ThePoint Questions Chapter 14 Maternity and Pediatric Nursing

c. antiretroviral Rationale: Women who are HIV-positive are given a combination of antiretroviral drugs to reduce the risk of perinatal transmission. ACOG and US Public Health Service recommend that women who are infected with HIV and have a plasma viral load of more than 1,000 copies/mL be counseled regarding the benefits of elective cesarean birth. Antibiotics would not be used. Ataractics and benzodiazepines would be used for systemic analgesia.

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering? a. ataractic b. antibiotics c. antiretrovirals d. benzodiazepines

c. baseline FHR Rationale: The baseline FHR averages 110 to 160 beats per minute over a 10-minute period. Fetal bradycardia occurs when the FHR is less than 110 beats per minute for 10 minutes or longer. Short-term variability is the beat-to-beat change in FHR. Baseline variability refers to the normal physiologic variations in the time intervals that elapse between each fetal heartbeat observed along the baseline in the absence of contractions, decelerations, and accelerations.

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as: a. short-term variability b. baseline variability c. baseline FHR d. fetal bradycardia

c. naloxone Rationale: Naloxone is an opioid antagonist that can be given to reverse the effects of the central nervous system depression, including respiratory depression, caused by opioids. It is also used to reverse the side effects of neuraxial opioids. Nalbuphine is an opioid. Hydroxyzine is an ataractics. Midazolam is a benzodiazepine.

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which medication readily available to reverse the effects of that opioid? a. hydroxyzine b. nalbuphine c. naloxone d. midazolam

d. FHR Rationale: When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? a. maternal comfort level b. fetal position c. signs of infection d. FHR

c. palpate the mother's radial pulse at the same time Rationale: To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be the most appropriate? a. instruct the woman to bend her knees and flex her hips b.have the woman lie completely flat on her back while auscultating c. palpate the mother's radial pulse at the same time d. ask the woman to hold her breath while assessing the FHR

b. recurrent late decelerations, d. fetal bradycardia, and e. sinusoidal pattern Rationale: FHR patterns that are predictive of abnormal fetal acid-base status include fetal bradycardia, sinusoidal pattern, and recurrent late decelerations. Fetal tachycardia and minimal variability, although each needs evaluation and continued monitoring, are not predictive of abnormal fetal acid-base status.

A nurse practitioner is conducting an in-service education program for a group of nurses working in the labor and birth unit. The program is focusing on interpreting FHR patterns. The nurse practitioner determines that the teaching was successful when the group identifies which patterns as indicating abnormal fetal acid-base status? Select all that apply. a. minimal variability b. recurrent late decelerations c. fetal tachycardia d. fetal bradycardia e. sinusoidal pattern

d. less anxiety Rationale: Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? a. increased cervical dilation b. increased feelings of control c. decreased sedation d. less anxiety

c. every 15 minutes Rationale: During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? a. every 10 minutes b. every 20 minutes c. every 15 minutes d. every 5 minutes

d. effleurage Rationale: Effleurage is a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions. Acupressure involves the application of a finger or massage at a trigger point to reduce the pain sensation. Patterned breathing involves controlled breathing techniques to reduce pain through a stimulus-response conditioning. Therapeutic touch involves light or firm touch to the energy field of the body using the hands to redirect the energy fields that lead to pain.

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: a. therapeutic touch b. patterned breathing c. acupressure d. effleurage

a. 7.2 Rationale: Umbilical cord blood acid-base analysis is considered the most reliable indication of fetal oxygenation and acid-base condition at birth. The normal mean pH value range is 7.2 to 7.3

Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH? a. 7.2 b. 6.8 c. 7 d. 7.4

-4 station -2 station 0 station +2 station +4 station Rationale: Progressive fetal descent (-5 to +4) is the expected norm during labor, moving downward from the negative stations to zero station to the positive stations in a timely manner

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used. +4 station -4 station 0 station +2 station -2 station

c. ischial spine Rationale: Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the mid pelvis. The ischial spines serve as landmarks and have been designated as zero station.

