Maternity Quiz #1
The health care provider completes the vaginal examination by determining that the presenting part of the fetus is at -1 station. What does this information mean? The head is at the ischial spines. The head is 1 cm above the ischial spines. The head is 1 cm below the ischial spines. The head is crowning and delivery imminent.
The head is 1 cm above the ischial spines. The head is 1 cm above the ischial spines, which are considered landmarks. Station above the spines is referred with the use of negative numbers; stations below the spines are expressed in positive numbers. When the widest part of the presenting part is at the spines, it is considered to be at 0 station. One centimeter below the spines would be scored as +1. Crowning would be scored as +4 station.
A newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How should the nurse remove the electrode? Giving the electrode a quick jerk Turning the electrode clockwise until it is free Untwisting the wires before pulling the electrode out Twisting the electrode counterclockwise until it is free
Twisting the electrode counterclockwise until it is free For the spiral electrode to be removed it must be turned counterclockwise. Quickly jerking the electrode may result in a lacerating injury to the scalp. The electrode is attached by turning it clockwise. It is unnecessary to untwist the wires; the electrode should not be pulled, because this may cause a scalp laceration.
A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response? "An oxytocic." "An analgesic." "A corticosteroid." "A beta-adrenergic."
"A beta-adrenergic." Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex. Analgesics do not halt preterm labor. Corticosteroids do not halt labor; they are used during preterm labor to accelerate fetal lung maturity, when birth is likely to occur within 24 to 48 hours.
Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? Ritodrine (Yutopar) Misoprostol (Cytotec) Terbutaline (Brethine) Betamethasone (Celestone)
Betamethasone (Celestone) Betamethasone (Celestone) enhances fetal lung maturity when administered before a preterm birth. Ritodrine (Yutopar) and Terbutaline (Brethine) are tocolytic agents used to prevent preterm birth; this birth is inevitable. Misoprostol (Cytotec) is used for labor induction.
A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential? Fundal height Obstetric history Time of the last meal Family history of bleeding disorders
Fundal height It is vital that a baseline measurement be obtained, because increasing fundal height is a sign of concealed hemorrhage.Taking an obstetric history, ascertaining the time of the last meal, and asking about a family history of bleeding disorders are all appropriate assessments, but none is a priority at this critical time.
The nurse is performing the nursery intake assessment of a 1-hour old newborn. The assessment reveals that the newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? Notify the practitioner, because circumoral pallor may indicate cardiac problems. Notify the practitioner, because both signs are indicative of increased intracranial pressure. Take no specific action, because both signs are expected in a newborn until 2 weeks of age. Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying.
Notify the practitioner, because circumoral pallor may indicate cardiac problems. Although acrocyanosis (cyanotic hands and feet) is common in the newborn, circumoral pallor is not a normal newborn finding. Circumoral pallor is one sign of cardiac pathology and indicates a need for further assessment and investigation by the healthcare provider. Neither circumoral pallor nor acrocyanosis is a sign of increased intracranial pressure. Circumoral pallor is not expected in the newborn; it may indicate cardiac pathology.
Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration. Elevating the legs Repositioning the client from side to side Increasing the rate of intravenous infusion Administering oxygen by way of facemask
Repositioning the client from side to side A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation. Increasing the rate of intravenous fluid administration and elevating the legs are interventions for placental perfusion problems and do not affect cord compression. (VEAL CHOP)
A client is admitted for induction of labor. An intravenous infusion of oxytocin (Pitocin) is started. When the client's contractions begin they are 1½ to 2 minutes in duration. While the nurse is in the room, one contraction lasts 3 minutes. What should the nurse do first? Give oxygen by nasal cannula. Turn off the oxytocin infusion. Reposition the monitoring belts. Place a call light next to the client.
Turn off the oxytocin infusion. The client has experienced a hypertonic contraction. The oxytocin must be stopped before another contraction occurs to prevent uterine rupture, fetal hypoxia, or both. Although giving oxygen is important and may eventually be done, it is not the priority. Although repositioning the monitoring belts may be necessary, it is not the priority. Placing a call light next to the client is unnecessary; the client receiving oxytocin for induction of labor should be continuously attended.
A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure therapy by way of an endotracheal tube. The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action? Infants with RDS often have some degree of atelectasis, and there should be no change in treatment. Inspiratory pressure on the ventilator is probably too low and should be increased for adequate ventilation. The endotracheal tube has slipped into the left mainstem bronchus and should be pulled back to ventilate both lungs. The infant may have a pneumothorax, and the practitioner should be called so that corrective therapy can be started immediately.
The infant may have a pneumothorax, and the practitioner should be called so that corrective therapy can be started immediately. Diminished breath sounds and the PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is receiving oxygen by way of positive pressure. Atelectasis is not expected; if it does occur, it requires immediate attention. Low inspiratory pressure is not the cause of the problem. Slippage of the endotracheal tube is not the cause of the problem.
The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks' gestation. Which result after 20 minutes is suggestive of fetal reactivity? Absence of long-term variability Above-average fetal baseline heart rate of 160 beats/min No late decelerations associated with contractions Two accelerations of 15 beats/min lasting 15 seconds
Two accelerations of 15 beats/min lasting 15 seconds According to the American Congress of Obstetricians and Gynecologists, fetal reactivity is a fetal tracing 15 beats' acceleration above baseline lasting 15 seconds or more; normal baseline rate; and long-term variability amplitude of 10 or more beats/min. An absence of long-term variability is an ominous sign that must be addressed. An above-average baseline heart rate is acceptable up to 160 beats/min. An increasing baseline heart rate is a sign of maternal infection. Contractions are not expected with a nonstress test; early, late, or variable fetal heart rate decelerations are associated with uterine contractions.
