OB TEST 2
During which period of gestation is gestational diabetes usually diagnosed? A. 28- 32 weeks B. 15-18 weeks C. 36-38 weeks D. 24-28 weeks
D. 24-28 weeks
Which of the following are acceptable maternal positions for labor and delivery? Select all that apply. A. Lithotomy B. Trendelenburg C. Kneeling D. Squatting E. Lateral recumbent
A. Lithotomy C. Kneeling D. Squatting E. Lateral recumbent
The nurse is caring for a pregnant client in the transition phase of labor. On assessment, which of the following are indications that this phase of labor is progressing? Select all that apply. A. The client is irritable. B. The client is talkative and excited. C. The client is unable to concentrate. D. The client feels discouraged. E. The client is nauseated.
A. The client is irritable. C. The client is unable to concentrate. D. The client feels discouraged. E. The client is nauseated.
A physician orders magnesium sulfate IV for a primigravida client at 37 weeks gestation diagnosed with severe preeclampsia. Which medication would the nurse have readily available at the client's bedside? A. Diazepam (Valium) B. Calcium gluconate C. Phenytoin (Dilantin) D. Hydralazine (Apresoline)
B. Calcium gluconate
During the fourth stage of labor, your client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. Which of the following should be the priority action of the nurse? A. Massage the fundus. B. Continue to monitor. C. Turn the client onto her left side. D. Place the bed in Trendelenburg position.
B. Continue to monitor. Rationale The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. Nurses can expect changes in the maternal vital signs in the fourth stage of labor. The uterus should be midline and firm; massage is not necessary. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.
A client in labor is having hypertonic contractions. Which assessment findings would the nurse observe with this contraction pattern? Select all that apply. A. Rapid dilation B. Painful contractions C. Fatigue D. Decreased maternal oxygenation E. Frequent contractions
B. Painful contractions C. Fatigue E. Frequent contractions
A nurse is writing a plan of care for a client at 34 weeks gestation with a placenta partially covering the cervical os. The plan of care includes which of the following? Select all that apply. A. Vaginal checks every shift B. Up ad lib C. Bed rest with bathroom privileges D. Assess uterine tone E. No vaginal exams
C. Bed rest with bathroom privileges D. Assess uterine tone E. No vaginal exams
A client at 8 weeks gestation is diagnosed with hyperemesis gravidarum. The nurse knows that this excessive vomiting during pregnancy will often result in which of the following conditions? A. Abortion B. Bowel perforation C. Electrolyte imbalance D. Gestational hypertension
C. Electrolyte imbalance
Which statement correctly describes the transition phase of labor? A. Onset of labor through cervical dilation of 3 cm B. Fetus descending into pelvis and internally rotating C. Longest stage, lasting 8dash-10 hours D. 8-10 cm dilation occurs, ending the first stage of labor
D. 8-10 cm dilation occurs, ending the first stage of labor
A 36 week laboring client is crying and says, "I don't think I can take staying in bed for so long. I want to go home." Which of the following is an appropriate nursing diagnosis? A. Risk for injury related to premature cervical dilation B. Knowledge deficit related to treatment for preterm labor C. Pain related to hypertonic labor pattern D. Ineffective coping related to imposed activity restrictions
D. Ineffective coping related to imposed activity restrictions
The nurse reviews the history and medical information forms that a new prenatal client has completed at her first prenatal visit. Which of the following entries would be concerning to the nurse? A. Daily multivitamin B. Had an abortion at the age of 16 C. Nonsmoker D. Methadone 20 mg every day
D. Methadone 20 mg every day
The nurse is trying to assist a woman in the first stage of labor into a comfortable position to help relieve back discomfort due to a posterior fetal position. Which of the following positions would be best for the nurse to try first? A. Sitting up B. Squatting C. Standing D. On her hands and knees
D. On her hands and knees
A woman at 28 weeks gestation is admitted to the hospital with possible placenta previa. What would the nurse expect to find on the admission assessment? A. Braxton-Hicks contractions B. Severe lower abdominal pain C. A board-like abdomen D. Painless vaginal bleeding
D. Painless vaginal bleeding
The nurse is discussing with the HIV-positive client possible signs that could indicate that she is developing symptomatic HIV infection. The symptoms include which of the following? Select all that apply. A. Persistent candidiasis B. Fatigue C. Behavioral changes D. Kaposi's sarcoma E. Weight loss
A. Persistent candidiasis B. Fatigue D. Kaposi's sarcoma
A woman admitted to the hospital with a diagnosis of possible ectopic pregnancy is presenting with abdominal pain and vaginal spotting for the past 24 hours. In reviewing her medical history the nurse knows that which of the following factors may be associated with ectopic pregnancy? A. Previously diagnosed with pelvic inflammatory disease (PID) B. Age younger than 20 years C. Recurrent spontaneous abortions D. Multiparity
A. Previously diagnosed with pelvic inflammatory disease (PID)
The nurse is assessing the power of the uterine muscle during the labor process. The nurse can expect to assess which of the following changes as a result of this process? A. Cervical lengthening B. A slowing of uterine contractions C. Cervical effacement D. An increase in maternal blood pressure
C. Cervical effacement Rationale Cervical effacement refers to the shortening or thinning of the cervix during labor. Normally, the cervix is long and thick, approximately 2-3 centimeters in length. The force of the uterine contractions causes the muscle fibers of the cervix to thin and shorten. Uterine contractions are a result of the power of the uterine muscle and will increase during labor. The maternal blood pressure should not increase in response to uterine contractions.
