Maternal Newborn (Exam 1)

34. Which assessment finding indicates a complication in the client attempting a vaginal birth after cesarean (VBAC)? a. Complaint of pain between the scapulae b. Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d. Pain level of 6 on scale of 0 to 10 during acme of contraction

ANS: A A client attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of contraction would be normal findings during labor.

9. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor? a. Incomplete uterine relaxation b. Maternal fatigue and exhaustion c. Maternal sedation with narcotics d. Administration of tocolytic drugs

ANS: A A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.

16. A client who is 32 weeks pregnant telephones the nurse at her obstetricians office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is: a. You should come into the office and let the doctor check you. b. Acetaminophen is acceptable during pregnancy. You should not take aspirin, however. c. Back pain is common at this time during pregnancy because you tend to stand with a sway back. d. Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.

ANS: A A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may prevent preterm birth. The client needs to be assessed for preterm labor before providing pain relief.

21. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy? a. Assessing FHR and maternal vital signs b. Performing a venipuncture for hemoglobin and hematocrit levels c. Placing clean disposable pads to collect any drainage d. Monitoring uterine contractions

ANS: A Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check the well-being of both the mother and the fetus. The blood levels can be obtained later. Assessing future bleeding is important; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not a top priority.

7. Birth for the nulliparous client with a fetus in a breech presentation is usually: a. cesarean section. b. vaginal birth. c. vacuumed extraction. d. forceps-assisted birth.

ANS: A Birth for the nulliparous client with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required.

22. Which order should the nurse expect for a client admitted with a threatened abortion? a. Bed rest b. Administration of ritodrine IV c. Nothing by mouth (nil per os [NPO]) d. Narcotic analgesia every 3 hours, as needed

ANS: A Decreasing the womans activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. Having the woman placed on NPO is unnecessary. At times, dehydration may produce contractions; therefore, hydration is important. Narcotic analgesia will not decrease the contractions and may mask the severity of the contractions.

13. A client who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurses priority action? a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the client with her hips slightly elevated.

ANS: A Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the client at high risk for uterine rupture. The client is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the client with her hips slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties.

32. When reviewing the prenatal record of a client at 42 weeks gestation, the nurse recognizes that induction of labor is indicated based on the finding of: a. reduced amniotic fluid volume. b. cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d. 1-pound weight gain at each of the last two weekly visits.

ANS: A Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-pound weight gain at each of the last two weekly visits are normal prenatal findings for a 42-week gestation.

9. With regard to hemorrhagic complications that may occur during pregnancy, what information is most accurate? a. An incompetent cervix is usually not diagnosed until the woman has lost one or two pregnancies. b. Incidences of ectopic pregnancy are declining as a result of improved diagnostic techniques. c. One ectopic pregnancy does not affect a womans fertility or her likelihood of having a normal preg d. Gestational trophoblastic neoplasia (GTN) is one of the persistently incurable gynecologic maligna

ANS: A Short labors and recurring losses of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence. Because diagnostic technology is improving, more ectopic pregnancies are being diagnosed. One ectopic pregnancy places the woman at increased risk for another one. Ectopic pregnancy is a leading cause of infertility. Once invariably fatal, GTN now is the most curable gynecologic malignancy.

35. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurses next action? a. Palpate the patients bladder for fullness. b. Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d. Reassure the patient that she is making adequate progress.

ANS: A The fetal presenting part is expected to descend at a minimal rate of 1 cm/hr in the nullipara and 2 cm/hr in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the nurse must assess for flow of urine and a distended bladder.

2. A pregnant womans amniotic membranes have ruptured. A prolapsed umbilical cord is suspected. What intervention would be the nurses highest priority? a. Placing the woman in the knee-chest position b. Covering the cord in sterile gauze soaked in saline c. Preparing the woman for a cesarean birth d. Starting oxygen by face mask

ANS: A The woman is assisted into a modified Sims position, Trendelenburg position, or the knee-chest position in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to relieve cord compression.

36. Emergency measures used in the treatment of a prolapsed cord include which of the following? (Select all that apply.) a. Administration of oxygen via face mask at 8 to 10 L/min b. Maternal change of position to knee-chest c. Administration of tocolytic agent d. Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area

ANS: A, B, C, E Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated.

