Midterm
During a physical assessment, the nurse palpates a pregnant client's fundus at the level of the umbilicus. What statement should the nurse make to the client about this assessment finding? "You are at 12 weeks of your pregnancy." "You are at 20 weeks of your pregnancy." "You are at 36 weeks of your pregnancy." "You can go into labor at any time now."
"You are at 20 weeks of your pregnancy."
The nurse is providing education about barrier contraceptives. Which statement by the client indicates a need for further education? "I have to wash my cervical caps after each use." "I can leave my diaphragm in for up to 48 hours." "I can insert my female condoms up to 8 hours before intercourse." "Male latex condoms when used correctly are an effective means of contraception."
"I can leave my diaphragm in for up to 48 hours."
The nurse is screening for potential exposure to toxoplasmosis. Which question is most appropriate? "Do you have old paint in the house?" "Do you use well water for drinking?" "Do you lock your medications in a cabinet:" "Do you have a cat in the house?"
"Do you have a cat in the house?"
A nurse is working with a pregnant client to schedule follow-up visits for the pregnancy. Which statement by the client indicates that she understands the scheduling? "I need to make visits every 2 months until I am 36 weeks' pregnant." "Once I get to 28 weeks' pregnant, I have to come twice a month." "From now until I am 28 weeks' pregnant, I will be coming once a month." "I will make sure to get a day off every 2 weeks to make my visits."
"From now until I am 28 weeks' pregnant, I will be coming once a month."
The nurse is assessing a client's risk for sexually transmitted infections. Which statement by the client would be cause for concern? "I am not sure if I want to keep the baby. It is a hard decision." "I am unsure who the father of the baby is. I will be raising it alone." "I needed Rho(D) immune globulin after my last pregnancy. Will I need it again?" "I only want my family to see the baby after it is born."
"I am unsure who the father of the baby is. I will be raising it alone."
A couple comes to the clinic for a fertility evaluation. The male partner is to undergo a semen analysis. After teaching the partner about this test, which client statement indicates that the client has understood the instructions? "I need to bring the specimen to the lab the day after collecting it." "I will place the specimen in a special plastic bag to transport it." "I have to abstain from sexual activity for about 2 to 5 days before the sample." "I will withdraw before I ejaculate during sex to collect the specimen."
"I have to abstain from sexual activity for about 2 to 5 days before the sample."
A pregnant woman has developed varicosities. Which statement would suggest she needs additional health teaching? "I maintain a high fluid intake." "I'll try not to stand for long periods." "I dorsiflex my feet and ankles frequently." "I wear knee-highs rather than pantyhose."
"I wear knee-highs rather than pantyhose."
A nurse is educating a pregnant client about obtaining a blood sample for an alpha-fetoprotein (AFP) level. Which response by the client indicates that the health teaching was successful? "If my AFP level is high, it could mean there is a problem with my baby's spinal cord." "If my AFP level is negative, it means the baby has no birth defects." "If my AFP level is low, then I won't need to follow up." "If there is a need to get my AFP level tested, a blood sample will be obtained around 11 weeks."
"If my AFP level is high, it could mean there is a problem with my baby's spinal cord."
A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement? "Our baby will come out facing the hip." "Our baby will come out face first." "Our baby will come out with the back of the head first." "Our baby will come out with the buttocks first."
"Our baby will come out face first."
A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response? "The anesthesiologist will do her best to avoid this." "The pain relief offered will compensate for the discomfort afterward." "Spinal headache is not a usual complication of epidural blocks." "Your health care provider knows what is best for you."
"Spinal headache is not a usual complication of epidural blocks."
A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." "This is not normal unless you are in active labor; come to the hospital and be checked." "That is something we expect with a second or third baby, but because it is your first, you need to be checked." "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."
The nurse educates a 15-year-old female client on ways to prevent pregnancy. Which statement will the nurse include in the teaching? "Oral contraceptive pills are effective at preventing pregnancy as long as you take one each week." "The withdrawal method is effective as long as you have a monogamous partner." "The use of a condom is a method often recommended to prevent pregnancy for people your age." "If you do not want to become pregnant within the next 10 years, an intrauterine device would be best."
