Module 1 NCLEX review questions

In order to reassure and educate pregnant clients about changes in their blood pressure, maternity nurses should be aware that:

compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term pregnancy. The tightness of a cuff that is too small produces a reading that is too high; similarly, the looseness of a cuff that is too large results in a reading that is too low. Because maternal positioning affects readings, blood pressure measurements should be obtained in the same arm and with the woman in the same position. The systolic blood pressure generally remains constant but may decline slightly as pregnancy advances. The diastolic blood pressure first drops and then gradually increases. This compression also leads to varicose veins in the legs and vulva.

A pregnant woman demonstrates understanding of the nurse's instructions regarding relief of leg cramps if she:

extends her leg and dorsiflexes her foot during the cramp. Pointing toes can aggravate rather than relieve the cramp. Application of heat is recommended. Extending the leg and dorsiflexing the foot is the appropriate relief for a leg cramp. Bearing weight on the affected leg can help to relieve the leg cramp, so it should not be avoided.

A nurse providing care to a woman in labor should be aware that a clinical indication for a cesarean birth:

is performed primarily for the benefit of the fetus and/or mother in the context of clinical conditions. Clinical indication for a cesarean section is based on preventing complications that would impact either the fetus or the mother leading to adverse outcomes. Preference of the patient is not a clinical indication for this type of surgery. Recovery time is increased relative to vaginal delivery as a cesarean section is considered to be a major abdominal surgery. Increased pain is not a clinical indication for a cesarean section. Pain management can be implemented through various strategies including but not limited to nonpharmacologic and pharmacologic methods.

A pregnant woman at 32 weeks of gestation complains of feeling dizzy and light-headed while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to:

turn the woman on her side. Vital signs can be assessed next. Breathing into a paper bag is the solution for dizziness related to respiratory alkalosis associated with hyperventilation. Raising her legs will not solve the problem since pressure will still remain on the major abdominal blood vessels, thereby continuing to impede cardiac output. During a fundal height measurement the woman is placed in a supine position. This woman is experiencing supine hypotension as a result of uterine compression of the vena cava and abdominal aorta. Turning her on her side will remove the compression and restore cardiac output and blood pressure.

In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information?

"Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." Maternal and fetal risks are associated with every cesarean section. This statement is the most appropriate. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure.

A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is:

"It is normal to be anxious about labor. Let us discuss what makes you feel afraid." This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool.

An expectant father confides in the nurse that his pregnant wife, 10 weeks of gestation, is driving him crazy. "One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?" The nurse's BEST response would be:

"This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant." Mood swings are a normal finding in the first trimester; the woman does not need counseling. This is the most appropriate response since it gives an explanation and a time frame for when the mood swings may stop.

A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse?

"We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage." Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low risk pregnancy and as long as labor is progressing normally.

A pregnant woman at 10 weeks of gestation jogs 3 or 4 times per week. She is concerned about the effect of exercise on the fetus. The nurse should inform her:

"You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month." The nurse should inform the woman that she may need to reduce her exercise level as the pregnancy progresses. Physical activity promotes a feeling of well-being in pregnant women. It improves circulation, promotes relaxation and rest, and counteracts boredom. Typically, running should be replaced with walking around the seventh month of pregnancy. Simple measures should be initiated to prevent injuries, such as warm-up and stretching exercises to prepare the joints for more strenuous exercise.

Nurses can advise their patients that which of these signs precede labor? (Select all that apply.)

-A return of urinary frequency as a result of increased bladder pressure. -Persistent low backache from relaxed pelvic joints -Stronger and more frequent uterine (Braxton Hicks) contractions After lightening a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor, women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term.

Vaginal examinations should be performed by the nurse under which of these circumstances? (Select all that apply.)

-An admission to the hospital at the start of labor. -On maternal perception of perineal pressure or the urge to bear down -When membranes rupture Vaginal examinations should be performed when the woman is admitted to the hospital or birthing center at the start of labor. An accelerated fetal heart rate (FHR) is a positive sign; variable decelerations, however, merit a vaginal examination. When the woman perceives perineal pressure or the urge to bear down is an appropriate time to perform a vaginal examination. After rupture of membranes (ROM) a vaginal examination should be performed. The nurse must be aware that there is an increased risk of prolapsed cord immediately after ROM. Examinations are never done by the nurse if vaginal bleeding is present since the bleeding could be a sign of placenta previa and a vaginal examination could result in further separation of the low-lying placenta.

