointestinal system is adjacent to the vagina where the medication is inserted. In addition, the nurse must be watchful for signs of labor.

A client has been diagnosed with water intoxication after having received IV oxy- tocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.

1 These are the classic signs of water intoxication. Clients who receive oxytocin over a long period of time are at high risk for water intoxication. The oxy- tocin molecule is similar in structure to the antidiuretic hormone (ADH) molecule. The body retains fluids in response to the medication much the same way it would in response to ADH. The nurse, therefore, should carefully monitor intake and output when clients are induced with oxytocin.

The nurse in the obstetrician's office is caring for four 25-week-gestation white prenatal clients who are carrying singleton pregnancies. With which of the follow- ing clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? 1. 38-year-old registered nurse in an abusive relationship. 2. 32-year-old secretary whose first child was born at 42 weeks' gestation. 3. 26-year-old attorney whose baby has a two-vessel cord. 4. 20-year-old college student with a history of long menstrual periods.

1, 2, 5 1, 2, and 5 are correct. 1. This client is high risk for PTL because she is over 35 years of age and in an abusive relationship. 2. A previous preterm delivery places a client at increased risk of preterm labor. 3. The presence of a two-vessel cord does not place a client at increased risk of preterm labor. 4. A history of long menstrual periods does not place a client at increased risk of preterm labor. 5. A woman who smokes cigarettes is at high risk for preterm labor. TEST-TAKING TIP: Even though medical and psychosocial histories are not ab- solute predictors of preterm labor, there are a number of factors that have been shown to place clients at risk, including pregnancy history of multiple gestations; previous preterm deliveries; cigarette smoking and/or illicit drug use; a number of medical histories like diabetes and hypertension; and social issues like adolescent pregnancy and domestic violence.

The nurse is monitoring a woman ,G2P1001, 41weeks 'gestation, in labor .A 12p.m. assessment revealed: cervix, 4 cm; 80% effaced; 3 station; and FH 124 with moder- ate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced; 3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; 3 station; and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1. Labor is progressing well. 2. The woman is likely carrying a macrosomic fetus. 3. The baby is in fetal distress. 4. The woman will be in second stage in about five hours.

2 Since the presenting part is not de- scending into the birth canal, the nurse can logically conclude that the baby is macrosomic. The test taker must carefully analyze the results of the three vaginal examinations. The fetal heart is virtually unchanged: the rate is within normal limits and the variability is nor- mal. There is no sign of fetal distress. The dilation and effacement are chang- ing, but the lack of progressive descent of the presenting part is unexpected When babies are too big to fit through a client's pelvis, they fail to descend. That is the conclusion that the nurse must make from the findings.

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4oF.

2 The baseline fetal heart rate has dropped over 20 bpm. This finding warrants that the oxytocin be stopped. The test taker must de- termine which of the vital signs is unsafe in the presence of oxytocin. Oxytocin in- creases the contractility of the uterine muscle. When the muscle contracts, the blood supply to the fetus is diminished. A drop in fetal heart rate, therefore, is indicative of poor oxygenation to the fetus and is unsafe in the presence of oxytocin

The doctor writes the following order for a 31-week-gravid client with sympto- matic placenta previa: weigh all vaginal pads and estimate blood loss. The nurse weighs one of the client's saturated pads at 24 grams and a dry pad at 4 grams. How many milliliters (mL) of blood can the nurse estimate the client has bled? __________ mL.

20 mL of blood The nurse must remember that 1 mL of fluid weighs approximately 1 gram. The nurse can estimate, therefore, that the blood loss is: 24 -4 = 20 mL of blood

A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

3 1. Oxytocin will increase the client's contrac- tions. The administration of this medica- tion is inappropriate at this time. 2. Methergine should never be administered unless the placenta is already delivered. 3. Magnesium sulfate is a tocolytic agent. It would be appropriate for this med- ication to be administered at this time. 4. Morphine sulfate is an opioid. There is no rationale for its administration in the scenario. TEST-TAKING TIP: The client in the scenario is exhibiting signs that meet the criteria for preterm labor. The test taker should deduce, therefore, that a tocolytic agent may be ordered in this situation. The only tocolytic agent included in the choices is magnesium sulfate.

A laboring woman, who has developed an apparent amniotic fluid embolism, is not breathing and has no pulse. In addition to calling for assistance, which of the follow- ing actions by the nurse, who is alone with the patient, is appropriate at this time? 1. Perform cardiac compressions and breaths in a 15 to 2 ratio. 2. Provide chest compressions at a depth of 3 inches. 3. Compress the chest at the lower 1⁄2 of the sternum. 4. Provide rescue breaths over a 10-second time frame.

