365 Exam 2

Upon vaginal examination, the nurse notes that the infant's anterior fontanel is to the back left side of the maternal pelvis. How does the nurse chart this position? 1.ROA 2.LOA 3.ROP 4.LOP

1. ROA rationale: The occiput is the landmark used for identifying fetal position. If the anterior fontanel is pointing to the back (posterior) left of the maternal pelvis, then the occiput is pointing toward the right, anterior maternal pelvis.

A nursing instructor explains to a group of students that an amnioinfusion is a procedure used most commonly in the first stage of labor to treat which type of decelerations? 1. Variable 2. Late 3. Early 4. Prolonged

1. variable

The nurse is caring for a patient with congenital heart disease who is beginning her prenatal care. Which normal cardiac changes during pregnancy can exacerbate cardiac disease during pregnancy? Select all that apply. 1.Increase in total blood volume from 30 to 50% 2.Decrease in heart rate by 10 to 20 beats per minute 3.The weight of the gravid uterus can lie on the inferior vena cava 4.Increased peripheral vascular resistance 5.Increased cardiac output

1.Increase in total blood volume from 30 to 50% 3.The weight of the gravid uterus can lie on the inferior vena cava 5.Increased cardiac output

The nurse is describing baseline fetal heart rate (FHR) to a practicum student. which would the nurse mention when teaching about the definition and assessment criteria related to baseline FHR? Select all that apply. 1."Periodic changes in baseline of FHR occur in relation to uterine contractions." 2."Recurrent changes in baseline of FHR occur in less than 50% of the contractions in 20 minutes." 3."Intermittent changes in baseline of FHR occur in greater than 50% of the contractions in 20 minutes." 4."Episodic changes in baseline of FHR occur independent of uterine contractions." 5."FHR is rounded to increments of 5 beats per minute during a 10-minute window. This must be at least 2 minutes of identifiable baseline segment."

1."Periodic changes in baseline of FHR occur in relation to uterine contractions." 4."Episodic changes in baseline of FHR occur independent of uterine contractions." 5. "FHR is rounded to increments of 5 beats per minute during a 10-minute window. This must be at least 2 minutes of identifiable baseline segment."

The nurse is receiving a report on a patient and notes that the patient's exam is 8/90/+2, with contractions every 2-3 minutes and lasting 70-90 seconds. The FHR is 145 bpm with minimal variability and repetitive late decelerations to 110's, lasting 60-100 seconds. which are the appropriate nursing interventions for this patient? Select all that apply. 1.Administer 02 at 10L/min via non-rebreather mask 2.Begin oxytocin at 2mu/min to hasten delivery 3.Position patient on either side. 4.Limit IV fluids to prepare for cesarean section and prevent fluid overload 5.Notify the provider

1.Administer 02 at 10L/min via non-rebreather mask 3.Position patient on either side. 5.Notify the provider

The nurse is preparing the client for epidural anesthesia. Which assessments or interventions would the nurse perform prior to administration? Select all that apply. 1.Check the platelet level. 2.Perform the procedure time-out. 3.Determine that the client is dilated to at least 5cm. 4.Ensure the consent has been signed. 5.Administer IV fluid bolus of normal saline or lactated ringers.

1.Check the platelet level. 2.Perform the procedure time-out. 4.Ensure the consent has been signed. 5.Administer IV fluid bolus of normal saline or lactated ringers.

The nurse assesses a patient who has an indeterminate fetal heart rate and places the patient on electronic fetal heart rate (FHR) monitoring. Which assessments are priorities from the electronic FHR monitoring? Select all that apply. 1.Clarify the pattern interpretation 2.Assess the baseline variability 3.Confirm maternal heart rate with fetal heart rate 4.Further assess fetal status 5.Determine fetal movement

1.Clarify the pattern interpretation 2.Assess the baseline variability 4.Further assess fetal status

A gravid patient at 8 weeks gestation presents to the emergency department reporting unilateral sharp lower abdominal pain, shoulder pain, and light vaginal bleeding. The nurse knows these signs and symptoms are associated with which pregnancy complication? 1.Ectopic pregnancy 2.Hydatidiform mole 3.Spontaneous abortion 4.Therapeutic abortion

1.Ectopic pregnancy Unilateral pain is more indicative of ectopic pregnancy, while shoulder pain is referred to as visceral pain from a ruptured tube.

