NUR 314 Practice Questions

Normal variability

6-25 bpm

A 40-year-old female client with a chronic pelvic infection expresses her desire to conceive post-treatment. When discussing this with the client the nurse keeps in mind that the client is at increased risk for which of the following?

Ectopic pregnancy Chronic pelvic infection increases the risk for narrowed or blocked fallopian tubes. It decreases the possibility of fertility or increases the risk of ectopic pregnancy. Only in case of a premature ovarian failure will the client experience symptoms of menopause earlier than expected. A client with hyperthyroidism will experience decreased or absent menses. The client with chronic pelvic infection is not susceptible to gestational diabetes. Clients with multiple gestations are more susceptible to gestational diabetes.

A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client?

Risk for fetal infection related to early rupture of membranes Once membranes have ruptured, the seal to the fetus is broken and microorganisms may infect the uterus or fetus. There is no indication in the scenario that a potential loss of pregnancy is evident, nor is there an indication of anticipatory grieving. As described in this scenario there is not a high probability of fetal death from placental dysfunction. A woman at 36 weeks' gestation would not be feeling powerless because of an inability to sustain pregnancy.

A client having an examination to check the placement of an intrauterine device (IUD) is diagnosed as being pregnant. For which action should the nurse prepare the client at this time?

Removal of the IUD A client may become pregnant with an intrauterine device (IUD) in place. If this occurs, it needs to be removed to prevent infection during pregnancy. The fetus does not need to be aborted, and the client will not spontaneously abort because the IUD is in place. The IUD cannot remain in place because of the risk for infection.

A mother in labor with ruptured membranes comes to the labor and delivery unit. It is determined that the fetus is in a single footling breech presentation. The nurse assesses the mother for which complication associated with this fetal position?

Cord prolapse All infants born breech are at greater risk for asphyxia and trauma at the time of birth. Infants born footling breech are at a higher risk for cord prolapse. Breech presentation does not affect the tone of the uterus nor does it increase the risk for placental abruption. A brachial plexus injury can occur with any fetal position during delivery. It is not specific to breech presentation.

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds that can prolong labor. The nurse is referring to which compounds?

catecholamines Fear and anxiety cause the release of catecholamines, such as norepinephrine and epinephrine, which stimulate the adrenergic receptors of the myometrium. This in turn interferes with effective uterine contractions and results in prolonged labor. Estrogen promotes the release of prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on the pelvic joints. Prostaglandins, oxytocin, and relaxin are not produced due to fear or anxiety in clients during labor.

A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which test would the nurse expect to be used to predict fetal lung maturity when the client goes into labor?

lecithin/sphingomyelin ratio The lecithin/sphingomyelin (L/S) ratio of the amniotic fluid helps predict the fetal lung maturity in a client with PROM who goes into labor. A reticulocyte count is used for testing sickle cell anemia. The Nitrazine test aids in the diagnosis of PROM and differentiates the amniotic fluid that leaks out after PROM from the normal vaginal secretion. It does not aid in determining fetal lung maturity. A test for antiphospholipids is done in diagnosing antiphospholipid syndrome, and does not aid in determining fetal lung maturity.

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction?

shortened A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.

A female patient is complaining of vaginal spotting and sharp colicky pain. She informs the nurse that her period is 2 weeks late. The patient should be investigated for which of the following?

Ectopic pregnancy Clinical symptoms of an ectopic pregnancy include delay in menstruation of 1 to 2 weeks, vaginal spotting, and sharp colicky pain. Trichomonas vaginalis causes a vaginal infection. The symptoms described in the scenario are not symptoms of cervical cancer or a yeast infection.

A client with diabetes is in the first trimester of pregnancy and is currently having difficulty keeping blood glucose levels within normal limits. The client explains that she has been "eating for two" so the baby is healthy. How should the nurse respond to the client?

"Elevated blood glucose levels in the first trimester have been linked to congenital anomalies." The first trimester of pregnancy is the most important time for fetal development. If the client can control hyperglycemia during this time, the chances of a congenital anomaly are greatly reduced. Infants of clients with poorly controlled diabetes tend to be large. At birth, babies born to clients with uncontrolled diabetes are prone to respiratory distress syndrome. Elevated blood glucose levels do not hasten the development of the fetus in utero and can lead to hydramnios.

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful?

"I will be sure to avoid getting pregnant for at least 1 year." After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.

A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best?

"Please come in now for an evaluation by your health care provider." Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage. The client looks frightened and confused and states that she does not believe in abortion. Which statement by the nurse is best?

"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.

Assessment of pregnant woman reveals that the woman has a BMI of 31. The woman is pregnant with one fetus. The nurse would most likely recommend a total weight gain of no greater than which amount?

20 lbs. Women whose weight falls into the normal BMI category (18.5 to 24.9) should aim to gain 25 to 35 lb; underweight women or those whose BMI is less than 18.5 should gain 28 to 40 lb; overweight women (a BMI over 25 to 29.9) should gain 15 to 25 lb; and obese women (a BMI over 30) should gain 11 to 20 lb.

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?

Magnesium Sulfate Magnesium sulfate is only given intravenously for preterm labor. Nifedipine and indomethacin are given orally for preterm labor. Betamethasone is given by intramuscular injection to help promote fetal lung maturity by stimulating surfactant production. It is not a tocolytic agent.

A pregnant client is diagnosed with placenta previa. Which action should the nurse implement immediately for this client?

Assess fetal heart sounds with an external monitor. For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine contractions are contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both mother and child. To ensure an adequate blood supply to the client and fetus, the client should be placed immediately on bedrest in a side-lying position.

The nurse provides education to a postterm pregnant client. information will the nurse include to assist in early identification of potential problems?