"The use of a condom is a method often recommended to prevent pregnancy for people your age."
A 38-year-old client wishes to discontinue use of oral contraceptive pills (OCPs) and attempt to conceive. The client says to the nurse, "I know a lot of women who have waited later to have children and became pregnant easily." How will the nurse respond? "As soon as you stop taking the pill, you should be able to conceive. There are no age-related problems with you becoming pregnant." "The age of a woman does not matter when trying to conceive, but you have been on birth control for a long time, thus it may take you longer." "You should be off of oral contraceptive pills for at least 1 year before trying, and then you may or may not be able to become pregnant." "Women in their late 30s who use oral contraceptive pills may face a delay in conception, as the body takes a few months to be able to conceive."
"Women in their late 30s who use oral contraceptive pills may face a delay in conception, as the body takes a few months to be able to conceive."
When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it." "If you end up having a cesarean, the epidural can be used for anesthesia during surgery." "You have no trouble walking around and using the bathroom after you receive the epidural."
"You have no trouble walking around and using the bathroom after you receive the epidural."
A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: +2 station. 0 station. -2 station. crowning.
-2 station.
Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? -2 -1 0 +1
0
A pregnant client is scheduled to undergo chorionic villus sampling (CVS) to rule out any birth defects. Ideally, when should this testing be completed? 10 to 12 weeks' gestation 7 to 9 weeks' gestation 5 to 6 weeks' gestation 4 to 5 weeks' gestation
10 to 12 weeks' gestation
Subfertility/infertility is said to exist when a couple has failed to achieve pregnancy after how many months of unprotected sexual intercourse?
12
A client in her first trimester is concerned about how weight gain will affect her appearance and questions the nurse concerning dietary restrictions. How much weight gain should the nurse point out will be safe for this client with a low BMI? 25 to 35 pounds (11 to 16 kilograms) 28 to 40 pounds (13 to 18 kilograms) 15 to 25 pounds (7 to 11 kilograms) 16 to 30 pounds (7.25 to 14 kilograms)
28 to 40 pounds (13 to 18 kilograms)
The nurse is helping a pregnant client adapt psychologically. What outcome best demonstrates that the client has successfully adapted to the second trimester? The client states that she is fully prepared for parenthood. The client accepts the pregnancy. The client accepts the reality and uniqueness of the baby. The client finishes making a detailed plan for labor and birth.
The client accepts the reality and uniqueness of the baby.
A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 5. 6. 7. 8.
7
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? 0 to 2 5 to 7 3 to 4 8 to 10
8 to 10
A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural? Review the woman's medical history and laboratory results, and interview her to confirm all information is accurate and up to date. Place the woman in the fetal position on the table, and keep her steady so that she won't move during the procedure. Administer a fluid bolus through the IV line to reduce the risk of hypotension. Prepare a sterile field with the supplies and medications that will be needed.
Administer a fluid bolus through the IV line to reduce the risk of hypotension.
Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? Encourage the woman to rest between contractions. Change the woman's position. Give the prescribed medication. Massage the woman's back.
Massage the woman's back.
The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? Acceleration of at least 15 bpm for 15 seconds Increase in variability by 27 bpm Deceleration followed by acceleration of 15 bpm Decrease in variability for 15 seconds
Acceleration of at least 15 bpm for 15 seconds
An Rh-negative client is having an amniocentesis. What is the highest priority nursing intervention to perform immediately after the procedure? Observe the client's vital signs for 2 hours. Administer Rh immune globulin. Observe fetal heart rate for 90 minutes. Monitor for labor contractions for 1 hour.
Administer Rh immune globulin.
The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? Assess maternal blood pressure. Assess for constipation. Assess for dry mouth. Assess fetal heart rate.
Assess fetal heart rate.