Which of the following describes Class I cardiac disease in pregnancy? A. Slight limitations in activity, comfortable at rest B. Cardiac insufficiency at rest, no activity tolerated C. No activity limitations, no signs of cardiac insufficiency D. Comfortable at rest, marked intolerance of activity
C. No activity limitations, no signs of cardiac insufficiency
A primigravid with insulin-dependent diabetes is at 32 weeks gestation and undergoes a nonstress test; the results of the test are documented as reactive. The nurse tells the client that the results indicate which of the following? A. A contraction stress test is necessary. B. Fetal biophysical profile. C. There is evidence of fetal well-being. D. The nonstress test should be repeated.
C. There is evidence of fetal well-being.
During change of shift report, the nurse is told that one of her clients is in the fourth stage of labor. When does the fourth stage of labor begin? A. With delivery of the fetus B. With fetal descent C. With the delivery of the placenta D. With complete cervical dilation
C. With the delivery of the placenta
Which condition occurs in the initial newborn period due to maternal diabetes? A. Hypertension B. Hypoglycemia C. Spontaneous abortion D. Hypobilirubinemia
B. Hypoglycemia
Which nursing intervention is recommended for the newborn of an HIV-positive client? A. Assessing vital signs every 10 minutes B. Waiting 24 hours for the first bath C. Encouraging breastfeeding over bottle feeding D. Delaying heel sticks until after the first bath
D. Delaying heel sticks until after the first bath
Which of the following descriptions refers to the orientation of the long axis of the fetus? A. Fetal position B. Fetal presentation C. Fetal attitude D. Fetal lie
D. Fetal lie Fetal lie refers to the orientation of the long axis of the fetus to the long axis of the mother. Fetal attitude refers to the relation of the fetal body parts to one another. Fetal presentation refers to the fetal body part that enters the pelvis first. Fetal position describes the location of a fixed reference point on the presenting part within the four quadrants of the maternal pelvis. Next Question
The nurse is caring for a woman who has been diagnosed with an ectopic pregnancy. The expected outcomes for nursing care include which of the following? Select all that apply. A. The woman remains on bed rest for 48 hours after the surgical removal of the tube. B. The woman is able to explain treatment alternatives. C. The woman and her partner are able to begin verbalizing their loss. D. The woman and her caregivers detect possible complications early and manage them successfully. E. The woman takes the prescribed antibiotics for the prescribed time.
B. The woman is able to explain treatment alternatives. C. The woman and her partner are able to begin verbalizing their loss. D. The woman and her caregivers detect possible complications early and manage them successfully.
A client is being admitted for hypovolemia secondary to hyperemesis gravidarum. When reviewing the client's history and lab values, the nurse would expect to see what finding? A. Decreased levels of human chorionic gonadotrophin (hCG) B.Hyperthyroidism C. Underweight or malnourished D. Maternal age older than 35 years
B.Hyperthyroidism
The nurse is educating a client who is 28 weeks pregnant with preterm labor. Which statements should the nurse include? Select all that apply. A. "Let's discuss the signs and symptoms of preterm labor." B. "You will not be able to see the provider while you are on bed rest." C. "Pelvic rest means no sexual activity during this period." D. "It is important to stay well hydrated during the day." E. "Staying on bed rest may help prevent a preterm delivery."