3 The lower half of the sternum should be compressed when delivering car- diac compressions. The American Heart Association frequently revises cardiopul- monary resuscitation (CPR) guidelines. The responses above reflect the 2005 guidelines. The test taker should make sure that he or she is familiar with cur- rent protocols. In addition to the re- sponses above, it is important for the rescuer to tilt the woman slightly toward the left to decrease the compression of the gravid uterus on the aorta and vena cava. (http://circ.ahajournals.org/content/ vol112/24_suppl/)

A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous ampicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery.

3 Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG. Although this is a woman who is in labor, the nurse must anticipate the needs of the neonate after delivery. Since it is recommended that the baby receive the medication within a restricted time frame, it is especially im- portant for the nurse to be proactive and obtain the physician's order.

Which of the tracings shown below would the nurse interpret as indicative of uteroplacental insufficiency?

3 his monitor tracing shows a fetal heart baseline with minimal variability and with late decelerations. These de- celerations are related to uteroplacen- tal insufficiency. A tracing that depicts decelerations that begin late in a con- traction and return to baseline well past the time that the contraction ends are called late decelerations. Late decelera- tions are related to poor uteroplacental blood flow.

The nurse is assessing the Bishop score on a postdates client. Which of the follow- ing measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilatation. 4. Fetal station. 5. Cervical position.

3,4,5 3, 4, and 5 are correct. 1. Gestational age is not part of the Bishop score. 2. The status of the membranes is not part of the Bishop score. 3. Cervical dilation is part of the Bishop score. 4. Fetal station is part of the Bishop score. 5. Cervical position is part of the Bishop score. TEST-TAKING TIP: The Bishop score is calculated to determine the inducibility of the cervix. Although gestational age may be an indication for calculating the score, it does not have a direct impact on the status of the cervix. Similarly, although rupture of the membranes may be an indication for calculating the score, that fact does not have a direct impact on the status of the cervix.

A client, G3P2002, is immediately postexternal version. The nurse monitors this client carefully for which of the following? 1. Decreased urinary output. 2. Elevated blood pressure. 3. Severe occipital headache. 4. Variable fetal heart decelerations.

4 1. A change in urinary output postexternal version is unlikely. 2. An elevation in the maternal blood pressure postexternal version is unlikely. 3. The presence of severe occipital headache postexternal version is unlikely. 4. The nurse should monitor the client carefully for variable fetal heart decelerations. TEST-TAKING TIP: The umbilical cord can become compressed during an external version. Variable decelerations are caused by umbilical cord compression. If the cord were to become compressed, the nurse would note variable decelerations on the fetal heart monitor tracing.

A nurse is caring for four clients on the labor and delivery unit. Which of the fol- lowing actions should the nurse take first? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is post-spontaneous abortion. 3. Assess the patellar reflexes of a client with mild preeclampsia. 4. Check the fetal heart rate of a client who just ruptured membranes.

4 The priority action for this nurse is to assess the fetal heart rate of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an obstetric emergency. Identifying the priority action is the most difficult thing that nurses must do. The nurse must deter- mine which of the situations is most life threatening. Of the four choices above, prolapsed cord is life threatening to the fetus. None of the other situations, as stated in the question, is life threatening to either the mother or the fetus.

The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? 1. Late decelerations. 2. Hyperthermia. 3. Hypotension. 4. Early decelerations.

1 This baby is high risk for the develop- ment of late fetal heart decelerations. The test taker must at- tend to all important information in the question. The gestational age of this fe- tus is 43 weeks. The baby and placenta, therefore, are both postdates. Placental function usually deteriorates after 40 weeks' gestation. Since late decelerations result from poor uteroplacental blood flow, the nurse should monitor this client carefully for late decelerations.

A nurse has been assigned to circulate during the cesarean section of triplets. Which of the following actions should the nurse take before the birth of the babies? Select all that apply. 1. Count the number of sterile sponges. 2. Document the time of the first incision. 3. Notify the pediatric staff. 4. Perform a sterile scrub. 5. Assemble the sterile instruments.

1,2,3 1, 2, and 3 are correct. 1. The circulating nurse should count the sterile sponges. This is done together with the scrub nurse. 2. The circulating nurse must document in the medical record all key events that occur during the surgery, includ- ing the time of the first incision. 3. The circulating nurse should notify the pediatric staff. There should be one resuscitation team assembled in the delivery room for each baby that will be delivered. 4. It is not necessary for the circulating nurse to perform a sterile scrub. He or she is a nonsterile member of the operative team. 5. It is not appropriate for the circulating nurse to assemble the sterile instruments because he or she is not sterile. TEST-TAKING TIP: The circulating nurse is responsible for coordinating the activity in the operating room. He or she is the only member of the team who is able to move freely throughout the room to make telephone calls, obtain needed supplies, maintain the documentation record, and so on. When multiple babies are being birthed, he or she is especially important. The more babies who are birthed at once—e.g., twins, triplets—the more vulnerable the babies are at birth. Multiple-gestation babies are often born preterm and small-for-gestational age. There must be a resuscitation team available for each baby in case emergent care is needed.