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What findings indicate that preterm labor may be occurring? (Select all that apply.)

-History of preterm labor experience with a prior pregnancy -The cervix is effacing and dilated to 2 cm. A significant risk factor for preterm birth is a preterm birth experience with a prior pregnancy. Irregular, mild contractions that do not cause cervical change are not considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor, such as cervical changes. Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Fetal heart rate is normal.

Which statements about multifetal pregnancy are most appropriate?(Select all that apply).

-The expectant mother often develops anemia because the fetuses have a greater demand for iron. -The mother should be counseled to increase her nutritional intake and gain more weight -Backache and varicose veins are often more pronounced. A woman with a multifetal pregnancy often develops anemia due to the increased demands of two fetuses. This should be monitored closely throughout her pregnancy. Twin pregnancies often end in prematurity. Serious efforts should be made to bring the pregnancy to term. The client may need nutrition counseling to ensure that she gains more weight than what is needed for a singleton birth. The considerable uterine distention is likely to cause backache and leg varicosities. Maternal support hose should be recommended. Spontaneous rupture of membranes before term is common.

For the labor nurse, care of the expectant mother begins with which situations? (Select all that apply.)

-The onset of progressive, regular contractions -Observation og bloody, or pink show -Spontaneous rupture of membranes Labor care begins with the onset of progressive, regular contractions. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when the blood-tinged mucoid vaginal discharge appears. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when amniotic fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Labor care begins when progressive, regular contractions begin, the blood-tinged mucoid vaginal discharge appears, or fluid is discharged from the vagina. The woman and the nurse can formulate their plan of care before labor or during treatment. Nursing care begins when patient identifies painful contractions. The onset of progressive, regular contractions signals the beginning of labor; not the intensity of the pain.

After delivering a healthy baby boy with epidural anesthesia, a woman on the after birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)

-administration of oral analgesics -assisting with a blood patch procedure -frequent monitoring of vital signs The nurse should suspect the patient is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief (Hawkins and Bucklin, 2012). Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential.

When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.)

-fetal heart rate of 100 beats/min -minimal variability on a fetal heart monitor After induction of the anesthetic, maternal blood pressure, pulse, and respirations and fetal heart rate and pattern must be checked and documented every 5 to 10 minutes. If signs of serious maternal hypotension (e.g., the systolic blood pressure drops to 100 mm Hg or less or the blood pressure falls 20% or more below the baseline) or fetal distress (e.g., bradycardia, minimal or absent variability, late decelerations) develop, emergency care must be given.

The labor and delivery nurse is admitting a woman complaining of being in labor. The nurse completes the admission database and notes that which factors may prohibit the woman from having a vaginal birth? (Select all that apply.)

-unstable coronary artery disease -previous cesarean birth -placenta previa Indications for cesarean birth include:MaternalSpecific cardiac disease (e.g., Marfan syndrome, unstable coronary artery disease)Specific respiratory disease (e.g., Guillain-Barré syndrome)Conditions associated with increased intracranial pressureMechanical obstruction of the lower uterine segment (tumors, fibroids)Mechanical vulvar obstruction (e.g., extensive condylomata)History of previous cesarean birthFetalAbnormal fetal heart rate (FHR) or patternMalpresentation (e.g., breech or transverse lie)Active maternal herpes lesionsMaternal human immunodeficiency virus (HIV) with a viral load of more than 1000 copies/mLCongenital anomaliesMaternal-FetalDysfunctional labor (e.g., cephalopelvic disproportion, "failure to progress" in labor)Placental abruptionPlacenta previaElective cesarean birth (cesarean on maternal request)The blood pressure can be elevated because of pain and is not necessarily a contraindication to vaginal birth until further assessment is completed. Having a history of three spontaneous abortions is not a contraindication to vaginal birth.

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system?

3-1-0-1-0. Using the GPTAL system, this woman's gravidity and parity information is calculated as follows:G: Total number of times the woman has been pregnant (she is pregnant for the third time) T: Number of pregnancies carried to term (she has one stillborn) P: Number of pregnancies that resulted in a preterm birth (she has none) A: Abortions or miscarriages before the period of viability (she has had one) L: Number of children born who are currently living (she has no living children)

Which hematocrit (Hct) and hemoglobin (Hgb) results represent(s) the lowest acceptable values for a woman in the third-trimester of pregnancy?