A. "Let's discuss the signs and symptoms of preterm labor." C. "Pelvic rest means no sexual activity during this period." D. "It is important to stay well hydrated during the day." E. "Staying on bed rest may help prevent a preterm delivery."
The nurse is caring for a client who believes she may be in labor. The nurse is aware of the theories of labor onset and makes an assessment to determine if the woman is in true labor. Which of the following are characteristics of true labor? Select all that apply. A. A regular contraction pattern is occurring. B. Cervical effacement is occurring. C. Contractions decrease with activity. D. Cervical dilation is occurring. E. The contractions start in the lower abdomen and sweep up.
A. A regular contraction pattern is occurring. B. Cervical effacement is occurring. D. Cervical dilation is occurring.
Ashley Estevez is 28 weeks pregnant and has been diagnosed with gestational diabetes. She tells you that she is afraid her baby will not be healthy. What nursing diagnosis is most appropriate for Ashley? A. Anxiety related to potential effects of disease processes B. Risk for injury related to maternal effects of disease processes C. Nutrition less than body requirements related to poor metabolism D. Knowledge deficit related to disease processes
A. Anxiety related to potential effects of disease processes
A 20-year-old client at 34 weeks gestation is admitted to the hospital with vaginal bleeding. After reviewing the client's history, which of the following factors might lead the nurse to suspect abruptio placentae? A. History of cocaine use B. Previous low transverse cesarean delivery C. Several hypotensive episodes D. One induced abortion
A. History of cocaine use
A nurse is caring for a client having a precipitous delivery in the emergency department. The nurse anticipates which of the following effects on the neonate? Select all that apply. A. Hypoxia B. Spinal compression C. Shoulder dystocia D. Neonatal intracranial hemorrhage E. Decreased intracranial trauma
A. Hypoxia D. Neonatal intracranial hemorrhage
What percentage of pregnancies is affected by cardiac disease? A. 15% B. 10% C. 1% D. 5%
C. 1%
The nurse is reviewing the medications for a 14-week gestation primigravida who has mitral valve stenosis. What medications would the nurse expect to be ordered for this client? A. Warfarin (Coumadin) B. Enoxaparin (Lovenox) C. Heparin D. Ardeparin (Normiflo)
C. Heparin
Which of the following signs may occur prior to the onset of labor? Select all that apply. A. Quickening B. Nesting C. Bloody show D. Loss of mucus plug E. Braxton Hicks contractions
B. Nesting C. Bloody show D. Loss of mucus plug E. Braxton Hicks contractions
The birth of the fetus ends which stage of labor? A. Fourth B. Third C. First D. Second
D. Second
Which of the following assessments confirm the presence of amniotic fluid? Select all that apply. A. Ferning pattern under microscopic exam B. Nitrazine pH paper turns blue C. Pooling of clear fluid on speculum with vaginal exam D. Increased urination E. Leaking fluid from vagina
A. Ferning pattern under microscopic exam B. Nitrazine pH paper turns blue
A pregnant client's preterm labor will be managed at home. The nurse anticipates which of the following in the plan of care? Select all that apply. A. Home uterine monitoring B. Administration of IV tocolytics C. Biophysical profiles and fetal kick counts D. Bed rest and pelvic rest E. Regular prenatal visits to assess cervical dilation
A. Home uterine monitoring C. Biophysical profiles and fetal kick counts D. Bed rest and pelvic rest E. Regular prenatal visits to assess cervical dilation
The nurse is caring for a pregnant client admitted with hyperemesis gravidarum. Treatment of hyperemesis gravidarum is aimed at which of the following? Select all that apply. A. Improving nutritional status B. Controlling vomiting C. Correcting dehydration D. Correcting fluid and electrolyte imbalance E. Correcting acidosis
A. Improving nutritional status B. Controlling vomiting C. Correcting dehydration D. Correcting fluid and electrolyte imbalance
The nurse is assessing a client's understanding of her preterm labor. Which of the following questions are appropriate to include? Select all that apply. A. "How is this affecting your pregnancy? What concerns do you have?" B. "Can you share with me what you know about the risks of preterm delivery?" C. "Do you have any questions about your pediatrician?" D. "Tell me what you understand about causes of preterm labor." E. "We will be doing fetal monitoring. Have you learned about this already?"