The nurse turns off the oxytocin (Pitocin) infusion after a period of hyperstimulation. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 120 seconds. 4. Attitude flexed.

2 A frequency pattern of every 3 minutes is ideal. This question is asking the test taker to evaluate an expected outcome. When a nurse intervenes, he or she is expecting a positive outcome. In this situation, the nurse is determining whether or not the action has reversed the hyperstimulation that developed from oxytocin administration. The nor- mal contraction frequency is evidence of a positive outcome.

A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes? 1. Intravenously. 2. Orally. 3. Endocervically. 4. Intrathecally.

3 Prepidil is administered endocervi- cally. Prostaglandins, hormone-like substances that mediate a wide range of physiological functions, do so locally. Prepidil, therefore, is ad- ministered adjacent to the cervix where it acts to soften the cervix in preparation for dilation and effacement.

A woman, G3P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be de- livered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.

At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like provid- ing oxygen by face mask and reposi- tioning the client, would also be indicated. If the client's practi- tioner is convinced that surgery is the only appropriate intervention, he or she could get a court order to mandate the woman to accept surgery. The nurse's role at this point, however, is to provide the client with care in a nonthreatening, compassionate manner. The nurse must acknowledge and accept the client's legal right to refuse the surgery.

A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).

1 1. The nurse must have calcium gluconate in the client's room. 2. Morphine sulfate should not be in the client's room. It is a controlled substance. 3. Narcan does not have to be in the client's room. 4. Demerol should not be in the client's room. It is a controlled substance. TEST-TAKING TIP: Calcium gluconate is the antidote for magnesium sulfate toxic- ity. It is very important the test taker know that, if needed, calcium gluconate must be administered very slowly. If calcium gluconate is administered rap- idly, the client may experience sudden convulsions.

A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes 1. 4. Blood pressure 140/90.

1 1. This client has likely developed dissem- inated intravascular coagulation (DIC). The nurse should watch for pink-tinged urine. 2. Early decelerations are noted normally during late first stage as well as the second stage of labor. They are unrelated to devi- ations in PT and PTT. 3. The reflex changes are unrelated to the lab deviations. 4. The blood pressure is consistent with mild preeclampsia. TEST-TAKING TIP: The test taker must be familiar with the implications of standard blood tests like PT and PTT. Even if the nurse did not know that clients who are di- agnosed with HELLP syndrome are at high risk for DIC, he or she should know that clients with prolonged PT and PTT times are at high risk for spontaneous bleeds.

The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.

1 Induction is contraindicated in trans- verse lie. A baby in the transverse lie is in a scapular presentation. The baby is incapable of being birthed vaginally. Whenever a vaginal birth is contraindi- cated, induction is also contraindicated.

A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take? 1. Check dilation and effacement. 2. Prepare the client for surgery. 3. Place the bed in Trendelenburg position. 4. Check the biophysical profile results.

1 It is appropriate for the nurse to assess the client's dilation and effacement. Although cesarean deliveries are recommended to be performed when a client has an active case of herpes simplex, surgical delivery is not indicated when no lesions are present. Clients who have histories of herpes with no current outbreak, there- fore, are considered to be healthy labor- ing clients who may deliver vaginally.

A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? 1. Breech presentation. 2. Station 3. 3. Oligohydramnios. 4. Dilation 2 cm.

1 When a baby is in the breech presen- tation, there is increased risk of pro- lapsed cord. When babies are in the breech presentation, the cord sometimes slips past the baby and becomes the pre- senting part. The weight of the baby then compresses the cord, preventing the baby from being oxygenated. Additional situations that are at high risk for cord prolapse are hydramnios, premature rup- ture of membranes, and negative fetal station.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hyper- tension and oligohydramnios. She is contracting q 3 min 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart brady- cardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

1 Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip. Oxytocin stimulates the contractility of the uterine muscle. When the muscle is contracted, the blood flow to the placenta is reduced. Whenever there is evidence of fetal com- promise and oxytocin is being infused, the intravenous should be stopped immediately in order to maximize placental perfusion.

A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.

2 The nurse should notify the health care practitioner of the client's request. The test taker should be aware of two important facts: pain is the fifth vital sign as identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and actions must be taken to reduce drug abusers' pain in the same manner that non-drug abusers' pain is managed. Although it is strongly discouraged for women to take illicit drugs when preg- nant, the nurse must maintain his or her caring philosophy and provide unbiased care to addicted clients.

A 30-year-old G2P0010 in preterm labor is receiving nifedipine (Procardia). Which of the following maternal assessments noted by the nurse must be reported to the health care practitioner immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2000 cc.