3. The reported incidence of ectopic pregnancy has steadily risen over the past 2 decades. Causes include the increase in sexually transmitted infections (STIs) accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse suspects that a client has early signs of ectopic pregnancy. The nurse should be observing the client for which signs or symptoms? (Select all that apply.) a. Pelvic pain b. Abdominal pain c. Unanticipated heavy bleeding d. Vaginal spotting or light bleeding e. Missed period

ANS: A, B, D, E A missed period or spotting can be easily mistaken by the client as an early sign of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage, which may progress to hypovolemic shock with minimal or even no external bleeding. In approximately one half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.

2. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.) a. Chromosomal abnormalities b. Infections c. Endocrine imbalance d. Systemic disorders e. Varicella

ANS: A, C, D, EInfections are not a common cause of early miscarriage. At least 50% of pregnancy losses result from chromosomal abnormalities. Endocrine imbalances such as hypothyroidism or diabetes are also possible causes for early pregnancy loss. Other systemic disorders that may contribute to pregnancy loss include lupus and genetic conditions. Although infections are not a common cause of early miscarriage, varicella infection in the first trimester has been associated with pregnancy loss.

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

ANS: A, C, D, EThe conditions listed are all acceptable indications for induction. Other conditions include intrauterine growth restriction (IUGR), maternal-fetal blood incompatibility, hypertension, and placental abruption. Elective inductions for the convenience of the woman or her provider are not recommended; however, they have become commonplace. Factors such as rapid labors and living a long distance from a health care facility may be valid reasons in such a circumstance. Elective delivery should not occur before 39 weeks of completed gestation.

1. A client who has undergone a D&C for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that her vital signs are stable, that bleeding has been controlled, and that the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, what information should discharge teaching include? (Select all that apply.) a.Iron supplementation b. Resumption of intercourse at 6 weeks postprocedure c. Referral to a support group, if necessary d. Expectation of heavy bleeding for at least 2 weeks e. Emphasizing the need for rest

ANS: A, C, E The woman should be advised to consume a diet high in iron and protein. For many women, iron supplementation also is necessary. The nurse should acknowledge that the client has experienced a loss, however early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure, including tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her health care provider.

5. A client with polyhydramnios was admitted to a labor-birth-recovery-postpartum (LDRP) suite. Her membranes rupture and the fluid is clear and odorless, but the fetal heart monitor indicates bradycardia and variable decelerations. Which action should be taken next? a. Perform Leopold maneuvers. b. Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d. Place the client in a high Fowler position.

ANS: B A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and decrease fetal oxygenation.

2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b. Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d. Performing vaginal examinations every hour while the client is in active labor

ANS: B Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity.

2. A perinatal nurse is giving discharge instructions to a woman, status postsuction, and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. What is the bestresponse by the nurse? a. If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if a. pregnancy, it would be better for you to use the most reliable method of contraception available. b. The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by me hormone that your body produces during pregnancy. If you were to get pregnant, then it would mak this cancer more difficult. c. If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy improve your chance of a successful pregnancy, not getting pregnant at this time is best. d. Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar preg

ANS: B Betahuman chorionic gonadotropin (beta-hCG) hormone levels are drawn for 1 year to ensure that the mole is completely gone. The chance of developing choriocarcinoma after the development of a hydatidiform mole is increased. Therefore, the goal is to achieve a zero human chorionic gonadotropin (hCG) level. If the woman were to become pregnant, then it may obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device (IUD) is acceptable.

11. Which laboratory marker is indicative of DIC? a. Bleeding time of 10 minutes b. Presence of fibrin split products c. Thrombocytopenia d. Hypofibrinogenemia

ANS: B Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys vasculature. Bleeding time in DIC is normal. Low platelets may occur but are not indicative of DIC because they may be the result from other coagulopathies. Hypofibrinogenemia occurs with DIC.