During the assessment of a women in labor, the nurse explains that certain landmarks are used to determine the progress of birth. The nurse identifies which area as one of these landmarks? a. pubic symphysis b. ischial tuberosity c. ischial spine d. cervical os

a. increasing the release of endorphins Rationale: Massage works as a form of pain relief by increasing the production of endorphins in the body. Endorphins reduce the transmission of signals between nerve cells and thus lower the perception of pain. Controlled breathing helps to distract the person from pain. Attention focusing and imagery prevent the sensation of contraction pain from reaching the brain. Cold causes vasoconstriction.

Massage is an effective nonpharmacologic technique that can help decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism? a. increasing the release of endorphins b. distracting the person from the pain c. preventing sensation from reaching the brain d. causing vasoconstriction

c. the cervical canal is 1 cm long Rationale: Effacement refers to the length of the cervical canal. At 0%, the cervical canal is 2 cm long. At 50%, 1 cm long. At 100%, the cervical canal is obliterated.

On examination, the nurse determines the client is at 50% effacement. This means: a. the cervical canal is 1.5 cm long b. the cervical canal is 2 cm long c. the cervical canal is 1 cm long d. the cervical canal is 2.5 cm long

b. neuraxial analgesia/anesthesia Rationale: Neuraxial analgesia/anesthesia is the administration of analgesic or anesthetic agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain. Neuraxial analgesia does not interfere with the progress or outcome of labor. This technique involving minimal motor blockade has become more popular. The most important complication associated with systemic analgesics is respiration depression. Systemic analgesia and regional analgesia/anesthesia have become less common due to their potential complications.

The client is requesting information on the various pain medication management techniques that are available so she can decide which option she would like to choose for her impending birth. While gathering together information, the nurse would indicate which technique as becoming very popular and effective? a. epidural analgesia b. neuraxial analgesia/anesthesia c. spinal analgesia d. systemic analgesia

c. apply warm compresses to the perineum Rationale: Applying warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent an episiotomy. Kegel exercises are for strengthening the pelvic muscles. Lying on the back puts added strain on the perineum, which may result in tearing and massaging the perineum during the last trimester, is not the optimum technique

The client wants to avoid an episiotomy. What technique would the nurse suggest the client try? a. give birth to the infant while lying on her back b. massage the perineum daily during the last trimester c. apply warm compresses to the perineum d. practice Kegel exercises during pregnancy

a. rupture of membrane Rationale: The insertion of the spiral electrode should be inserted only by a skilled practitioner. Ruptured membranes, cervical dilation of at least 2 cm, and the presenting fetal part low enough to allow placement of the scalp electrode are all necessary.

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? a. rupture of membranes b. cervical dilation of 1 cm c. the presenting fetal part not visible d. insertion by any staff

d. Every 15 Minutes Rationale: It is recommended that the FHR be assessed during the second stage of labor every 15 minutes by doppler or continuously by EFM

The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR by doppler at what frequency? a. Every 20 minutes b. Every 10 minutes c. Every 30 minutes d. Every 15 minutes

c. acme Rationale: The acme is the peak intensity of a contraction. The increment refers to the building up of the contraction. The decrement refers to the letting down of the contraction. Diastole refers to the relaxation phase of a contraction.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction? a. decrement b. diastole c. acme d. increment

c. 6.5 Rationale: Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH ranges from 6.5 to 7.5

The nurse test the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? a. 5 b. 5.5 c. 6.5 d. 6

c. prolonged decelerations Rationale: Prolonged decelerations are associated with prolonged cord compression, placental abruption (abruptio placentae), cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well being.