3 1. Mild tachycardia is an expected, but benign, side effect. 2. Wakefulness is an expected, but benign side effect. 3. Audible rales should be reported to the health care practitioner. 4. Daily output of 2,000 mL is within nor- mal. TEST-TAKING TIP: The presence of audi- ble rales is indicative of pulmonary edema, a serious side effect related to the medication. The pulmonary edema may be caused by the development of congestive heart failure. Whenever a client is on nifedipine, the nurse should regularly monitor the client's lung fields.

A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1. Administer bethamethasone (Celestone) 12 mg IM daily times 2. 2. Maintain strict bed rest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 cc/hr).

3 An order to assess the woman's cervi- cal dilation should be questioned. If the nurse were to as- sess the cervical dilation of a client with complete previa, he or she could punc- ture the placenta. Vaginal examinations are absolutely contraindicated with a diagnosis of complete placenta previa. Betamethasone is administered to pro- mote maturation of the baby's lungs.

A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures.

4 1. Completely depressed patellar reflexes are a sign of magnesium sulfate toxicity. This is not an expected outcome. 2. A normal urinary output is important, but it is not an expected outcome related to magnesium sulfate administration. 3. A normal respiratory rate is important, but it is not an expected outcome related to magnesium sulfate administration. 4. The absence of seizures is an expected outcome related to magnesium sulfate administration. TEST-TAKING TIP: Eclamptic clients have seized. Magnesium sulfate is ordered and administered to these clients because it is an anticonvulsant. An expected outcome of its administration, therefore, is that the client will have no more seizures.

Four women request to labor in the hospital bathtub. Which of the women is at in- creased risk from the procedure? 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with prolonged rupture of the membranes.

4 A woman with prolonged rupture of the membranes should be discouraged from laboring in the water bath. Hydrotherapy is an ex- cellent complementary therapy for the laboring woman. The warm water is re- laxing and many women find that their pain is minimized. Women with pro- longed rupture of the membranes, how- ever, are at high risk for intrauterine in- fection and, if they labor in the tub, pathogens can ascend into the uterine cavity more easily.

The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler's position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.

4 Increasing the IV rate helps to im- prove perfusion to the placenta. Because the fetus is being oxygenated via the placenta, it is essential that in cases of fetal distress, the amount of oxygen perfusing the pla- centa be maximized. That requires high concentrations of oxygen being adminis- tered via mask, blood volume being increased by increasing the IV drip rate, and cardiac blood return being maxi- mized by positioning the client in order to remove pressure from the aorta and the vena cava.

A client is receiving terbutaline (Brethine) for preterm labor. Which of the follow- ing findings would warrant stopping the infusion? 1. Fetal heart rate 210 bpm. 2. Maternal heart rate 60 bpm. 3. Early decelerations. 4. Beat-to-beat variability.

4, 5 4 and 5 are correct. 1. A decrease in the frequency of the contrac- tions from q 3 min × 90 sec to q 2 min × 60 is the expected, therapeutic response. This change does not warrant stopping the medication. 2. A change in fetal heart rate pattern from no decelerations to early decelerations is a benign change. This change does not warrant stopping the medication. 3. Minimal variability is a sign of poor fetal oxygenation, whereas moderate variabil- ity is a sign of good fetal oxygenation. This change does not warrant stopping the medication. 4. When the fetal heart rate pattern is greater than 200 bpm, the medication should be stopped. 5. Terbutaline is contraindicated when the membranes have ruptured prematurely. TEST-TAKING TIP: Terbutaline, a beta agonist, stimulates the "fight or flight" response in the mother and in the fetus. The fetal heart rate, therefore, increases in response to the medication. When the rate is too high, however, there is insufficient time for the blood to enter the heart, which leads to a drop in car- diac output.

A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultates the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the health care provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask.

1 1. The nurse should assess the fetal heart and the maternal pulse simultaneously. 2. It is not necessary to notify the doctor at this time. 3. It is not necessary to stop the medication at this time. 4. It is not necessary to administer oxygen to the mother at this time. TEST-TAKING TIP: Because the medication should increase both the mother's pulse and fetal heart rates, it is likely that the fetal monitor is mistakenly registering the maternal pulse rather than the fetal heart rate. If the pulsations are the same when the radial pulse of the mother and the fetal heart are monitored simultane- ously, the nurse can determine that, indeed, the mother's pulse rate is being monitored.

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the fol- lowing actions should the nurse perform first? 1. Put the client in the knee chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.

1 The first action the nurse should take is to place the woman in the knee chest position. The weight of the fetus on the prolapsed cord can rapidly result in fetal death. Therefore, the nurse must act quickly to relieve the pressure on the cord. Additional actions that can take pressure off the cord are placing the client in the Trendelenburg position and pushing the head off the cord with a gloved hand. This situation is an obstet- ric emergency.

Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.

1 Fundal heights increase during preg- nancy approximately 1 cm per week. When a placental abruption occurs, the height increases hour by hour. When a placenta abrupts, it separates from the uterine wall. As a result, a pool of blood appears behind the placenta. The pool of blood takes up space leading to an increase in the size of the uterus. The fundal height increases as the uterine size increases.

A physician writes the following order—administer ampicillin 1 Gm IV q 4 h until delivery—for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacterium is sexually transmitted. 4. The bacterium causes puerperal sepsis.

2 1. Although the bacterium can cause chorioamnionitis, this is not the rationale for administering the antibiotic during labor. 2. Babies are susceptible to neonatal sepsis from vertical transmission of the bacteria. 3. The bacteria are not sexually transmitted. Approximately one third of all women carry group B strep as normal vaginal and/or rectal flora. 4. Puerperal sepsis is usually caused by Staphylococcus aureus or group A strep. TEST-TAKING TIP: At approximately 36 weeks' gestation, pregnant women are cultured for group B strep. If they culture positive, standard protocol is to administer a broad-spectrum antibiotic IV q 4 hours from the time her mem- branes rupture until delivery. That action markedly decreases the vertical transmission of the bacteria to neonates.

The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and head board. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler's position.

2 1. Eclamptic clients should be monitored for proteinuria, not for the presence of ketones. 2. The side rails of an eclamptic client's bed should be padded. 3. Eclamptic clients should be kept in a low-stimulation environment. 4. There is no rationale for placing the head of an eclamptic patient's bed in high- Fowler's position. TEST-TAKING TIP: Eclamptic clients have had at least one seizure. To protect them from injury during any potential subsequent seizures, the nurse should pad the head- board and the side rails of the client's bed.

The physician has ordered Prepidil (dinoprostone) for 4 gravidas at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. G1P0000 contracting every 20 minutes 30 seconds. 4. G6P3202 with blood pressure 140/90 and pulse 92.

2 This client's fetus is already showing signs of fetal distress. Induction in- creases the risk of fetal injury. It is important to re- member that although the fetus of a pregnant woman may be at term, it is not always safe for labor contractions to be stimulated. Although Prepedil is not di- rectly used for induction, it is an agent that promotes cervical ripening in prepa- ration for labor. A baby who is exhibiting signs of poor uteroplacental blood flow is likely to be compromised further by the addition of the medication.

During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? 1. Into the musculature of the buttock. 2. Through the urinary meatus. 3. Through the rectal sphincter. 4. Into the head of the clitoris.

3 1. A laceration into the musculature of the buttocks is defined as a second-degree laceration. 2. A fourth-degree laceration extends through the rectal sphincter. 3. A fourth-degree laceration extends through the rectal sphincter. 4. A fourth-degree laceration extends through the rectal sphincter. TEST-TAKING TIP: One of the many comp - lications that can occur with the delivery of a macrosomic baby is a perineal lacera- tion. If the laceration is extensive and it progresses through the rectal sphincter, it is defined as a fourth degree. As a result, this client is at high risk for the development of a vaginal-rectal fistula.

The health care practitioner performed an amniotomy 5 minutes ago on a client, G3P1011, 41 weeks' gestation, 4 station, and ROP position. The fetal heart rate is 140 with variable decelerations. The fluid is green tinged and smells musty. The nurse concludes that which of the following situations is present at this time? 1. The fetus is postterm. 2. The presentation is breech. 3. The cord is prolapsed. 4. The amniotic fluid is infected.

3 1. The fetus is full-term. Post-term is de- fined by most texts as 42 weeks' gestation or later and by some as 41 weeks' gesta- tion or later. 2. The fetus is not breech; it is vertex. 3. It is likely that the cord is prolapsed because the amniotomy was performed when the presenting part was not yet engaged and because variable decelera- tions are seen on the FH monitor. 4. If the client were infected, the amniotic fluid would be foul smelling. TEST-TAKING TIP: The likelihood of a prolapsed cord occurring during an amniotomy increases when the fetal presenting part is in negative station. As the amniotic fluid is released from the uterus during the rupture of mem- branes, the cord can slip and precede the fetus. At that time, variable decel- erations are seen on the electronic fetal monitor tracing because the cord is be- ing compressed by the presenting part.

A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).

4 1. Oxytocin (Pitocin) is a medication that contracts the uterus. It would not be administered prior to an external version. 2. Ergonovine (Methergine) is a medication that contracts the uterus. It should never be administered prior to the delivery of the placenta. 3. Betamethasone (Celestone) is a steroid that is administered to the mother of a preterm infant to stimulate the maturation of the fetus's lung fields. It would not be administered prior to an external version. 4. Terbutaline (Brethine) is a smooth, muscle-relaxing agent. It would be administered prior to an external version. TEST-TAKING TIP: It is important that the uterine muscle not impede the physician's manipulations during an external version. To facilitate the movement, therefore, a muscle relaxant is administered. Terbu- taline is one relaxing agent that is used by obstetricians.