17. Which maternal condition always necessitates delivery by cesarean birth? a. Marginal placenta previa b. Complete placenta previa c. Ectopic pregnancy d. Eclampsia

ANS: B In complete placenta previa, the placenta completely covers the cervical os. A cesarean birth is the acceptable method of delivery. The risk of fetal death occurring is due to preterm birth. If the previa is marginal (i.e., 2 cm or greater away from the cervical os), then labor can be attempted. A cesarean birth is not indicated for an ectopic pregnancy. Labor can be safely induced if the eclampsia is under control.

20. During the course of the birth process, the physician suspects that a shoulder dystocia is occurring and asks the nurse for assistance. Which priority action should be taken by the nurse in response to this request? a. Put pressure on the fundus. b. Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the client not to push until you prepare vacuum extraction device for physician. d. Reposition the client to facilitate birth.

ANS: B In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer recommended as a treatment strategy because it can cause additional problems. Vacuum extraction will not help solve this birth issue and may lead to further complications. Repositioning of the client may not be effective to relieve this condition and facilitate birth.

6. Which technique is least effective for the client with persistent occiput posterior position? a. Squatting b. Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d. Rocking the pelvis back and forth while on hands and knees

ANS: B Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior.

16. In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio placentae? a. Bleeding b. Intense abdominal pain c. Uterine activity d. Cramping ANS: BPain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

ANS: B Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

30. Which finding would indicate an adverse response to terbutaline (Brethine)? a. Fetal heart rate (FHR) of 134 bpm b. Heart rate of 122 bpm c. Two episodes of diarrhea d. Fasting blood glucose level of 100 mg/dL

ANS: B Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.

4. A client in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will be prescribed for at-home continuation of the tocolytic effect? a. Buccal oxytocin (Pitocin) b. Terbutaline sulfate (Brethine) c. Calcium gluconate (Calgonate) d. Magnesium sulfate

ANS: B The client receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. Pitocin increases the strength of contractions and is used to augment or stimulate labor. Buccal Pitocin dosing is uncontrollable. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug.

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

ANS: B The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch. The prognosis for a vaginal birth is good. Only 30% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The anthropoid pelvis is a long narrow oval, with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth.

4. A 26-year-old pregnant woman, gravida 2, para 1-0-0-1, is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, which diagnostic procedure will the client most likely have performed? a. Amniocentesis for fetal lung maturity b. Transvaginal ultrasound for placental location c. Contraction stress test (CST) d. Internal fetal monitoring

ANS: B The presence of painless bleeding should always alert the health care team to the possibility of placenta previa, which can be confirmed through ultrasonography. Amniocentesis is not performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus is presumed to have immature lungs at this gestational age, and the mother is given corticosteroids to aid in fetal lung maturity. A CST is not performed at a preterm gestational age. Furthermore, bleeding is a contraindication to a CST. Internal fetal monitoring is also contraindicated in the presence of bleeding.

5. A laboring woman with no known risk factors suddenly experiences spontaneous ROM. The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. No change in uterine resting tone has occurred. The fetal heart rate (FHR) begins to decline rapidly after the ROM. The nurse should suspect the possibility of what condition? a. Placenta previa b. Vasa previa c. Severe abruptio placentae d. Disseminated intravascular coagulation (DIC)

ANS: B Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. The umbilical blood vessels thus are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the FHR without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and is considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity typically is tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as the hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome. This woman did not have any prior risk factors.

15. The fetus in a breech presentation is often born by cesarean birth because: a. the buttocks are much larger than the head. b. compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d. postpartum hemorrhage is more likely if the client delivers vaginally.

ANS: B After the fetal legs and trunk emerge from the clients vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage.

9. What is the correct terminology for an abortion in which the fetus dies but is retained within the uterus? a. Inevitable abortion b. Missed abortion c. Incomplete abortion d. Threatened abortion

ANS: B Missed abortion refers to the retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion, the woman has cramping and bleeding but no cervical dilation.