33% Hct; 11 g/Dl Hbg. This is within normal limits in the nonpregnant woman. This is within normal limits for a nonpregnant woman. Represents the lowest acceptable value during the first and the third trimesters. This represents the lowest acceptable value for the second trimester when the hemodilution effect of blood volume expansion is at its peak.

A pregnant woman is the mother of two children. Her first pregnancy ended in a still birth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the 5-digit system to describe this woman's current obstetric history, the nurse would record _.

4-1-2-0-2. Gravida (the first number) is 4 since this woman is now pregnant and was pregnant 3 times before. Para (the next 4 numbers) represents the outcomes of the pregnancies and would be described as: 4T: 1 = Term birth at 41 weeks of gestation (son) 4P: 2 = Preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter) 4A: 0 = Abortion: none occurred 4L: 2 = Living children: her son and her daughter.

Which description of the phases of the second stage of labor is accurate?

Active Pushing (Descent) phase: Significant increase in contractions, Ferguson reflux activated, average duration varies. The latent phase is the lull, or "laboring down," period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The active phase occurs in the first stage of labor indicating cervical progression from 5 to 7 cm. The active pushing (descent) phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The transition phase is the final phase in the first stage of labor; contractions are strong and painful.

Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?

Active: Moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to have a drink with dinner now. The nurse tells her:

Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy. Regardless of which trimester the woman has reached, no amount of alcohol during pregnancy has been deemed safe for the fetus. Neither one drink per night nor three drinks per week is a safe recommendation. Although the first trimester is a crucial period of fetal development, pregnant women of all gestations are counseled to eliminate all alcohol from their diet. A safe level of alcohol consumption during pregnancy has not yet been established. Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised.

Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period?

Encourage skin-to-skin contact of mother and baby. The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. The father or support person is likely anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin and breastfeeding has been initiated.

Which test is performed to determine if membranes are ruptured?

Fern test A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. Artificial rupture of membranes (AROM) is the procedure of artificially rupturing membranes, usually with a device known as an AmniHook.

If exhibited by a pregnant woman, what represents a positive sign of pregnancy?

Fetal heartbeat auscultated with Doppler/fetoscope. Morning sickness and quickening, along with amenorrhea and breast tenderness, are presumptive signs of pregnancy; subjective findings are suggestive but not diagnostic of pregnancy. Other probable signs include changes in integument, enlargement of the uterus, and Chadwick sign. A positive pregnancy test is still considered to be a probable sign of pregnancy (objective findings are more suggestive but not yet diagnostic of pregnancy) since error can occur in performing the test or in rare cases human chorionic gonadotropin (hCG) may be detected in the urine of nonpregnant women. Chances of error are less likely to occur today since pregnancy tests used are easy to perform and are very sensitive to the presence of the hCG associated with pregnancy. Detection of a fetal heartbeat, palpation of fetal movements and parts by an examiner, and detection of an embryo/fetus with sonographic examination would be positive signs diagnostic of pregnancy.

Which presumptive signs (felt by the woman) or probable sign (observed by the examiner) of pregnancy is not matched with another possible cause?

Goodell sign: Cervical polyps. Amenorrhea sometimes can be caused by stress, vigorous exercise, early menopause, or endocrine problems. Quickening can be gas or peristalsis. Goodell sign might be the result of pelvic congestion, not polyps. Chadwick sign might be the result of pelvic congestion.

During a client's physical examination, the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as: A. Hegar sign B. McDonald sign C. Chadwick sign D. Goodell sign

Hegar sign. At approximately 6 weeks of gestation, softening and compressibility of the lower uterine segment occur; this is called the Hegar sign. The McDonald sign indicates a fast-food restaurant. The Chadwick sign is a blue-violet cervix caused by increased vascularity; this occurs around the fourth week of gestation. Softening of the cervical tip is called the Goodell sign, which may be observed around the sixth week of pregnancy.

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester?

Increased pulse rate. Splitting of S1 and S2 is more audible. Between 14 and 20 weeks of gestation, the pulse increases about 10 to 15 beats/min, which persists to term. In the first-trimester blood pressure usually remains the same as the prepregnancy level, but it gradually decreases up to about 20 weeks of gestation. During the second trimester both the systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Production of RBCs accelerates during pregnancy.

A pregnant woman's last menstrual period began on April 8, 2009, and ended on April 13. Using Nägele's rule, her estimated date of birth would be _.

January 15, 2010. Nägele's rule requires subtracting 3 months and adding 7 days and 1 year if appropriate to the first day of a pregnant woman's last menstrual period. When this rule is used with April 8, 2009, the estimated date of birth is January 15, 2010.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take?

