Thisssss bishhhhh

11. During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs? A) Turn the patient onto the left side. B) Assess fetal heart rate for fetal safety. C) Test a sample of amniotic fluid for protein. D) Instruct to bear down with the next contraction.

B

15. While conducting Leopold maneuvers, the nurse determines that the fourth maneuver does not need to be done. What information caused the nurse to make this decision? A) The fetus is in a cephalic presentation. B) The fetus is not in a cephalic presentation. C) The nurse palpated angular bumps and nodules. D) The nurse palpated a round and hard mass that moves freely.

B

10. As a woman enters the second stage of labor, which of the following would you expect to assess? A) Feelings of being frightened by the change in contractions B) Complaints of feeling hungry and unsatisfied C) Falling asleep from exhaustion D) Expressions of satisfaction with her labor progress

A

4. To assess the frequency of a woman's labor contractions, you would time A) the beginning of one contraction to the beginning of the next. B) the end of one contraction to the beginning of the next. C) the interval between the acme of two consecutive contractions. D) how many contractions occur in 5 minutes.

A

7. To teach a pregnant woman effleurage, which of the following would you include? A) Lightly tracing a pattern on her abdomen with her fingertips. B) Massaging the uterine fundus at the peak of each contraction. C) Holding her breath and pushing with contractions. D) Exhaling into a paper bag to prevent dizziness.

A

8. A pregnant woman's husband wants to act as her coach during labor. You would explain a coach's role to him as a(n) A) important participant in a successful labor. B) observer who must take careful notes. C) person convenient for furnishing supplies. D) auxiliary person to assist as necessary.

A

8. A woman asks you if she can eat something during labor. Which of the following would be your best response? A) "You could have some hard candy to suck on." B) "Stomach-emptying time increases during labor, so food is not advised." C) "Most women in labor need to drink a protein supplement." D) "Eating during labor is recommended because it increases the frequency of contractions."

A

9. The nurse is teaching a pregnant patient the cardinal movements of labor. What should the nurse explain that occurs once the fetal head presses on the sacral nerves at the pelvic floor? A) The fetal head bends forward onto the chest. B) The fetal head rotates into a transverse position. C) The head extends so that the face and chin are born. D) The shoulders move into an anteroposterior position.

A

3. The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? (Select all that apply.) A) False labor contractions are irregular. B) True labor contractions disappear when asleep. C) False labor contractions lead to cervical dilation. D) True labor contractions occur in the abdomen and groin. E) False labor contractions do not increase in duration, frequency, and intensity.

A&E

2. Which of the following would be a danger signal of labor for a woman in labor? A) Blood-tinged vaginal discharge at full dilation B) Meconium-stained amniotic fluid C) Maternal pulse of 90 to 95 beats per minute D) Fetus presenting in an LOA position

B

5. After pelvic measurements, a patient who is 20 weeks pregnant is informed that the diagonal conjugate diameter is narrow. For which component of labor should the nurse plan care to address? A) Powers B) Passage C) Passenger D) Psychological outlook

B

7. If the monitor pattern of uteroplacental insufficiency were present, which of the following would you do first? A) Help the woman to sit up in a semi-Fowler's position. B) Turn her or ask her to turn to her side. C) Administer oxygen at 3 to 4 L by nasal cannula. D) Ask her to pant with the next contraction.

B

9. A woman is planning to take an expectant parents' class during pregnancy. Material you would expect her to learn in this type of course would include which of the following? A) Chest-breathing exercises to use in labor B) Beginning newborn care C) How to use a uterine monitor during labor D) Ways to use abdominal breathing

B

9. A woman's physician has told her he wants to use an episiotomy for delivery. She asks you what the purpose of this is. Which of the following would be your best answer? A) "It prevents distention of the bladder." B) "It relieves pressure on the fetal head." C) "It aids contraction of the uterus following delivery." D) "It is done primarily for the physician's benefit."