The nurse is reviewing the signs of labor with a client entering the last phase of the third trimester of pregnancy. What should the nurse include as an indication that the labor is beginning? excessive fatigue and headache sharp, right-sided abdominal pain evidence of bloody show an increased pulse rate and upper abdominal pain
evidence of bloody show
During which time is the nurse correct to document the end of the third stage of labor? Following fetal birth When pushing begins At the time of placental delivery When the mother is moved to the postpartum unit
At the time of placental delivery
A pregnant client is experiencing leg cramps. What will the nurse include in the client's teaching plan as a relief measure? Select all that apply. Avoid full leg extension with toes pointed. Elevate lower extremities. Elevate the knees on two pillows. Stand on each leg and perform a squat. Bend the knee and perform dorsiflexion.
Avoid full leg extension with toes pointed. Elevate lower extremities.
Which change related to the vital signs is expected in pregnant women? Pulse decreases. Lung space increases. Blood pressure decreases. Temperature decreases.
Blood pressure decreases.
The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? Continue to monitor the client and the fetal heart rate.. Promptly inform the primary care provider. Reposition the client. Advocate for the client to have a vaginal examination.
Continue to monitor the client and the fetal heart rate..
Which nursing action is applied throughout all stages of labor? Discourage the client from ambulating after the rupture of membranes. Do not allow the client to lay flat on her back for long periods. Place the client on nothing by mouth (NPO) status while in labor. Limit the client to have no more than one support person in the labor room.
Do not allow the client to lay flat on her back for long periods.
The school nurse is counseling a sexually active 16-year-old adolescent about the various forms of contraception. She is afraid of getting pregnant or contracting a sexually transmitted infection because her boyfriend refuses to use a condom. In answering the client's questions as to which option will be best suit her needs, which form should the nurse recommend? Female condom Tubal ligation Oral contraceptive Coitus interruptus
Female condom
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? Fetal heart rate in relation to contractions The station in which the fetus is located Maternal heart rate and blood pressure Maternal request for pain medication
Fetal heart rate in relation to contractions
A nursing instructor is conducting a session introducing a group of nursing students to the various pieces of equipment used for intermittent fetal monitoring. The instructor determines the session is successful after the students correctly choose which methods can be used? Select all that apply. Doppler fetoscope intrauterine pressure catheter external fetal monitor Leopold's palpation
Doppler fetoscope external fetal monitor
Which would be a normal finding by the nurse during a physical exam of a woman in her third trimester? Dyspnea Kyphosis Ptyalism Increased hematocrit
Dyspnea
The nurse is instructing a client who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply. False labor contractions are irregular. True labor contractions disappear when asleep. False labor contractions lead to cervical dilation. True labor contractions occur in the abdomen and groin. False labor contractions do not increase in duration, frequency, and intensity.
False labor contractions are irregular. False labor contractions do not increase in duration, frequency, and intensity.
The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? Notify the RN that client's blood pressure has increased. Notify the RN about the lack of FHR variability. Help the client regain control of her breathing technique. Assist the client into a hands-and-knees position.
Help the client regain control of her breathing technique.
The nurse is monitoring the electronic fetal heart rate monitor and notes the following: variable V-shaped decelerations in the fetal heart rate (FH)R lasting about 30 seconds, accelerations of about 5 beats/min before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? Discontinue supplemental oxygen. Help the woman change positions. Encourage pushing with contractions during second stage of labor. Start an oxytocic infusion and decrease the rate of IV fluids.
Help the woman change positions.
The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful? Instruct on the labor process. Initiate comfort measures. Limit interruptions in the room. Encourage support person interaction.
Initiate comfort measures.
A client reports constant redness and itching of the palms early in the pregnancy. The client fears that they are suffering an allergic reaction. Which instruction will the nurse provide? It is caused by increased estrogen levels and should disappear in time. It is likely an allergic reaction to a lotion. The body is more sensitive during pregnancy. It is a sign of capillary leakage from the increase in blood volume. It is a sign of high blood pressure. You may need to be started on an antihypertensive drug.
It is caused by increased estrogen levels and should disappear in time.
A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position? Long axis of fetus is at 60° to that of client. Long axis of fetus is parallel to that of client. Long axis of fetus is perpendicular to that of client. Long axis of fetus is at 45° to that of client.
Long axis of fetus is perpendicular to that of client.
The fetal heart rate tracing of a woman in the early stage of labor shows early decelerations. Which action by the nurse would be appropriate to do first? Continue to monitor the fetal heart rate. Prepare for an imminent birth. Notify the health care provider Have the woman turn on her side.