Continue to monitor fetal movements daily. The nurse will teach the postterm client to monitor fetal movements daily to help determine if the fetus is experiencing distress. A 24-hour urine is needed for postterm clients; however, this is not collected daily. Although all pregnant clients should avoid dehydration, there is no indication this client needs to increase her fluid intake and this will not help identify potential problems. Monitoring bowel movements for constipation is not needed.

A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position?

Lie in a semi-recumbent position. Semi-recumbent position is the best position for circulation of the mother and fetus. Lying flat on the back can induce supine hypotensive syndrome and fully recumbent impedes other circulation. The high Fowler position would not be comfortable for sleeping, as well as possibly impede the blood flow through the hips and lower abdomen.

A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?

Ectopic Pregnancy The most commonly reported symptoms of ectopic pregnancy are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered. A healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

Elevated Liver Enzymes HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia is not a part of this syndrome. HELLP may increase the woman's risk for DIC but it is not an assessment finding.

A pregnant client reports feeling pain similar to menstrual cramps. What should the nurse explain about this client's symptoms?

If rhythmical, they could indicate preterm labor. Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically contracts and then relaxes again. These sensations are Braxton Hicks contractions and can be similar to a forceful menstrual cramp. These contractions are not usually a sign of beginning labor but should be reported for evaluation. A rhythmic pattern of even very light but persistent contractions could be a beginning sign of preterm labor. Exercise or rest does not reduce the frequency of Braxton Hicks contractions.

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy?

Methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully; descent in the pelvis; abnormal fetal heart rate patterns or acute pulmonary edema; and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

The nurse is caring for a client who has a multifetal pregnancy. What topic should the nurse prioritize during health education?

Signs of preterm labor The client with a multifetal pregnancy must be made aware of the risks posed by preterm labor. There is no corresponding increase in the risk for hypertension or blood incompatibilities. Parenting skills are secondary to physiologic needs at this point.

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?

Stop the infusion immediately. The woman is exhibiting signs of uterine hyperstimulation, which necessitate stopping the oxytocin infusion immediately to prevent further complications. Once the infusion is stopped, the nurse should notify the birth attendant and continue to monitor the woman's contractions and fetal heart rate.

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)?

Strong abdominal cramping Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.

A physician has prescribed magnesium sulfate for a client with premature labor. Data collection reveals the client's respiratory rate is 12 breaths/minute, and urine output is 30 ml/hour. The magnesium sulfate serum levels are 7 mg/dl. When questioned, the client reports feeling warm and flushed. Based upon the nurse's understanding of magnesium sulfate, what action is most appropriate?

The client's response is appropriate and within normal limits; therefore, no action is Magnesium sulfate is associated with feelings of warmth and flushing; these symptoms do not indicate toxicity or allergic reaction. Respirations of 12 breaths/minute are considered normal. Urine output should be at least 30 ml/hour. Serum levels of magnesium sulfate should be between 4 and 8 mg/dl to promote a therapeutic response.

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect?

firm, rigid uterus on palpation The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

A pregnant client is being admitted for severe preeclampsia. In which room location should the nurse place this client?

in the back private room With severe preeclampsia, hospitalization is required so that bed rest can be enforced and the client can be observed more closely. A client with severe preeclampsia is admitted to a private room so that rest is undisturbed. Noises such as a baby crying, elevator doors opening and closing, and conversation from the nurse's station are sufficient to trigger a seizure. A private room will help reduce the likelihood of seizure development.

A nurse is describing the risks associated with post-term pregnancies as part of an in-service presentation. The nurse determines that more teaching is needed when the group identifies which factor as an underlying reason for problems concerning the fetus?

increased amniotic fluid volume Fetal risks associated with a post-term pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline after 38 weeks' gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult (Norwitz, 2019). All of these issues can compromise fetal well-being and lead to fetal distress.

A nurse is preparing an in-service education program for a group of nurses about dystocia involving problems with the passenger. Which problem would the nurse likely include as the most common?

persistent occiput posterior position Common problems involving the passenger include occiput posterior position, breech presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to cephalopelvic disproportion (CPD), and structural anomalies. Of these, persistent occiput posterior is the most common malposition, occurring in about 15% of laboring women.

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

knee-chest Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

The nutritional needs of an adolescent pregnant client are unique because:

owing to typical food choices, an adolescent is often lacking calcium, iron, and folic acid in the diet. A pregnant adolescent has the same caloric requirements as an older pregnant woman of the same BMI (2500 calories a day for normal weight BMI). Often adolescents are already deficient in their caloric intake and therefore have to increase their daily calorie consumption by more than the recommended 300 calories a day to meet a diet of 2500 calories. Adolescents snack frequently but do not typically eat three meals a day. Parents may be very involved in the diets of these clients in that they often buy and cook the food that they consume.

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor Preterm labor is the occurrence of regular uterine contractions accompanied by cervical effacement and dilation (dilatation) before the end of the 37th week of gestation. If not halted, it leads to preterm birth. Normal labor can occur after the 37th week. Dystocia refers to a difficult labor. Precipitate labor is one that is completed in less than 3 hours from the start of contraction to birth.

A pregnant client at 24 weeks' gestation arrives in the office and reports that her feet and legs are swelling. During a client evaluation, the nurse notes that she can elicit a 4-mm skin depression that disappears in 10 to 15 seconds. The client is considered at risk for preeclampsia. What additional assessment would be beneficial for the nurse to complete?

weight gain Although edema is not a cardinal sign of preeclampsia, weight should be monitored frequently to identify sudden gains in a short time span. A urine culture is not indicated but urine would be checked for protein. A complete blood count may be done to evaluate the woman's status but would provide little information about the client's risk for preeclampsia. Fundal height is a routine assessment completed at each visit.