A. "How is this affecting your pregnancy? What concerns do you have?" B. "Can you share with me what you know about the risks of preterm delivery?" D. "Tell me what you understand about causes of preterm labor." E. "We will be doing fetal monitoring. Have you learned about this already?"
A client is told that her pelvic diameters are slightly contracted. The client asks the nurse what this means for her vaginal birth plan. What is the correct response by the nurse? A. "You will have a trial of labor first; a cesarean section will occur if the trial is not successful." B. "Yes, you can deliver vaginally." C. "You will have to have a cesarean delivery." D. "It might be possible, but I would count on a cesarean delivery."
A. "You will have a trial of labor first; a cesarean section will occur if the trial is not successful."
If the placenta is not delivered within _____ minutes of giving birth, it must be manually removed. A. 30 B. 5 C. 10 D. 60
A. 30
You are caring for Sarah Smith, a laboring client, who has a Class II cardiac disease. She is undergoing a trial of labor for a vaginal delivery. During labor, she begins experiencing angina and dyspnea that gets progressively worse, despite treatment. You anticipate the need for which of the following? A. A C-section delivery B. Stat pitocin order C. IV bolus D. Respiratory consultation
A. A C-section delivery
The midwife asks the nurse to assist the laboring client with McRoberts maneuver to help with shoulder dystocia. What is the appropriate nursing action? A. Ask the client to flex her knees to her chest. B. Apply suprapubic pressure for 5 minutes. C. Rotate the fetal shoulder 180 degrees. D. Apply firm pressure to the fundus until the shoulder releases.
A. Ask the client to flex her knees to her chest.
The nurse is instructing a pregnant client on the signs of impending labor. Which of the following should the nurse include as premonitory signs of labor? Select all that apply. A. Bloody show B. Burst of energy C. Increased fatigue D. Decreased vaginal discharge E. Easier breathing
A. Bloody show B. Burst of energy E. Easier breathing
What are the contractions associated with false labor called? A. Braxton Hicks B. Early labor pains C. Acme D. Chadwick's sign
A. Braxton Hicks
A laboring client suddenly sits up in bed, is dyspneic, becomes cyanotic, and has frothy sputum from her mouth. The nurse is unable to palpate a pulse. What is the initial action by the nurse? A. Call for assistance and start CPR. B. Position the client on her side with her feet elevated. C. Assess the fetal heart rate. D. Obtain the client's blood pressure.
A. Call for assistance and start CPR.
A pregnant client is admitted to the hospital in premature labor. The nurse anticipates which of the following assessment findings? A. Cervical dilation B. Decreased fetal movement C. Elevated blood pressure D. Headache
A. Cervical dilation
Which of the following are risk factors for gestational diabetes? Select all that apply. A. Chronic hypertension B. Previous gestational diabetes C. Underweight for height D. Family history of diabetes E. Maternal age younger than 25
A. Chronic hypertension B. Previous gestational diabetes D. Family history of diabetes
When caring for a pregnant client who has a history of rheumatic heart disease, the nurse would be alert for the increased risk of which of the following? A. Congestive heart failure B. Peripartum cardiomyopathy C. Mitral valve prolapse D. Cardiac arrhythmias
A. Congestive heart failure
What is an appropriate nursing diagnosis for a client with Class III cardiac disease? A. Decreased cardiac output related to effects of disease process B. Altered thought processes related to chronic disease impairment C. Risk for infection related to elevated levels of blood glucose D. Knowledge deficit related to newborn care
A. Decreased cardiac output related to effects of disease process
A woman is being discharged after being treated for a hydatidiform mole (gestational trophoblastic disease). In doing her discharge teaching, what should the nurse include? A. Do not become pregnant for at least 1 year. B. Have hemoglobin and hematocrit checked weekly for 3 months. C. RhoGam should be given with the next pregnancy and delivery. D. Have blood pressure checked weekly for 3 months.