Notify the health care provider
A young client comes to the clinic and requests birth control pills to prevent a pregnancy. She tells the nurse that she is worried that she will get mixed up on what days to take the pills. Which would be the best type of pills to prescribe this client? Oral contraceptive pills (OCPs) packaged with 21 pills Oral contraceptive pills packaged with 28 pills Oral contraceptive pills packaged with 30 pills Oral contraceptive pills packaged with 14 pills
Oral contraceptive pills packaged with 28 pills
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Palpate the mother's radial pulse at the same time. Ask the woman to hold her breath while assessing the FHR. Have the woman lie completely flat on her back while auscultating. Instruct the woman to bend her knees and flex her hips.
Palpate the mother's radial pulse at the same time.
A client received a scheduled dose of depot medroxyprogesterone acetate (DMPA) 6 weeks ago. Today, the client reports that a regular menstrual cycle is 2 weeks late. What is the first thing that should be done for this client? Perform a pregnancy test. Provide prenatal counseling. Discuss pregnancy termination options. Explain side effects of the contraceptive.
Perform a pregnancy test.
A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply. Provide the client clear information on procedures involved. Encourage the client to have a sense of mastery and self-control. Encourage the client to have a positive reaction to pregnancy. Instruct the client to spend some time alone each day. Instruct the client to begin changing the home environment.
Provide the client clear information on procedures involved. Encourage the client to have a sense of mastery and self-control. Encourage the client to have a positive reaction to pregnancy.
The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? transition second third active
Second
A pregnant woman tends not to eat for long periods of time because of her busy work schedule. What process safeguards her fetus from becoming hypoglycemic during this time? The brain is too undeveloped to use glucose. Women naturally ingest complex carbohydrates to last for long periods during pregnancy. Somatomammotropin helps to regulate glucose levels. Fetal oxygen interferes with the metabolism of glucose and prolongs its action.
Somatomammotropin helps to regulate glucose levels.
A labor and delivery nurse knows that when assessing a woman's contraction pattern, it is important to include which of the following? Select all that apply. frequency duration status of membranes intensity activity of fetus
frequency duration intensity
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? The contraction pains are 2 minutes apart and 1 minute in duration. The client reports back pain, and the cervix is effacing and dilating. The contraction pains have been present for 5 hours, and the patterns are regular. After walking for an hour, the contractions have not fully subsided.
The client reports back pain, and the cervix is effacing and dilating.
Which assessment finding is most important as labor progresses? The client is remaining in control of emotions. Labor is completed within 18 hours. The uterus relaxes completely between contractions. The pulse and respirations rise with the work of labor.
The uterus relaxes completely between contractions.
The nurse is caring for a multigravid client at 38 weeks' gestation and is reviewing diagnostic studies that estimate 1 liter of amniotic fluid surrounding the fetus. The nonstress test is reactive with a heart rate of 142 beats/min and moderate variability. The client verbalizes lower back discomfort. Which interpretation of the fetal status will the nurse make? There is no concerning data. Fetal heart rate is normal and kidney function exists. There is limited amniotic fluid, but the fetal heart is not compromised. The fetal heart is stressed, with an elevated heart rate and nonstress test reactivity. The mother is experiencing back labor pains, causing a rupture of membranes.
There is no concerning data. Fetal heart rate is normal and kidney function exists.
The nurse is preparing a teaching session for a client considering tubal ligation. Which factor should the nurse prioritize in this session? Wait several months after birth, and schedule the surgery as an outpatient. The procedure is easy to perform and will be painless. This is a permanent and irreversible procedure for birth control. She must have signed consent from her partner.
This is a permanent and irreversible procedure for birth control.