A nurse is discussing the indications for an ultrasound with pregnant women in a prenatal education class. A client, who is in her first trimester, asks the nurse which tests the ultrasound could assess for at this time. Which would be an appropriate nursing response? Select all that apply. 1.Estimate gestational age 2.Evaluate the uterus structures 3.Confirm intrauterine pregnancy 4.Detect fetal anomalies 5.Confirm fetal cardiac activity

1.Estimate gestational age 2.Evaluate the uterus structures 3.Confirm intrauterine pregnancy 5.Confirm fetal cardiac activity Rationale: The fetal anomalies are detected in the second trimester ultrasound (when check anatomy)

The nurse is caring for a patient who was just admitted to the labor and delivery (L&D) unit. Her exam is 6/90/0. The initial fetal heart monitor (FHM) strip is Category I. Her pregnancy was complicated by gestational diabetes mellitus (GDM), well controlled with diet. The nurse will base assessment interventions related to the frequency of assessment of the FHR for this patient on The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), which is? 1.Every 15 minutes during the active phase and every 5 minutes for the second stage 2.Every 30 minutes during the active phase and every 15 minutes for the second stage 3.Every 60 minutes during the active phase and every 30 minutes for the second stage 4. Every hour, on the hour

1.Every 15 minutes during the active phase and every 5 minutes for the second stage Rationale: AWHONN recommends women with risk factors be monitored every 15 minutes during the active phase and every 5 minutes during the second stage. This woman is high risk because of her GDM.

The provider orders an amnioinfusion for a patient who is a G2P1 at 40 weeks gestation. which education would the nurse provide to the patient? Select all that apply. 1.Explain placement of intrauterine pressure catheter into the uterus. 2.Explain that the procedure is performed to resolve all types of decelerations. 3.Explain that room temperature sterile IV fluids are infused to cushion the umbilical cord. 4.Inform patient that she will remain flat until infusion is completed. 5.Discuss that fluid will continue to leak vaginally and should be monitored to prevent over-distention.

1.Explain placement of intrauterine pressure catheter into the uterus. 3.Explain that room temperature sterile IV fluids are infused to cushion the umbilical cord. 5.Discuss that fluid will continue to leak vaginally and should be monitored to prevent over-distention. rationale: option 1: fluid infused into the uterus transcervically via the IUPC increases intraamniotic fluid to cushion the umbilical cord and reduce cord compression. Option 2: This does not resolve all types of decelerations and is generally performed for variable decelerations to alleviate cord compression. Option 3: Normal saline or lactated ringers are infused at room temperature. Option 4: The patient is not to remain flat during an amnioinfusion. Side-lying is optimal in order to improve fetal circulation. Option 5: patient should understand the fluid leaking is normal during labor and will be monitored.

The nurse is caring for a laboring client who is waiting for the anesthesiologist to come administer the epidural. Which does the nurse anticipate that the obstetrician will order for this client to prevent a common adverse reaction following the epidural placement? 1.IV fluid bolus 2.Left-tilt position 3.Check vitals every 5 minutes 4.Assist client to bathroom

1.IV fluid bolus

The client asked the nurse what a complication of the amniocentesis procedure could be. which would be the nurse's best response? Select all that apply. 1.Maternal or fetal hemorrhage 2.Leakage of amniotic fluid 3.Preterm labor 4.Maternal or fetal infection 5.Nausea/vomiting

1.Maternal or fetal hemorrhage 2.Leakage of amniotic fluid 3.Preterm labor 4.Maternal or fetal infection Rationale: Option 1: This can be as a result of trauma to the fetus or placenta resulting in bleeding. Option 2: The needle puncture on the amniotic membrane can result in uterine rupture resulting in fluid leakage. Option 3: Loss of amniotic fluid can cause pre-term labor, abdominal contractions. Option 4: The puncture of the skin or abdomen can place the mother and/or fetus at risk for infection. Option 5: Nausea/vomiting can be common discomforts of pregnancy. They are not related specifically to an amniocentesis procedure.

A client was recently admitted to the labor and delivery unit in active labor. The nurse performs Leopold's maneuvers during the assessment. During the third maneuver, the nurse notes a firm and fixed fetal part. Which position correlates with this assessment finding? 1.Occiput 2.acromion 3.Sacrum 4.Transverse

1.Occiput

There are several patients on the labor and delivery unit. Which patients are at risk for disseminated intravascular coagulation (DIC)? Select all that apply. 1.Patient with term intrauterine fetal demise 2.Patient with severe preeclampsia 3.Patient with gestational diabetes 4.Patient with twin pregnancy 5.Patient with HELLP syndrome

1.Patient with term intrauterine fetal demise 2.Patient with severe preeclampsia 5.Patient with HELLP syndrome

. The Labor and Delivery unit educator is teaching a group of nurses how to respond when a nurse assesses a patient that is demonstrating minimal or absent variability. Which responses by the nurses are correct regarding appropriate interventions? Select all that apply. 1.Perform vibroacoustic stimulation 2.Change maternal position 3.Provide oxygen via nasal cannula 4.Give an IV fluid bolus 5.Discontinue oxytocin

1.Perform vibroacoustic stimulation 2.Change maternal position 4.Give an IV fluid bolus 5.Discontinue oxytocin

The Labor and Delivery unit educator is teaching a group of nurses how to respond when a nurse assesses a patient that is demonstrating minimal or absent variability. Which responses by the nurses are correct regarding appropriate interventions? Select all that apply. 1.Perform vibroacoustic stimulation 2.Change maternal position 3.Provide oxygen via nasal cannula 4.Give an IV fluid bolus 5.Discontinue oxytocin

1.Perform vibroacoustic stimulation 2.Change maternal position 4.Give an IV fluid bolus 5.Discontinue oxytocin4 Rationale: 3 administer with nonrebreather mask