A. Do not become pregnant for at least 1 year.
A client at 39 weeks gestation is demonstrating signs of beginning labor. The nurse realizes that which of the following hormonal actions is occurring, resulting in the onset of labor? A. Increase in estrogen B. Decrease in corticosteroids C. Decrease in prostaglandins D. Increase in progesterone
A. Increase in estrogen
What are the indicators that require electronic fetal monitoring (EFM)? Select all that apply. A. Labor augmentation B. Primigravida C. Maternal complications of pregnancy D. Oxytocin administration E. Fetal complications
A. Labor augmentation C. Maternal complications of pregnancy D. Oxytocin administration E. Fetal complications Today most institutions use EFM for all clients; however, it is mandatory for high-risk clients. These include clients who have had maternal complications during pregnancy as well as any fetal complications. In addition, the client whose labor is induced or augmented with Pitocin requires EFM. A Primigravida does not require EFM unless there are other indicators present.
A client is admitted to the labor unit with mild contractions. On assessment, the client appears excited and readily follows directions. The nurse understands this information to indicate that the client is most likely in what phase of labor? A. Latent B. Transition C. Active D. Second
A. Latent Rationale The latent phase is characterized by mild contractions. During this time, the woman is excited that labor has begun and readily follows direction. The active phase is characterized by an increase in discomfort. During the transition phase of labor, women find it difficult to concentrate. Contractions are strong and painful. The woman might become apprehensive and irritable during this stage. The second stage is the pushing stage. It is considered a stage of labor, not a phase of labor.
The student nurse is assisting the delivery nurse during the admittance of a woman in labor. The student nurse is preparing herself for the labor and delivery process and is aware that which of the following can affect the labor process? Select all that apply. A. Maternal pushing B. The maternal psyche C. The position of the fetus D. The power of contractions E. Presence of a support person
A. Maternal pushing B. The maternal psyche C. The position of the fetus D. The power of contractions The "5 Ps" that can affect the labor process include the power of uterine contractions, maternal pushing, fetal (passenger) position, maternal position, and maternal psyche or emotional state. The health care provider's philosophy of labor and the presence of a support are not included in the "5 Ps" that can affect the labor process.
A client with grade II abruptio placentae is admitted to the emergency room. The client is at 35 weeks gestation and complaining of severe abdominal pain and uterine tenderness. In managing the care of a client with abruptio placentae, the nurse would expect to do which of the following? Select all that apply. A. Monitor the mother for signs of hypovolemic shock. B. Evaluate uterine hyperactivity. C. Evaluate fetal status. D. Evaluate the mother for painless uterine bleeding. E. Prepare the mother for a cesarean delivery.
A. Monitor the mother for signs of hypovolemic shock. B. Evaluate uterine hyperactivity. C. Evaluate fetal status. E. Prepare the mother for a cesarean delivery.
Which of the following are signs of true labor? Select all that apply. A. Regular contraction pattern B. Contractions that become more intense C. Activity does not decrease contractions D. Cervical dilation E. Position change lessens contractions
A. Regular contraction pattern B. Contractions that become more intense C. Activity does not decrease contractions D. Cervical dilation
A student nurse is caring for a client who was admitted to rule out an ectopic pregnancy. Which of the following assessment findings would indicate that the client's condition is worsening? Select all that apply. A. Free of abdominal pain B. Sudden severe lower quadrant abdominal pain C. Temperature of 100.2 F D. Rapid, thready pulse Profuse hemorrhage
B. Sudden severe lower quadrant abdominal pain C. Temperature of 100.2 F D. Rapid, thready pulse Profuse hemorrhage
A woman at 39 weeks gestation presents to triage in labor and delivery with complaints of contractions every 3dash-5 minutes. The nurse assesses fetal presentation to determine which of the following? A. The extent of fetal flexion B. The fetal part that is in the pelvis C. The fetal size D. The fetal angle
B. The fetal part that is in the pelvis
The nurse formulates a diagnosis of fear related to fetal outcomes for a laboring client with fetal malpresentation. What is an appropriate client outcome to include in the care plan? A. The mother safely delivers a viable newborn. B. The mother reports a decrease in fear and anxiety related to the birth. C. The mother identifies two support people for the birth. D. The mother is able to verbalize understanding of the labor process.