During which phase of labor would the nurse anticipate providing the most emotional support for the mother? Active phase of labor Final phase of labor Transition phase of labor Latent phase of labor
Transition phase of labor
The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? Cord compression Maternal hypotension Maternal fatigue Uteroplacental insufficiency
Uteroplacental insufficiency
The nurse is caring for a client who prefers resting on her back during the labor process. To facilitate client wishes, which nursing action is required? Raise the head of the bed Place the tocometer low on abdomen Utilize a wedge under one hip Elevate the knee gatch
Utilize a wedge under one hip
A client with liver disease is seen in the clinic wanting to begin contraception. The nurse recognizes that which type of contraception is best for this client? Oral contraceptive pills (OCPs) Subdermal hormone implant Intramuscular injections Vaginal estrogen/progestin (contraceptive) ring
Vaginal estrogen/progestin (contraceptive) ring
-Vaginal birth of a live male in the vertex presentation, ROA position The above nurse's note was documented in the client's record by the labor room nurse. In which position was the client born? With the occiput facing the right anterior quadrant of the pelvis Rear facing with the occiput facing the posterior quadrant of the pelvis With the right side presenting, and the occiput facing the anterior quadrant With the brow facing the right anterior quadrant of the pelvis
With the occiput facing the right anterior quadrant of the pelvis
A woman needing home care will be discharged from an antepartum unit in 3 hours. The woman will be monitored for BP and blood glucose, and instruction will be given regarding her self-administration of subcutaneous heparin. The agency is contacted and arrangements are made for which person to make the initial visit? an RN an unlicensed assistive personnel (UAP) an LPN a certified home assistant
an RN
Immediately after birth, the nurse shows the mother a part of the skull appearing as a diamond-shaped area which closes by approximately 18 months after birth? The nurse refers to this area as which of the following? vertex occiput brow anterior fontanel (fontanelle)
anterior fontanel (fontanelle)
The school nurse is preparing a health education session on the topic of birth control for a college group. Which method should the nurse emphasize for this group? barrier hormonal rhythm transdermal
barrier
The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? occiput face buttocks shoulder
buttocks
A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present? intact membranes cervical dilation (dilatation) of 2 cm or more floating presenting fetal part a neonatologist to insert the electrode
cervical dilation (dilatation) of 2 cm or more
The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage? perineum cervix back birth canal
cervix
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: acupressure. patterned breathing. therapeutic touch. effleurage.
effleurage
A nurse is caring for several women in labor. The nurse determines that which woman is in the latent phase of labor? contractions every 5 minutes, cervical dilation (dilatation) 3 cm contractions every 3 minutes, cervical dilation (dilatation) 6 cm contractions every 2½ minutes, cervical dilation (dilatation) 8 cm contractions every 1 minute, cervical dilation (dilatation) 9 cm
contractions every 5 minutes, cervical dilation (dilatation) 3 cm
A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: cranial bones overlapping at the suture lines. extreme pressure in the vaginal vault. a congenital defect. prolonged labor.
cranial bones overlapping at the suture lines.
A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? decreased alertness increased agitation low Apgar increased crying
decreased alertness
The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action? delayed umbilical cord clamping clamping the cord immediately clamping the cord at 1 minute giving the infant oxygen as needed
delayed umbilical cord clamping
Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect? slipping of the periosteal joint developmental dysplasia of the hip (DDH) normal newborn variation overriding of the pelvic bone
developmental dysplasia of the hip (DDH)
A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? diffuse abdominal cramping rupturing of fetal membranes start of regular contractions dilation (dilatation) of cervix diameter to 10 cm
dilation (dilatation) of cervix diameter to 10 cm
A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply. a relaxed and distended uterus falling downward of uterus in the abdomen fresh gushing of blood from the vagina umbilical cord descending lower down a globular shaped uterus
fresh gushing of blood from the vagina umbilical cord descending lower down a globular shaped uterus
A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. current pregnancy history fundal height measurement support system estimated date of birth membrane status contraction pattern
fundal height measurement membrane status contraction pattern
The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply. hepatitis B vaccination hepatitis A vaccination intravenous immune globulin G hepatitis B immune globulin
hepatitis B vaccination hepatitis B immune globulin
The nurse is caring for a woman who has entered the second stage of labor. Which action by the woman would the nurse correct? crying during uterine contractions verbalizing anger toward the support person pushing with the uterine contractions holding breath during pushing
holding breath during pushing
A nurse is providing care to a client in labor. A pelvic exam reveals a vertex presentation with the presenting part tilted toward the left side of the mother's pelvis and directed toward the anterior portion of the pelvis. When developing this client's plan of care, which intervention would the nurse include? implementing measures for a vaginal birth preparing the client for a cesarean birth assisting with artificial rupture of the membranes instituting continuous internal fetal monitoring
implementing measures for a vaginal birth
A 33-year-old G1 P0000 patient is on home care for preterm contractions. The client tells her home care nurse that she is afraid to have a bowel movement and has stopped taking her iron supplement. The nurse teaches the client the importance of iron and also suggests: limiting her intake of green leafy vegetables. increasing her intake of oatmeal with milk. limiting her intake of carrots and fish. increasing her intake of fried corn chips.