Notify the primary health care provider immediately (HCP). Although delivery is a priority, notification of the nursery nurse is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section may be warranted. Performing a straight cath at this time would not be prudent as it is more likely that a foley catheter will have to be inserted if a cesarean section becomes the mode of delivery. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase intravenous (IV) fluid, and provide oxygen. Also, if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.

For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse?

One fetal movement noted in 1 hour of assessment by the mother. A fetal heart rate of 116 beats/min is a normal finding at 42 weeks of gestation. Cervical dilation of 2 cm with 50% effacement is a normal finding in a 42-week gestation woman. A score of 8 on the biophysical profile (BPP) is a normal finding in a 42-week gestation pregnancy. Self-care in a postterm pregnancy should include performing daily fetal kick counts 3 times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation.

A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority?

Place the woman in the knee-chest position. A. The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord.B. If the cord is protruding from the vagina, it may be covered with a sterile towel soaked in saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing priority.C. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete. D. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. This intervention should be initiated after pressure is relieved on the cord. Not only should the woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers to lift the presenting part off the cord.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be:

Progressive uterine contractions with cervical change. Regular, progressive uterine contractions that increase in intensity and frequency are the definitive signs of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer.

What laboratory results would be a cause for concern if exhibited by a woman at her first prenatal visit during the second month of her pregnancy?

Rubella titer 1:6. A rubella titer of less than 1:10 indicates a lack of immunity to rubella, a viral infection that has the potential to cause teratogenic effects on fetal development. Arrangements should be made to administer the rubella vaccine after birth during the after birth period since administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women receiving the vaccine during the postpartum period should be cautioned to avoid pregnancy for 3 months.

Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be increased?

Squatting. A semirecumbent position does not assist in increasing the size of the pelvic outlet. Although sitting may assist with fetal descent, this position does not increase the size of the pelvic outlet. Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet.

Concerning the third stage of labor, nurses should be aware that:

The duration of the third stage may be as short as 3 to 5 minutes. The placenta cannot detach itself from a flaccid (relaxed) uterus. B. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. C. Which surface of the placenta comes out first is not clinically important. D. The major risk for women during the third stage of labor is after birth hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data?

The fetal presenting part is 1 cm above the ischial spines. Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

A nurse is reviewing information related to home pregnancy tests so as to prepare for a patient teaching session. Which statement by the patient indicates that additional instruction is needed following the teaching session?

The patient states that there is no need for concern as home pregnancy test results are 100% correct. Home pregnancy testing while reliable does not provide 100% correct results. There are other variables such as medication history as well as timing of specimen, collection and interpretation that may lead to inaccurate results. Following directions, noting a color change as a positive result and being able to perform the test without any assistance in the home setting all indicate that the patient has an understanding of the process.

Fetal well-being during labor is assessed by:

The response of the fetal heart rate (FHR) to uterine contractions (UCs). Fetal well-being during labor can be measured by the response of fetal heart rate (FHR) to uterine contractions (UCs). In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

Turn the woman to the left lateral position or place a pillow under her hip. Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The intravenous (IV) rate should be kept at the current rate or increased to maintain the appropriate perfusion. Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of:

a fetal heart rate (FHR) of 180 with absence of variability. The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. This fetal heart rate (FHR) is nonreassuring. The oxytocin should be immediately discontinued and the physician should be notified. Unless a change occurs in the FHR pattern that is nonreassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the client's membranes have ruptured.

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be:

alteration in the pattern of fetal movement Constipation is a normal discomfort of pregnancy that occurs in the second and third trimesters. An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy. Heart palpitations are a normal change related to pregnancy. This is most likely to occur during the second and third trimesters. As the pregnancy progresses, edema in the ankles and feet at the end of the day is not uncommon.

A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to:

assess the fetal heart rate (FHR) pattern. The first nursing action after the membranes are ruptured is to check fetal heart rate (FHR). Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy). These are all important and should be done after the FHR and pattern are assessed.

When assessing the fetal heart rate (FHR) of a woman at 30 weeks gestation, the nurse counts a rate of 82 beats/min. Initially the nurse should:

assess the woman's radial pulse. The expected fetal heart rate (FHR) is 120 to 160 beats/min. The nurse may have inadvertently counted the uterine souffle, the beat-like sound of blood flowing through the uterine blood vessels, which corresponds to the mother's heartbeat. The physician should be notified if the FHR is confirmed to be 82 beats/min. Allow the woman to hear the heartbeat as soon as a full assessment is made.