B. The mother reports a decrease in fear and anxiety related to the birth.
A nurse is caring for a client going into the fourth stage of labor. The nurse expects to assess which of the following during this time? A. Minimal vaginal discharge B. Uterus firm and midline C. Vital signs every hour D. Maternal burst of energy
B. Uterus firm and midline Rationale During the fourth stage of labor, the uterus should be firm and midline in the abdomen about midway between the symphysis and umbilicus. In the fourth stage of labor, nurses can expect changes in the maternal vital signs. Expect to perform assessments every 15 minutes x 4, then every 30 minutes x 2, then every hour until stable. The vaginal drainage, known at lochia rubra, should be moderate in amount. The woman may report feeling chilled, thirsty, hungry, and tired.
A nurse is caring for a pregnant client who is being monitored for gestational hypertension. Which assessment finding indicates a worsening of gestational hypertension and the need to notify the health care provider? A. Urine output has increased. B. Edema 2+ C.Blood pressure is 140/90. D.Complaints of blurred vision and a headache
D.Complaints of blurred vision and a headache
A client has delivered her first child at 37½ weeks; the baby weighs 5 lb 3 oz. Which statement by the nurse is appropriate? A. "You delivered a near term baby." B. "The baby was right on time and she was born at term." C. "Your baby is doing well for a preterm infant." D. "The baby's skin looks good for being postterm.
B. "The baby was right on time and she was born at term."
You are caring for Adam, who was born 2 hours ago. His mother is HIV positive. You anticipate which of the following orders for Adam? A. Perform heel stick prior to bathing B. AZT syrup PO per protocol, first dose within 8 hours C. Strict contact isolation precautions D. Hold first bath 24 hours
B. AZT syrup PO per protocol, first dose within 8 hours
The nurse is performing an assessment on a woman at 38 weeks gestation who believes she is in labor. The nurse determines the woman is experiencing false labor. Which of the following is a characteristic of false labor? A. Back pain with contractions B. Braxton-Hicks contractions C. A regular contraction pattern D. Cervical dilation at 4 cm
B. Braxton-Hicks contractions
The nurse has taught a diabetic primigravida client about the symptoms of hyperglycemia and hypoglycemia. The client understands the instruction when she states that hyperglycemia may be manifested by which of the following? A. Blurred vision B. Dehydration C. Pallor D. Sweating
B. Dehydration
Which term refers to the shortening or thinning of the cervix during labor? A. Contraction B. Effacement C. Dilation D. Acme
B. Effacement Cervical effacement refers to the shortening or thinning of the cervix that occurs during labor. Dilation refers to the widening of the cervical os, or opening. Contractions occur across the entire uterus during labor. Acme refers to the peak of a uterine contraction
A client is admitted to the obstetrical unit with preterm labor. The nurse anticipates that the client will have which of the following needs? A. Anxiety medication order B. Emotional support C. Work release note D. Financial difficulties
B. Emotional support
he nurse is caring for a woman in the second stage of labor. The nurse is aware that during this stage the fetus goes through positional changes in order to pass through the mother's pelvic canal. Which of the following are positional changes that the fetus undergoes? Select all that apply. A. Constitution B. Extension C. Expulsion D. Flexion E. Descent
B. Extension C. Expulsion D. Flexion E. Descent
A multigravida client at 12 weeks gestation comes to the clinic reporting that she is experiencing severe morning sickness and that she "has not been able to keep anything down for 6 days." The nurse should assess for the signs and symptoms of which of the following? A. Hypercalcemia B. Hypokalemia C. Hypobilirubinemia D. Hyperglycemia
B. Hypokalemia
Which of the following would be avoided for an HIV-positive client who is in labor? A. IV fluids B. Internal fetal monitoring C. Pain medication D. Foley catheter
B. Internal fetal monitoring
The nurse is making a plan of care for a client with severe preeclampsia. One of the complications is HELLP syndrome. Which of the following laboratory values would indicate the patient has gone into HELLP syndrome? Select all that apply. A. Low hemoglobin B. Low hematocrit C. Low platelets D. Elevated liver enzymes E. Low liver enzymes
B. Low hematocrit C. Low platelets D. Elevated liver enzymes
A nurse is caring for a pregnant client with preeclampsia. She is at the bedside and notes that the client has now progressed to eclampsia. What would be the nurse's first priority? A. Administer oxygen by mask. B. Maintain an open airway. C. Administer magnesium sulfate IV. D. Assess BP and fetal heart rate.