1. Indications for a primary cesarean birth are often nonrecurring. Therefore, a woman who has had a cesarean birth with a low transverse scar may be a candidate for vaginal birth after cesarean (VBAC). Which clients would beless likely to have a successful VBAC? (Select all that apply.) a. Lengthy interpregnancy interval b. African-American race c. Delivery at a rural hospital d. Estimated fetal weight <4000 g e. Maternal obesity (BMI >30)

ANS: B, C, E Indications for a low success rate for a VBAC delivery include a short interpregnancy interval, non-Caucasian race, gestational age longer than 40 weeks, maternal obesity, preeclampsia, fetal weight greater than 4000 g, and delivery at a rural or private hospital.

28. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes? a. Apply oxygen at 8 to 10 L/min. b. Stop the Pitocin infusion. c. Position the client in the knee-chest position. d. Increase the main line infusion to 150 mL/hr.

ANS: C A drop in the fetal heart rate following rupture of the membranes indicates a compressed or prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping the Pitocin infusion and increasing the main line fluid do not directly affect cord compression.

15. A woman arrives at the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion? a. Incomplete b. Inevitable c. Threatened d. Septic

ANS: C A woman with a threatened abortion has spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would have heavy bleeding, mild-to-severe cramping, and cervical dilation. An inevitable abortion demonstrates the same symptoms as an incomplete abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic abortion has malodorous bleeding and typically a dilated cervix.

3. A pregnant client with premature rupture of membranes is at higher risk for postpartum infection. Which assessment data indicate a potential infection? a. Fetal heart rate, 150 beats/min b. Maternal temperature, 99 F c. Cloudy amniotic fluid, with strong odor d. Lowered maternal pulse and decreased respiratory rates

ANS: C Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/min is often the first sign of intrauterine infection. A temperature of 100.4 F or higher is a classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

14. Which factor should alert the nurse to the potential for a prolapsed umbilical cord? a. Oligohydramnios b. Pregnancy at 38 weeks of gestation c. Presenting part at a station of 3 d. Meconium-stained amniotic fluid

ANS: C Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the client at high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the client at risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.

20. What condition indicates concealed hemorrhage when the client experiences abruptio placentae? a. Decrease in abdominal pain b. Bradycardia c. Hard, boardlike abdomen d. Decrease in fundal height

ANS: C Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. Abdominal pain may increase. The client will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height increases.

6. A woman arrives for evaluation of signs and symptoms that include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination, the nurse notices an ecchymotic blueness around the womans umbilicus. What does this finding indicate? a. Normal integumentary changes associated with pregnancy b. Turner sign associated with appendicitis c. Cullen sign associated with a ruptured ectopic pregnancy d. Chadwick sign associated with early pregnancy

ANS: C Cullen sign, the blue ecchymosis observed in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy and exhibits a brown pigmented, vertical line on the lower abdomen. Turner sign is ecchymosis in the flank area, often associated with pancreatitis. A Chadwick sign is a blue-purple cervix that may be seen during or around the eighth week of pregnancy.

3. The nurse is preparing to administer methotrexate to the client. This hazardous drug is most often used for which obstetric complication? a. Complete hydatidiform mole b. Missed abortion c. Unruptured ectopic pregnancy d. Abruptio placentae

ANS: C Methotrexate is an effective nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and measures less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole, for a missed abortion, or for abruptio placentae.

10. The management of the pregnant client who has experienced a pregnancy loss depends on the type of miscarriage and the signs and symptoms. While planning care for a client who desires outpatient management after a first-trimester loss, what would the nurse expect the plan to include? a. Dilation and curettage (D&C) b. Dilation and evacuation (D&E) c. Misoprostol d. Ergot products

ANS: C Outpatient management of a first-trimester loss is safely accomplished by the intravaginal use of misoprostol for up to 2 days. If the bleeding is uncontrollable, vital signs are unstable, or signs of infection are present, then a surgical evacuation should be performed. D&C is a surgical procedure that requires dilation of the cervix and scraping of the uterine walls to remove the contents of pregnancy. This procedure is commonly performed to treat inevitable or incomplete abortion and should be performed in a hospital. D&E is usually performed after 16 weeks of pregnancy. The cervix is widely dilated, followed by removal of the contents of the uterus. Ergot products such as Methergine or Hemabate may be administered for excessive bleeding after miscarriage.