A woman is delivering a macrosomic baby. The midwife is performing a mediolat- eral episiotomy. Draw a line where the episiotomy is being performed.

invert V The test taker should have drawn an epi- siotomy that is about 45° from the midline. The direction in which the episiotomy is performed is usually dependent upon whether the practitioner is left-handed or right-handed. TEST-TAKING TIP: Although the nurse does not perform the episiotomy, he or she is responsible for documenting the procedure in the medical record as well as for evaluating the incision postpartum. The mediolateral episiotomy is often performed when a macrosomic baby is being birthed. If a midline episiotomy were performed, and it were to extend, it could extend to, or even through, the rectal sphincter.

A woman, 32 weeks' gestation, contracting every 3 min 60 sec, is receiving mag- nesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.

1 1. The urinary output should be carefully monitored. 2. Magnesium sulfate administration does not place clients at high risk for a temper- ature elevation. 3. Magnesium sulfate administration does not place clients at high risk for cessation of peripheral circulation. 4. Magnesium sulfate administration does not place clients at high risk for retinal edema. TEST-TAKING TIP: Even though this client is receiving magnesium sulfate to treat preterm labor and not preeclampsia, the medication still has the same side effects. Magnesium sulfate is excreted through the kidneys. If the urinary output drops, the concentration of magnesium sulfate can rise in the bloodstream. Because, at toxic levels, the client can experience respira- tory depression and cardiac compromise, it is very important for the nurse carefully to monitor the client's urinary output.

The nurse is admitting a 38-week-gestation client in labor. The nurse is unable to find the fetal heart beat with a Doppler. Which of the following comments by the nurse would indicate that the nurse is in denial? 1. "I'll keep trying until I find the heart beat." 2. "I am sure it is the machine. If I change the battery, I'm sure it will work." 3. "I am so sorry. I am not able to find your baby's heart beat." 4. "Sometimes I really hate these machines."

1 1. This is an example of the stage of denial. 2. This is an example of the stage of bargaining. 3. This is an example of the stage of acceptance. 4. This is an example of the stage of anger. TEST-TAKING TIP: It is essential that the test taker be familiar with the concepts of grief and mourning. Everyone who is caring for a couple who experiences a fetal or neonatal loss, as well as the couple themselves, will progress through the stages of grief. It is very important that the nurse realize that grieving is individual and that the stages of grief are never experienced in a linear fashion. Health care staff progress rapidly through the stages, whereas the couple's grief is likely to be delayed.

A 38-week-gestation woman is in labor and delivery with a painful, board-like ab- domen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.

1 A fetal heart check is the appropriate assessment. The clinical scenario is indicative of a placental abruption. Since the only oxygenation available to the fe- tus is via the placenta, the appropriate action by the nurse at this time is to de- termine the well-being of the fetus.

A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begin oxytocin drip rate at 0.5 millunits/min. 2. Assess fetal heart rate every 10 minutes. 3. Weigh all vaginal pads. 4. Assess hematocrit and hemoglobin.

1 An order for oxytocin administration should be questioned. Since the stem states that this woman has symptomatic pla- centa previa, the test taker can conclude that the woman is bleeding vaginally. It would be appropriate to monitor the fetal heart for any signs of distress, to weigh pads to determine the amount of blood loss, and to assess the hematocrit and hemoglobin to check for anemia. Labor, however, is contraindicated since vaginal delivery is contraindicated.

A client, G4P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 3, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6oF, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin suppository? 1. Bishop score of 10. 2. Fetal heart of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.

4 A contraction frequency of 1 minute, even with a short duration, would warrant the removal of the medication. A frequency of 1 minute, even if the duration were 30 seconds, would mean that there were only 30 seconds when the uterine muscle was relaxed. This short amount of time would not provide the pla- centa with enough time to be sufficiently perfused. Fetal bradycardia is a likely re- sponse to such a short frequency period.

A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diag- nosis of acute oligohydramnios. The nurse must carefully observe this client for signs of which of the following? 1. Fetal distress. 2. Dehydration. 3. Oliguria. 4. Jaundice.

1 1. The nurse should carefully monitor the client for fetal distress. 2. It is unlikely that the client is dehydrated. 3. It is unlikely that the client will have oliguria. 4. It is unlikely that the client will develop jaundice. TEST-TAKING TIP: Oligohydramnios is often seen in post-term pregnancies. When the placenta begins to deteriorate, the hydration of the baby drops. Because the predominant component of amniotic fluid is fetal urine, when the baby is de- hydrated, the quantity of amniotic fluid drops. Fetal distress can occur because of two factors: cord compression, because there is insufficient fluid to cushion the umbilical cord, and uteroplacental insuf- ficiency, because the placenta is function- ing suboptimally.