B

14. After assessment, the nurse determines that a pregnant patient's fetus has a face presentation that is pointing to the patient's left side with transverse pointing. How should the nurse document this assessment finding? A) LCT B) LMT C) LOT D) ROA

B Fetal position is the relationship of the presenting part to a specific quadrant and side of the patient's pelvis. The maternal pelvis is divided into four quadrants according to the mother's right and left. Four parts of a fetus are landmarks to describe the relationship of the presenting part to one of the pelvic quadrants that include the occiput (O), the chin (mentum [M]), the sacrum (Sa), or the acromion process (A). Position is indicated by an abbreviation of three letters. The first letter defines whether the landmark is pointing to the patient's right (R) or left (L).The middle letter denotes the fetal landmark. The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T). The nurse should document LMT. The other choices are incorrect interpretation of the findings and use of the abbreviations.

1. The fetus of a woman you care for during labor is in a vertex presentation and at a -1 station. You would interpret this to mean that the fetal head is A) at the ischial spines. B) engaged. C) floating. D) crowning.

C

13. To deliver her infant, a woman is asked to push with contractions. Which of the following is the most effective and safest pushing technique to teach her? A) Lying supine with legs in lithotomy stirrups B) Squatting while holding her breath C) Head elevated, grasping knees, breathing out D) Lying on side, arms grasped on abdomen

C

14. A woman is admitted to a labor unit in active labor. Which of the following assessments would alert you to the possibility that she may have difficulty accepting this child? A) "I'm so tired of being pregnant." B) "I haven't been able to sleep well lately." C) "I want this baby to be a boy." D) "I am so exhausted."

C

15. The first stage of labor is often a time of introspection. In light of this, which of the following would guide your planning of nursing care? A) A woman should be left entirely alone during this period. B) A woman will rarely speak or laugh during this period. C) A woman may spend time thinking about what is happening to her. D) No nursing care is needed to be done during this time.

C

3. Dilation follows effacement in the primipara. Full dilation is a usual distance of A) 3 to 4 cm. B) 7 to 8 cm. C) 8 to 10 cm. D) 12 to 14 cm.

C

5. You place an external fetal monitor on a woman in labor. Which of the following instructions would be best to give her? A) Lie supine so the tracing does not show a shadow. B) Avoid flexing her knees so her abdomen is not tense. C) Lie on her side so she is comfortable. D) Avoid using her call bell to reduce interference.

C

8. During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time? A) Risk for fluid volume deficit B) Anxiety related to stress of labor C) Risk for ineffective breathing pattern related to breathing exercises D) Powerlessness related to duration of labor

C

V- Variable

C- Cord Compression

10. The nurse is determining care for a patient entering the active phase of labor. Which outcome would be the most appropriate for the patient at this time? A) Patient will develop an irresistible urge to push. B) Patient will combat feelings of nausea to prevent vomiting. C) Patient will remain in the supine position during contractions. D) Patient will adjust body to attain the most comfortable position.

D

11. As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, which of the following would you do next? A) Test a sample of amniotic fluid for protein. B) Ask her to bear down with the next contraction. C) Elevate her hips to prevent cord prolapse. D) Assess fetal heart rate for fetal safety.

D

12. During the second stage of labor, a woman is generally A) very aware of activities immediately around her. B) anxious to have people around her. C) no longer in need of a support person. D) turning inward to concentrate on body sensations.

D

12. The nurse is concerned that a patient in the second stage of labor will experience a drop in blood pressure. What should the nurse do to prevent this from occurring? A) Position the patient supine. B) Encourage oral fluid intake. C) Administer intravenous fluids. D) Position the patient side-lying.

D

13. A pregnant patient in labor is being encouraged to push with contractions. In which position should the nurse assist to help the patient at this time? A) Squatting while holding the breath B) Lying on side, arms grasped on abdomen C) Lying supine with legs in lithotomy stirrups D) Semi-Fowler's position with legs bent against the abdomen

D

6. During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding? A) Variable decelerations that are too unpredictable to count B) Fetal baseline rate increasing at least 5 mmHg with contractions C) A shallow deceleration occurring with the beginning of contractions D) Fetal heart rate declining late with contractions and remaining depressed

D

6. If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which of the following patterns would you anticipate seeing on the monitor? A) A shallow deceleration occurring with the beginning of contractions B) Variable decelerations, too unpredictable to count C) Fetal baseline rate increasing at least 5 mm Hg with contractions D) Fetal heart rate declining late with contractions and remaining depressed

D

E- Early Decels

H- Head Compression

A- Accelerations

O - OK

L-Late Decels

P - Placenta