A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond? "Eat as you have been during your pregnancy." "Drink a lot of milk—the added calcium will help you make milk." "Your body produces the milk your baby needs as a result of the vigorous suckling." "You'll need greater amounts of the same foods you've been eating and more fluids."
"You'll need greater amounts of the same foods you've been eating and more fluids." Compared with the prenatal diet, the diet for lactation requires an increased intake of all food groups, vitamins, and minerals, plus increased fluid to replace that lost with milk secretion. Breastfeeding mothers need an additional 500 calories and 5 g of protein per day more than during pregnancy to maintain adequate milk production. The client needs additional calories, not just additional milk. Telling the client that her body produces the milk her baby needs as a result of the vigorous suckling does not address the mother's concern; optimal nutrition is necessary to produce an adequate milk supply.
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? Placenta previa Precipitous birth Abruptio placentae Breech presentation
Abruptio placentae Abruptio placentae indicates premature placental separation; the classic signs are abdominal rigidity, a tetanic uterus, and dark-red bleeding. Placenta previa occurs with a low-lying placenta and is manifested by painless bright-red bleeding. Information on cervical effacement, dilation, and station is required before the nurse can come to this conclusion. Fetal presentation is not related to the client's signs and symptoms.
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action? Notifying the health care provider Resuming continuous fetal heart monitoring Continuing to monitor the maternal vital signs Documenting the fetal heart rate as an expected response to contractions
Notifying the health care provider Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous; the fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.
A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. What should the nurse instruct the client to do? Take slow, deep breaths. Hold her breath and push with each contraction. Breathe faster than usual with long cleansing breaths. Pant and then exhale through the mouth with pursed lips
Pant and then exhale through the mouth with pursed lips The client cannot bear down when panting and exhaling. The objective is to control the birth and prevent injury to both mother and newborn. The nurse should place a hand on the perineum to apply gentle pressure and then support the head as it emerges. Slow breaths enhance relaxation; this type of breathing is impossible to achieve when the fetal head is crowning. Holding the breath and pushing will result in a precipitous birth that could cause injury to both mother and newborn. Breathing faster than usual and taking long cleansing breaths are impossible to achieve when the fetal head is crowning.
A nurse is caring for a client who is scheduled for a modified radical mastectomy. What should the nurse tell the client to expect in the immediate postoperative period? Portable wound drainage system Sling to support the affected arm High-carbohydrate diet to promote healing Large pressure dressing over the incision site
Portable wound drainage system Suction (negative pressure) is used to remove blood and serum. Use of a sling should be avoided to prevent muscle stiffness; a regimen of gentle exercises helps restore muscle function. A high-protein diet, not a high-carbohydrate diet, promotes healing. Use of a portable drainage system obviates the need for a large pressure dressing.
A primigravida in the first trimester tells a nurse that she has heard that hormones play an important role in pregnancy. Which hormone should the nurse tell the client maintains pregnancy? Prolactin Estrogen Progesterone Somatotropin
Progesterone Progesterone is a female sex hormone, produced by the ovaries and placenta, that prepares the endometrium for implantation of the fertilized ovum, maintains pregnancy, and plays a role in the development of the mammary glands. Prolactin is secreted by the anterior lobe of the pituitary gland; it is responsible for initiating and maintaining milk secretion from the mammary glands. Estrogen is a female sex hormone that starts to prepare the endometrium for implantation and promotes development of secondary sex characteristics. Somatotropin is a growth hormone secreted by the anterior pituitary gland.
A pregnant client who has asthma is expected on the unit for induction of labor. What medication should the nurse question when evaluating newly written prescriptions from the practitioner? Albuterol inhaler Epidural anesthesia Intravenous D5W with piggyback oxytocin (Pitocin) Prostaglandin E2 (Prostin E2) vaginal suppository
Prostaglandin E2 (Prostin E2) vaginal suppository One side effect of prostaglandin E2 (Prostin E2) is bronchoconstriction, which may cause a bronchospasm in a client with asthma. An albuterol inhaler may be used as needed. Epidural anesthesia is not contraindicated for pregnant clients with asthma. Intravenous D5W with piggyback oxytocin (Pitocin) is not contraindicated for a pregnant client with asthma.
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. What infant safety education should be provided? Select all that apply. Wash your hands before touching the newborn. Send the newborn to nursery to be monitored during the night. All client identification bands should remain in place until discharge. Do not let anyone remove the infant from your sight while you are in the hospital. Check the identification of staff and if there is a question of validity, call the nursing station.
Wash your hands before touching the newborn. All client identification bands should remain in place until discharge. Check the identification of staff and if there is a question of validity, call the nursing station. Mothers, significant others or persons of the mother's choice, and the infant must continue to wear identification bands during the entire hospital stay. These bands show which baby belongs to which mother. The mother should call the nursing station to verify any person appearing to be staff if she has any question about who the person is. Proper identification must be worn by staff at all times. Washing hands before touching the newborn will decrease the chance of infectious transfer of microorganisms to newborn. Safety is the most important concern. There may be times when procedures, assessments, showering, and other activities involve the newborn's being taken from the mother's room. Only well-identified staff members caring for the client should be allowed to take infant out of the mother's sight. It is not necessary to send the newborn to the nursery during the night; the mother may keep the baby at her side during this time.