The nurse is caring for a 30-week-gestation client whose fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of preeclampsia. 4. How to do fetal kick counts.

2 1. Fetal fibronectin is not related to glucose metabolism. 2. Positive fetal fibronectin levels are seen in clients who deliver preterm. 3. Fetal fibronectin is not related to hyper- tensive conditions. 4. Fetal fibronectin is not related to fetal distress. TEST-TAKING TIP: Fetal fibronectin (fFN) is a substance that is metabolized by the chorion. Although positive during the first half of pregnancy, it is very rare to see positive results between 24 and 34 weeks' gestation unless the client's cervix begins to efface and dilate. It is an excellent pre- dictor of preterm labor (PTL); therefore, many practitioners assess the cervical and vaginal secretions of women at high risk for PTL for the presence of fFN.

A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? 1. Notify the health care practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.

2 Standard precautions are indicated in this situation. Although HPV is a sex- ually transmitted infection and it can, in rare instances, be contracted by the neonate from the mother, the Centers for Disease Control and Prevention do not recommend that cesarean section be performed merely to prevent vertical transmission of HPV (http://www.cdc. gov/std/HPV/common-infection/CDC_ HPV_ClinicianBro_LR.pdf, p 10)

Which of the following is the appropriate nursing care outcome for a woman who suddenly develops an amniotic fluid embolism during her labor? 1. Client will be infection-free at discharge. 2. Client will exhibit normal breathing function at discharge. 3. Client will exhibit normal gastrointestinal function at discharge. 4. Client will void without pain at discharge.

2 The appropriate nursing care out- come is that the client survives and is breathing normally at discharge. At the time of placental separation or sometimes during stage 1 of labor, a small amount of amniotic fluid sometimes seeps into the mother's blood- stream via the chorionic villi. With the contraction of the uterus, the fluid is shunted into the peripheral circulation and forced into the woman's lung fields. If there is meconium or other foreign material in the fluid, the woman's prog- nosis declines. Women who experience forceful, rapid labors are especially at risk for this life-threatening complication.

An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular con- centrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby that is postmature.

2 The practitioner should increase the dosage of oxytocin at a minimum time interval of every 30 minutes. The half-life (the time it takes half of a medication to be metabo- lized by the body) of oxytocin is relatively long—about 15 minutes. And at least 3 half lives usually elapse before thera- peutic responses are noted. Increasing the infusion rate too rapidly, therefore, can lead to hyperstimulation of the uter- ine muscle and consequent fetal distress.

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3 1. A hematocrit of 48% is indicative of hemo- concentration, not of HELLP syndrome. 2. Abnormal potassium levels are not related to HELLP syndrome. 3. Low platelets are consistent with the diagnosis of HELLP syndrome. 4. Abnormal sodium levels are not related to HELLP syndrome. TEST-TAKING TIP: HELLP is the acronym for a serious complication of pregnancy and labor and delivery. The letters repre- sent the following information: H, hemol- ysis; EL, elevated liver enzymes; LP, low platelets. When a client has HELLP syn- drome, the nurse would, therefore, expect to see low hemoglobin and hematocrit lev- els, high aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, and low platelets, as seen in the scenario.

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G3P0020, 17 years of age. 2. G4P2101, cancer survivor. 3. G5P1211, cocaine abuser. 4. G6P0323, 27 weeks' gestation.

3 Cocaine is a powerful vasoconstrictive agent. It places pregnant clients at high risk for placental abruption. It is very important that the test taker not read into any question or response. In the preceding question, all four of the women have had compli- cated pregnancies. The test taker should not presume the cause of the complica- tions when they are not stated but rather look for the answer that does absolutely place the client at high risk for the abruption.

A woman, G3P2002, 42 weeks' gestation, is admitted to the labor suite for induc- tion. A biophysical profile (BPP) report on the client's chart states BPP score of 6 of 10. The nurse should monitor this client carefully for which of the following? 1. Maternal hypertension. 2. Maternal hyperglycemia. 3. Increased fetal heart variability. 4. Late fetal heart decelerations.

4 1. There is nothing in the scenario that indicates that the woman is at high risk for hypertensive illness. 2. There is nothing in the scenario that indicates that the woman is at high risk for hyperglycemia. 3. Increased fetal heart variability is not expected in this situation. 4. The baby is at high risk for late fetal heart decelerations secondary to a postmature placenta. TEST-TAKING TIP: A BPP of 8 or lower indicates that the fetus is in jeopardy. The five assessments that constitute the BPP are nonstress test (NST), fetal movement, fetal breathing, amniotic fluid volume, and fetal tone. Each assessment is given a score of 0 or 2.