8. A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which differential diagnosis would not be applicable for this client? a. Placenta previa b. Abruptio placentae c. Spontaneous abortion d. Cord insertion

ANS: C Spontaneous abortion is another name for miscarriage; it occurs, by definition, early in pregnancy. Placenta previa is a well-known reason for bleeding late in pregnancy. The premature separation of the placenta (abruptio placentae) is a bleeding disorder that can occur late in pregnancy. Cord insertion may cause a bleeding disorder that can also occur late in pregnancy.

31. A dose of dexamethasone 12 mg was administered to a client in preterm labor at 8:30 AM on March 12. The nurse knows that the next dose must be scheduled for: a. 2:30 PM on March 12. b. 8:30 PM on March 12. c. 8:30 AM on March 13. d. 2:30 PM on March 13.

ANS: C The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 2:30 PM on March 12, 8:30 PM on March 12, and 2:30 PM on March 13 do not fall within this recommendation.

23. Which finding on a prenatal visit at 10 weeks of gestation might suggest a hydatidiform mole? a. Complaint of frequent mild nausea b. Blood pressure of 120/80 mm Hg c. Fundal height measurement of 18 cm d. History of bright red spotting for 1 day, weeks ago

ANS: C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the clients history, bleeding is normally described as brownish.

18. Which assessment finding indicates uterine rupture? a. Fetal tachycardia occurs. b. The client becomes dyspneic. c. Labor progresses unusually quickly. d. Contractions abruptly stop during labor.

ANS: D A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.

17. Which is (are) the priority nursing assessment(s) for the client having tocolytic therapy with terbutaline (Brethine)? a. Intake and output b. Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d. Fetal heart rate, maternal pulse, and blood pressure

ANS: D All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured, but these are not relevant to the medication.

7. The nurse who elects to practice in the area of womens health must have a thorough understanding of miscarriage. Which statement regarding this condition is most accurate? a. A miscarriage is a natural pregnancy loss before labor begins. b. It occurs in fewer than 5% of all clinically recognized pregnancies. c. Careless maternal behavior, such as poor nutrition or excessive exercise, can be a factor in causing d. If a miscarriage occurs before the 12th week of pregnancy, then it may be observed only as moderate blood loss.

ANS: D Before the sixth week, the only evidence might be a heavy menstrual flow. After the 12th week, more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but it occurs, by definition, before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriages can be caused by a number of disorders or illnesses outside the mothers control or knowledge.

27. Which finding by the nurse on a vaginal exam would be a concern if a spontaneous rupture of the membranes occurred? a. Cephalic presentation b. Left occiput position c. Dilation 2 cm d.Presenting part at 3 station

ANS: D If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.

11. A laboring client in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain? a. You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger. b. Let me take off the monitor belts and help you get into a more comfortable position. c. You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain. d. I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.

ANS: D Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the client cope with the situation, no matter at what stage. It is important to get her into a more comfortable position, but fetal monitoring should continue. Breathing will not decrease the pain.

8. Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous client with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous client at 39 weeks of gestation who is expecting twins

ANS: D Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this clients uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an overdistended uterus.

15. Which classification of placental separation is not recognized as an abnormal adherence pattern? a. Placenta accreta b. Placenta increta c. Placenta percreta d. Placenta abruptio

ANS: D Placenta abruptio is premature separation of the placenta as opposed to partial or complete adherence. This classification occurs between the 20th week of gestation and delivery in the area of the decidua basalis. Symptoms include localized pain and bleeding. Placenta accreta is a recognized degree of attachment. With placenta accreta, the trophoblast slightly penetrates into the myometrium. Placenta increta is a recognized degree of attachment that results in deep penetration of the myometrium. Placenta percreta is the most severe degree of placental penetration that results in deep penetration of the myometrium. Bleeding with complete placental attachment occurs only when separation of the placenta is attempted after delivery. Treatment includes blood component therapy and, in extreme cases, hysterectomy may be necessary.

24. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Which information assists the nurse in developing the plan of care? a.Bed rest and analgesics are the recommended treatment. b. She will be unable to conceive in the future. c. A D&C will be performed to remove the products of conception. d. Hemorrhage is the primary concern.