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe:

bloody show. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct. Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens.

The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by:

change in position. Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration may reduce maternal cardiac output. Regional anesthesia may reduce maternal cardiac output. Intravenous analgesic may reduce maternal cardiac output.

The nurse's priority action when observing early deceleration indicating expected head compression during contractions is to:

change maternal position. The usual priority is as follows:1. Change maternal position (side to side, knee chest).2. Discontinue oxytocin if infusing.3. Administer oxygen at 8 to 10 L/min by nonrebreather face mask.4. Notify physician or nurse-midwife.5. Assist with vaginal or speculum examination to assess for cord prolapse.6. Assist with amnioinfusion if ordered.7. Assist with birth (vaginal assisted or cesarean) if pattern cannot be corrected

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use:

counterpressure against the sacrum. Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

Which characteristic is associated with false labor contractions?

decrease in intensity with ambulation False labor does not lead to changes in the cervix. Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.

On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should:

describe the finding in the nurse's notes. An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix. Other actions would be implemented when nonreassuring or ominous changes are noted.

With regard to systemic analgesics administered during labor, nurses should be aware that:

effects on the fetus and newborn can include decreased alertness and delayed sucking. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. Intravenous (IV) administration is preferred over intramuscular (IM) administration because the drug acts faster and more predictably. Patient-controlled analgesia (PCAs) result in decreased use of an analgesic.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:

encouraging the woman to try various upright positions, including squatting and standing Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is:

fentanyl (Sublimaze). Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.

A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates an understanding of the nurse's instructions if she states that a positive sign of pregnancy is:

fetal movement palpated by the nurse-midwife. A positive pregnancy test is a probable sign of pregnancy. Positive signs of pregnancy are those that are attributed to the presence of a fetus, such as hearing the fetal heartbeat or palpating fetal movement. Braxton Hicks contractions are a probable sign of pregnancy. Quickening is a presumptive sign of pregnancy.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that:

hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. The woman and her partner should experiment with massage before labor to see what might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to:

help the woman breath into a paper bag. Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension.

Which statement is most likely to be associated with a breech presentation?

high rate of neuromuscular disorders. Breech is the most common malpresentation affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as is the fetal head. Diagnosis is made by abdominal palpation and vaginal examination. It is confirmed by ultrasound. Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus.

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:

hypotension Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic because it would be with a low spinal (saddle block) anesthetic. Limited perception of bladder fullness is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to:

initiation of epidural anesthesia that resulted in maternal hypotension. Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring fetal heart rate (FHR) pattern.

An expectant couple asks the nurse about intercourse during pregnancy and if it is safe for the baby. The nurse should tell the couple that:

intercourse and orgasm are often contraindicated if a history or signs of preterm labor are present. Some spotting can normally occur as a result of the increased fragility and vascularity of the cervix and vagina during pregnancy. Intercourse can continue as long as the pregnancy is progressing normally. Safer-sex practices are always recommended; rupture of the membranes may require abstaining from intercourse. Uterine contractions that accompany orgasm can stimulate labor and would be problematic if the woman were at risk for or had a history of preterm labor.

With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that:

its most important function is to afford the opportunity to administer antenatal glucocorticoids. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Administering intravenous fluids in the presence of pulmonary edema (regardless of origin) is contraindicated as it will lead to fluid overload.

During the first trimester the pregnant woman would be most motivated to learn about:

measures to reduce nausea and fatigue so she can feel better. Fetal development concerns are more apparent in the second trimester when the woman is feeling fetal movement. Impact of a new baby on the family would be appropriate topics for the second trimester when the fetus becomes "real" as its movements are felt and its heartbeat heard. During this trimester a woman works on the task of, "I am going to have a baby." During the first trimester a woman is egocentric and concerned about how she feels. She is working on the task of accepting her pregnancy. Motivation to learn about childbirth techniques and breastfeeding is greatest for most women during the third trimester as the reality of impending birth and becoming a parent is accepted. A goal is to achieve a safe passage for herself and her baby.

A nurse caring for a woman in labor understands that moderate variability of the fetal heart rate might be caused by:

methamphetamines. Maternal ingestion of narcotics may be the cause of absent or minimal variability. The use of barbiturates may also result in a significant decrease in variability as these are known to cross the placental barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause moderate variability. Tranquilizer use is a possible cause of absent or minimal variability in the fetal heart rate.