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? a. accelerations b. early decelerations c. prolonged decelerations d. variable decelerations

d. below T8 level Rationale: Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord

When assessing the effectiveness of the obstetrical regional analgesia received by a client, the nurse recognizes it is successful by the complete loss of pain sensation at which level of the spinal cord? a. below T5 level b. below T7 level c. below T6 level d. below T8 level

b. FHR fluctuates from 6 to 25 beats per minute Rationale: Variability is described in four categories: absent, minimal, moderate (normal), and marked. Absent is where the fluctuations range is undetectable. Minimal fluctuations range observed at <5 beats per minute. Moderate (normal) fluctuations range from 6 to 25 beats per minute. Marked fluctuations range >25 beats per minute.

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the patient? a. FHR fluctuation range is undetectable b. FHR fluctuates from 6 to 25 beats per minute c. FHR less than 5 beats per minute d. FHR fluctuates over 25 beats per minute

b. clear Rationale: Amniotic fluid should be clear when membranes rupture. During and amniotomy, a disposable plastic hook (an amnihook) is used to perforate the amniotic sac. Cloudy or foul smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IGUR), maternal hypertension, diabetes, or chorioamnioitis.

A nurse is caring for a woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal? a. green b. clear c. cloudy d. malodorous

a. types of decelerations and d. variability Rationale: Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations like electronic fetal monitoring (EFM) can.

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all that apply. a. types of decelerations b. rhythm c. changes in baseline d. variability e. FHR baseline

a. fetal hypoxia, d. effect of maternal analgesia, and e. prolonged umbilical cord compression Rationale: Fetal bradycardia occurs when the FHR is below 110 bpm and lasts 10 minutes or longer. It can be the initial response of a healthy fetus to asphyxia. Causes of fetal bradycardia might include fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block. Maternal fever and prematurity are associated causes of fetal tachycardia.

A nurse is reviewing the FHR and notes it to be in the range of 100 to 106 bpm over the past 10 minutes. What conditions might the nurse suspect as the cause? Select all that apply. a. fetal hypoxia b. prematurity c. maternal fever d. effect of maternal analgesia e. prolonged umbilical cord compression

d. decreased alertness Rationale: Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding.

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? a. low Apgar b. increased agitation c. increased crying d. decreased alertness

a. enlists the aid of gravity to move the fetus, c. increases the urge to push during the second stage, d. helps the fetus line up with the angle of the pelvis, e. encourages rotation of the fetus, and f. enhances the effectiveness of contractions Rationale: Walking, like standing, takes advantage of gravity, makes contractions more productive, helps to increase the urge to push in the second stage, helps the fetus line up with the angle of the maternal pelvis, and encourages rotation of the fetus. Lunging widens one side of the pelvis.

The nurse encourages a woman in labor to ambulate based on the understanding that ambulating does what? Select all that apply a. enlists the aid of gravity to move the fetus b. widens one side of the pelvis c. increases the urge to push during the second stage d. helps the fetus line up with the angle of the pelvis e. encourages rotation of the fetus f. enhances the effectiveness of contractions

a. continuous support through the labor process helps decrease the need for pain medication Rationale: Continuous labor support involves offering a sustained presence to the laboring woman. A support person can assist and provide aid with acupressure, massage, music therapy, or therapeutic touch. Research has validated the value of continuous labor support versus intermittent support in terms of lower operative deliveries, cesarean birth, and request for pain medication.

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? a. continuous support through the labor process helps decrease the need to pain medication b. lying on an ice pack can help decrease the need for pain medication c. sitting in a hot tub helps decrease the need for pain medication d. a quick epidural can replace the need for pain medication

Determine presentation Determine position Confirm presentation Determine attitude Rationale: Leopold's maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of 4 specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. With the woman in the supine position, preform the first maneuver to determine presentation. The second maneuver determines position. The third maneuver will confirm presentation. The fourth maneuver is preformed to determine the attitude of the fetus.

The nurse will be preforming the Leopold's maneuver to determine the position of the fetus. List in order the steps the nurse would take. All options must be used. Determine attitude Determine presentation Confirm presentation Determine position