increasing her intake of oatmeal with milk.
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process? early-stage labor before dilation (dilatation) only just before birth just after birth
just before birth
A client is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this client? latent phase active phase transition phase none of the above
latent phase
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? transition phase stage two latent phase stage three
latent phase
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: right upper quadrant. right lower quadrant. left upper quadrant. left lower quadrant.
left lower quadrant.
A woman is taking vaginal progesterone suppositories during her first trimester because her body does not produce enough of it naturally. She asks the nurse what function this hormone has in her pregnancy. What should the nurse explain is the primary function of progesterone? maintains the endometrial lining of the uterus during pregnancy ensures the corpus luteum of the ovary continues to produce estrogen contributes to mammary gland development regulates maternal glucose, protein, and fat levels
maintains the endometrial lining of the uterus during pregnancy
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypotension and fetal tachycardia maternal hypertension and fetal bradycardia maternal hypotension and fetal bradycardia maternal hypertension and fetal tachycardia
maternal hypotension and fetal bradycardia
A nurse is conducting an in-service program for a group of nurses working in the labor and birth suite of the facility. After teaching the group about the factors affecting the labor process, the nurse determines that the teaching was successful when the group identifies which component as part of the true pelvis? Select all that apply. pelvic inlet cervix mid pelvis pelvic outlet vagina pelvic floor muscles
mid pelvis pelvic inlet pelvic outlet
After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production? convection nonshivering thermogenesis cold stress bilirubin conjugation
nonshivering thermogenesis
A student nurse is preparing an illustration for a health fair depicting the various types of twins. Which format will the student use to depict identical twins? two separate eggs and different sperm two separate eggs and one sperm one egg and two different sperm one egg and one sperm
one egg and one sperm
A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation? relationship of the presenting part to the maternal pelvis part of the fetal body entering the maternal pelvis first relation of the fetal presenting part to the maternal ischial spine relation of the different fetal body parts to one another
part of the fetal body entering the maternal pelvis first
While discussing labor with a client and her partner, the nurse is asked what the best position is for giving birth to the baby. The nurse provides them with information that indicates research has shown which position as the best? position of comfort for the mother lying on her back with feet in stirrups squatting semi-Fowler position
position of comfort for the mother
Blood work results show that a client has a luteal defect, which is suspected to be the primary cause of her subfertility. The nurse explains that this condition is generally corrected by which of the following? progesterone vaginal suppositories myomectomy diathermy clomiphene citrate
progesterone vaginal suppositories
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? relaxin progesterone oxytocin prolactin
relaxin
he health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? insertion by any staff rupture of membranes cervical dilation of 1 cm the presenting fetal part not visible
rupture of membranes
A pregnant client is visiting the clinic and complains about the tiny, blanched, slightly raised end arterioles on her face, neck, arms, and chest. The nurse should explain that these are normal during pregnancy and are referred to as: epulis. linea nigra. striae gravidarum. telangiectasias.
telangiectasias.
A couple has chosen fertility awareness as their method of contraception. The nurse explains that the unsafe period for them during the menstrual cycle would be at which time? midway between the normal menstrual cycle three days before and three days after ovulation six days before the onset of menstruation five days after the first day of the menstrual cycle
three days before and three days after ovulation
A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? transition phase latent phase active phase early phase
transition phase
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. uterine resting tone frequency of contractions change in temperature change in blood pressure intensity of contractions
uterine resting tone frequency of contractions intensity of contractions