A maternal serum alpha-fetoprotein (MSAFP) test is performed at 16 to 18 weeks of gestation. An elevated level has been associated with:

open neural tube defects such as spina bifida. Low levels of MSAFP are associated with Down syndrome. Sickle cell anemia is not detected by the MSAFP. Cardiac defects would not be detected with the MSAFP. A triple marker test determines the levels of MSAFP along with serum levels of estriol and human chorionic gonadotropin; an elevated level is associated with open neural tube defects.

With regard to medications, herbs, immunizations, and other substances normally encountered, the maternity nurse should be aware that:

prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus. This is especially true for new medications and combinations of drugs. The greatest danger of drug-caused developmental defects exists in the interval from fertilization through the first trimester, when a woman may not realize that she is pregnant. Live-virus vaccines should be part of postpartum care; killed-virus vaccines may be administered during pregnancy. Secondhand smoke is associated with fetal growth restriction and increases in infant mortality.

A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a:

primipara. A primipara is a woman who has completed one pregnancy with a viable fetus. To remember terms, keep in mind that gravida is a pregnant woman; para comes from parity, meaning a viable fetus; primi means first; multi means many; and null means none. A primigravida is a woman pregnant for the first time. A multipara is a woman who has completed two or more pregnancies with a viable fetus. A nulligravida is a woman who has never been pregnant.

After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is:

referred. Visceral pain is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early after birth period is uterine. This pain is very similar to that experienced in the first stage of labor.

Nurses should be aware of the different experience can make in labor pain, such as:

sensory pain for nulliparous women often is greater than for multiparous women during early labor. Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

The nurse advises the woman who wants to have a nurse-midwife provide obstetric care that:

she must be having a low risk pregnancy. Most nurse-midwife births are managed in hospitals or birth centers; a few may be managed in the home. Nurse-midwives may practice with physicians or independently with an arrangement for physician backup. They must refer clients to physicians for complications. Care in a midwifery model is noninterventional, and the woman and family usually are encouraged to be active participants in the care. This does not imply that medications for pain control are prohibited. Midwives usually see low risk obstetric clients. Care is often noninterventional with active involvement from the woman and her family. Nurse-midwives must refer clients to physicians for complications.

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to:

stop the Pictocin. The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.

A woman is evaluated to be using an effective bearing-down effort if she:

takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. Bearing-down efforts should begin during the active-descent phase of the second stage of labor when the urge to bear down (Fresno reflex) is perceived. Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal. Pushing gently between contractions is only advised when the fetal head is being delivered.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that:

the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation. Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of potentially unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain.

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:

the examiner's hand should be placed over the fundus before, during, and after contractions. The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.

The nurse knows that the second stage of labor, the active descent phase, has begun when:

the woman experiences a strong urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. During the active descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern?

variability averages between 6 and 10 beats per minute. Fetal heart rate (FHR) should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well oxygenated fetus with a functioning autonomic nervous system.

With regard to dysfunctional labor, nurses should be aware that:

women who have dysfunctional labor are more likely to deliver via cesarean birth. Dysfunctional labor is more likely to occur as a result of a structural (pelvic) abnormality. A gynecoid pelvis is considered to be a normal pelvic structure. Women who have dysfunctional labor are more likely to deliver via cesarean section as compared to vaginal delivery. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years of age.

The charge nurse on the maternity unit is orienting a new nurse to the unit and explains that the 5 Ps of labor and birth are: (Select all that apply.)

-passenger -passageway -psychological response -powers -position Five factors affect the process of labor and birth. These are easily remembered as the five Ps: passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response.

The maternity nurse should notify the health care provider about which assessment findings during labor? (Select all that apply.)

-positive urine drug screen -increased systolic blood pressure during first stage -respiratory rate of 10 breaths/min The health care provider should be alerted to a positive urine drug screen, because certain drugs will have an effect on pain medications that can be safely administered. The respiratory rate usually increases during labor. A rate of 10 is low and needs to be reported. Decreased blood glucose levels (due to exertion and glucose consumption for energy), and increased systolic blood pressure, elevated white blood cell count (due to stress response), and a slightly elevated temperature (up to 100.4° F) are expected findings during labor.

If exhibited by an expectant father, what would be a warning sign of ineffective adaptation to his partner's first pregnancy?

Consistently changes the subject when the topic of the fetus/newborn is raised. Persistent refusal to talk about the fetus-newborn may be a sign of a problem and should be assessed further.