A client is in active labor. Which of the following assessments would warrant im- mediate intervention? 1. Maternal PaCO2 of 40 mm Hg. 2. Alpha-fetoprotein values of 2 times normal. 3. 3 fetal heart accelerations during contractions. 4. Fetal scalp sampling pH of 7.19.

4 A fetal scalp pH of 7.19 is indicative of an acidotic fetus. The test taker must read all four responses before choosing the best response. Although "2" includes a value that is not normal, it does not de- scribe a situation that requires the nurse to take immediate action. A fetal scalp sampling pH below 7.20, however, is of immediate concern.

A nurse is monitoring a client who is receiving an amnioinfusion. Which of the fol- lowing assessments is critical for the nurse to make in order to prevent a serious complication related to the procedure? 1. Color of the amniotic fluid. 2. Maternal blood pressure. 3. Cervical effacement. 4. Uterine resting tone.

4 The uterine resting tone should be carefully monitored with an internal pressure electrode during amnioinfusion. Because fluid is being instilled into the uterine cavity, there is potential for the fluid to overload the space. As a result, the uterine resting tone will increase dramatically with the potential that the uterus could rupture. It is critically important, therefore, that the nurse monitor the resting tone fre- quently throughout the procedure.

An insulin-dependent diabetic is in active labor. The physician has written the fol- lowing order: Administer regular insulin 5 units per hour via IV pump. The insulin has been diluted as follows: 50 units/500 mL normal saline. At what rate should the nurse set the pump? __________ mL/hr.

50ml/hr 50 mL/hr 50 units/500 mL = 5 units/x mL 50 x = 5 × 500 50 x = 2,500 x = 50 mL/hr TEST-TAKING TIP: There are two impor- tant things for the test taker to remem- ber in relation to this question. First, this is a ratio and proportion question. The known quantity, 50 units/500 mL, is placed on one side of the equation, and the unknown, 5 units/x mL, is placed on the other side of the equation. With cross multiplication, the correct answer is found. Second, IV pumps are always set at a mL/hr setting. There is, there- fore, no need to know a drop factor. The test taker should also note that the term "units" is written out. The Joint Commission has identified a number of unacceptable abbreviations. U and mU are unacceptable; instead, "units" and "milliunits" must always be written out.

A physician has given a nurse a verbal order to apply cricoid pressure. Which of the following is the likely indication for the action? 1. Forceps delivery. 2. Endotracheal tube insertion. 3. Epidural insertion. 4. Third stage of labor.

2 1. Cricoid pressure is not indicated during forceps deliveries. 2. Cricoid pressure is indicated during endotracheal intubation. 3. Cricoid pressure is not indicated during the administration of epidural anesthesia. 4. Cricoid pressure is not indicated during the third stage of labor. TEST-TAKING TIP: When a client is being intubated, there is a possibility that the stomach contents will be regurgitated. When the vomiting occurs, the client may aspirate the contents. Because the contents are highly acidic, the trachea and lung fields can become damaged. Cricoid pressure helps to reduce the potential for respiratory aspiration of the stomach contents.

Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3 1. A history of hypothyroidism does not place a client who is to receive a beta agonist medication at risk. 2. A history of breast cancer does not place a client who is to receive a beta agonist medication at risk. 3. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order. 4. A history of asthma does not place a client who is to receive a beta agonist medication at risk. TEST-TAKING TIP: The test taker should remember that beta agonists stimulate the "fight or flight" response. The client's heart rate will increase precipitously and there is a possibility that the potassium levels of the client may fall. These side effects place the client with heart disease at risk of heart failure and/or dysrhyth- mias. The client is also at high risk for pulmonary edema and congestive heart failure, so lung field assessments should be done regularly.

The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Spinal clients complain of nausea and vomiting.

3 1. The level of pain relief is similar between the two types of anesthesia. 2. The level of placement of the needle is the same in the two types of anesthesia. 3. Epidurals do not fully sedate the motor nerves of the client. Epidural clients are capable of moving their lower extremities even when fully pain free. 4. Both epidural and spinal anesthesia clients have the potential of experiencing nausea and vomiting. TEST-TAKING TIP: The single most impor- tant difference between epidural and spinal anesthesia is the depth of needle insertion. Epidural anesthesia is administered into the epidural space. This is outside of the spinal canal. The anesthesia, therefore, is not in direct contact with the spinal nerves. In contrast, spinal anesthesia, instilled into the spinal canal, is in direct contact with the spinal nerves. All of the spinal nerves of spinal anesthesia clients are anesthetized, including motor nerves. Spinal anesthesia clients are paralyzed until the anesthesia is metabolized by the body.