ANS: D Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture to prevent hemorrhaging. If the tube must be removed, then the womans fertility will decrease; however, she will not be infertile. A D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.

1. The obstetric provider has informed the nurse that she will be performing an amniotomy on the client to induce labor. What is the nurses highest priority intervention after the amniotomy is performed? a.Applying clean linens under the woman b.Taking the clients vital signs c.Performing a vaginal examination d.Assessing the fetal heart rate (FHR)

ANS: D The FHR is assessed before and immediately after the amniotomy to detect any changes that might indicate cord compression or prolapse. Providing comfort measures, such as clean linens, for the client is important but not the priority immediately after an amniotomy. The womans temperature should be checked every 2 hours after the rupture of membranes but not the priority immediately after an amniotomy. The woman would have had a vaginal examination during the procedure. Unless cord prolapse is suspected, another vaginal examination is not warranted. Additionally, FHR assessment provides clinical cues to a prolapsed cord.

29. When increasing the IV infusion rate of terbutaline (Brethine) 0.01 mg/min every 30 minutes, the nurse knows to stop increasing the rate when the: a. maximum dose of 0.1 mg/min is reached. b. systolic blood pressure falls below 110 mm Hg. c. contractions are less than two in a 10-minute period. d. maternal heart rate remains over 120 beats/min.

ANS: D The infusion rate is not increased or may be decreased if the maternal pulse rate remains over 120 beats/min (bpm). A maximum dose of 0.1 mg is above the recommended maximum rate, systolic blood pressure below 110 mm Hg may be a normal finding for this client, and the medication should continue to be increased until the maximum level is reached or contractions stop.

12. Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b. Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d. Reposition the mother with her hips higher than her head.

ANS: D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority.

A nurse is providing teaching to a client who is at 40 wks gestation and has a new prescription for misoprostol. Which of the following instruction should the nurse include in the teaching? "I can administer oxytocin 4 hrs after the insertion of the medication."

"I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.

18. What is the correct definition of a spontaneous termination of a pregnancy (abortion)? a. Pregnancy is less than 20 weeks. b. Fetus weighs less than 1000 g. c. Products of conception are passed intact. d. No evidence exists of intrauterine infection.

ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete and may be caused by many problems, one being intrauterine infection.

21. A pregnant client who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered an fFN (fetal fibronectin) test. Which instructions should be given to the client related to this clinical test? a. Client must be NPO prior to testing. b. Blood work will be drawn every week to help confirm the start of preterm labor. c. Client should refrain from sexual activity prior to testing. d. A urine specimen will be collected for testing.

ANS: C Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive cervical manipulation, in the presence of bleeding, and as a result of sexual activity.

19. Which intervention should be incorporated in a plan of care for a labor client who is experiencing hypertonic labor? Vaginal exam is unchanged from prior exam3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b. AROM c. Performing a vaginal exam to denote progress d. Preparing the client for epidural administration as ordered by the physician

ANS: D The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore, augmentation would not be advised as this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided.

A nurse is caring for a client who is at 36 wks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? biophysical profile amniocentesis cordocentesis kleihauer-betke test

Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.

A nurse is assessing a client who has severe preeclampsia. which of the following manifestations should the nurse expect? +2 DTRs proteinuria of 200 mg in a 24hr specimen polyuria blurred vision

Blurred vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? depression polyuria hypotension urticaria

Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation oxytocin infusion and should be reported to the provider? late decels moderate variability of the FHR cessation of uterine dilation prolonged active phase of labor

Late decelerations Rationale: Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

A nurse is caring for a postpartum client who is recieving heparin vi continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? administer aspirin for pain. maintain the client on bed rest. massage the affected leg every 12 hr apply cold compress to the affected calf.

Maintain the client on bed rest. The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? check the clients cap refil massage the fundus insert an indwelling urinary catheter for the client. prepare the client for a blood transfusion

Massage the client's fundus. rationale: Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? lochia serosa vaginal discharge vaginal pressure intermittent vaginal pain yellow exudate vaginal discharge

Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.