B. Maintain an open airway.
Which are acceptable maternal assessments that occur during the third stage of labor and delivery? Select all that apply. A. Apgar scoring B. Monitor for signs of placental separation C. Examine placenta D. Vaginal exam to assess fetal station E. Monitor maternal vital signs
B. Monitor for signs of placental separation E. Monitor maternal vital signs
The nurse is assessing clients in the prenatal clinic. Which are maternal risk factors for preterm labor? Select all that apply. A. Maternal obesity B. Preterm premature rupture of membranes C. Intrauterine bleeding D. Maternal genital tract infection E. African American race
B. Preterm premature rupture of membranes C. Intrauterine bleeding D. Maternal genital tract infection E. African American race
The nurse is caring for four laboring clients. The nurse determines that which of the following clients is at greatest risk for a prolapsed umbilical cord? A. 40 weeks, 8 cm dilated, 75% effaced, 0 station, intact membranes B. 38 weeks, 3 cm dilated, 80% effaced, 0 station, intact membranes C. 40 weeks, 5 cm dilated, 100% effaced, -2 station, ruptured membranes D. 39 weeks, 9 cm dilated, 100% effaced, +1 station, ruptured membranes
C. 40 weeks, 5 cm dilated, 100% effaced, -2 station, ruptured membranes
A nurse performs a cervical exam on a client with ruptured membranes and palpates a loop of umbilical cord. What is the initial nursing action? A. Stopping oxytocin administration immediately B. Preparing an amnioinfusion to try and float the cord up into the uterus C. Applying firm pressure on the presenting part to relieve cord compression D. Giving the mother oxygen via face mask at 15 L/min
C. Applying firm pressure on the presenting part to relieve cord compression
The nurse knows that teaching has been effective when the client reports that the frequency of her contractions are 3 minutes apart when timed from which of the following? A. End of one contraction until the beginning of the next contraction B. Beginning to the end of the same contraction C. Beginning of one contraction until the beginning of the next contraction D. Beginning of one contraction to the end of the next contraction
C. Beginning of one contraction until the beginning of the next contraction
Maria delivered a newborn yesterday. She had a vaginal delivery and received an epidural for pain management. Which of the following assessment findings is most concerning to you? A. Discomfort with bowel elimination B. Reports of mild uterine cramping C. Client complaints of numbness in her left leg D. Reports of thirst
C. Client complaints of numbness in her left leg
A. Increased hemoglobin and increased white blood cell count (WBC) B. Increased platelet count and decreased red blood count (RBC) C. Decreased CD4+ T lymphocyte count and decreased hemoglobin D. Decreased erythrocyte sedimentation rate (ESR) and increased hematocrit
C. Decreased CD4+ T lymphocyte count and decreased hemoglobin
During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client? A. Impaired gas exchange related to respiratory effects of substance abuse B. Activity intolerance related to decreased tissue oxygenation C. Imbalanced nutrition: less than body requirements related to limited food intake D. Risk for infection related to IV drug use
C. Imbalanced nutrition: less than body requirements related to limited food intake
pregnant client at 40 weeks gestation is admitted in early labor. The client asks the nurse how long her labor will be. Which of the following should the nurse consider when determining what to tell the client? A. The second stage is usually the longest stage, lasting about 5 hours. B. The third stage is usually the longest stage, lasting about 4 hours. C. The first stage is usually the longest stage, lasting from 6 to 10 hours. D. The fourth stage is usually the longest stage, lasting about 6 hours.
C. The first stage is usually the longest stage, lasting from 6 to 10 hours. ationale The first stage of labor is usually the longest, lasting an average of 8-10 hours for primiparas and 6-7 hours for multiparas. The length of the second stage of labor varies from pregnancy to pregnancy, with a range of 30 minutes to 3 hours and an average of 1-2 hours for primiparas and 5-30 minutes and an average of 30 minutes for multiparas. The third stage of labor begins with the delivery of the fetus and ends with the delivery of the placenta. This stage lasts an average of 5-10 minutes but can last up to 30 minutes. The fourth stage of labor begins with the delivery of the placenta and ends in the first 1 to 4 hours immediately post delivery.
You are caring for Joyce Stanley, who just gave birth an hour ago. Which of the following nursing assessments requires further evaluation? A. Mild uterine cramping B. Complaints of being chilled C. Moderate amount of lochia rubra D. Soft uterine fundus
D. Soft uterine fundus