The nurse is caring for a gravid patient who is carrying twins. Which complications would the nurse monitor the patient for? Select all that apply. 1.Preeclampsia 2.Gestational diabetes 3.Abruptio placentae 4.Sickle cell anemia 5.Cardiomyopathy

1.Preeclampsia 2.Gestational diabetes 3.Abruptio placentae 5.Cardiomyopathy

The nurse is caring for a patient with placenta previa. Which would be included in the plan of care? Select all that apply. 1.Promptly report any increase in vaginal bleeding. 2.Assess fetal heart rate continuously with fetal scalp electrode. 3.Limit vaginal exams to once a shift. 4.Establish and maintain intravenous (IV) access. 5.Ensure the availability of blood products.

1.Promptly report any increase in vaginal bleeding. 4.Establish and maintain intravenous (IV) access. 5.Ensure the availability of blood products. rationale: Rapid and massive blood loss may necessitate immediate delivery.Hemorrhage may occur, requiring immediate fluid replacement and/or blood transfusion. Transfusion of blood products may be needed. DOn't insert anything w/ placenta previa

A gravid woman has been admitted with preeclampsia. The nurse knows to watch for signs of potential eclampsia. Which signs or symptoms might indicate impending eclampsia? Select all that apply. 1.Severe headache 2.Clonus 3.Seeing flashes of light 4.Epigastric pain 5.Deep tendon reflex (DTR) +2

1.Severe headache 2.Clonus 3.Seeing flashes of light 4.Epigastric pain rationales: Severe headache can indicate cerebral vasospasm or ischemia, which can trigger seizures. Clonus indicates Central Nervous System (CNS) irritability, increasing the risk of seizure. Visual changes can indicate Central Nervous System (CNS) irritability, increasing the risk of seizure. This is a sign of liver involvement, which indicates worsening preeclampsia. Option 5: A DTR +2 is normal; hyperreflexia might indicate impending seizure.

The nurse is caring for a client being augmented with oxytocin. What potential complications should the nurse observe the client for? Select all that apply. 1.Tachysystole 2.Late decelerations on the fetal monitor 3.Episodic accelerations 4.Uterine rupture 5.Maternal edema

1.Tachysystole 2.Late decelerations on the fetal monitor 4.Uterine rupture 5.Maternal edema

A client who is 21 weeks pregnant is scheduled for an amniocentesis today. The client informs the nurse that her bladder feels full. which is the nurse's best response? 1."Do not drink any more liquids for the rest of the day." 2."Empty your bladder before the test." 3."You will need to measure the urine. 4."Keep your bladder full for the procedure."

2."Empty your bladder before the test." Rationale: The bladder should be emptied. A full bladder may be needed for ultrasound visualization for gestational age less than 20 weeks.

The nurse is providing prenatal education to a patient expecting twins. Which statement by the patient indicates the need for further teaching? 1. "My babies might be born too early." 2."If my babies are both girls, they must be identical twins." 3."I need to eat well because I'm at risk for anemia." 4. I might have pregnancy complications."

2."If my babies are both girls, they must be identical twins." Fraternal twins (dizygotic) can be either the same gender or different genders.

A patient has just had a cerclage procedure for cervical insufficiency. which anticipatory guidance should the nurse provide prior to discharge? 1."A cesarean delivery will be necessary for your birth, due to the cerclage." 2."The stitch in your cervix should be removed if you go into labor." 3."The stitch in your cervix should be removed no later than 20 weeks' gestation." 4."The cerclage will prevent you from delivering a preterm baby."

2."The stitch in your cervix should be removed if you go into labor." rationale: A cerclage is removed at 36 to 37 weeks, or when labor ensues, in order to prevent cervical tearing during labor.

the nurse is caring for a woman with preterm premature rupture of membranes, not in active labor. Which of the following nursing actions would be included in the plan of care for this patient? Select all that apply. 1.Digital vaginal exams every four hours 2.Assess for signs of infection 3.Assess fetal heart rate with internal fetal scalp electrode 4.Report maternal fever to provider 5.Placement of a Foley catheter

2.Assess for signs of infection 4.Report maternal fever to provider Rationale: Uterine infection would change the management plan to move toward delivery. Maternal fever is sign of uterine infection.

The nurse is providing education to a client on when the Intravenous Catheter can be discontinued following a cesarean section. What information will the nurse include? 1.Client has adequate pain control with oral medication. 2.Client can maintain oral hydration without nausea. 3.Client has active bowel sounds in all four quadrants. 4.Client is breastfeeding infant well every couple of hours.

2.Client can maintain oral hydration without nausea.

The nurse is reviewing the biophysical profile (BPP) results and would expect which variables to be included in this test? Select all that apply 1.Fetal position 2.Fetal tone 3.Amniotic fluid volume 4.Fetal breathing movements 5.Fetal movement

2.Fetal tone 3.Amniotic fluid volume 4.Fetal breathing movements 5.Fetal movement Rationale: Option 1: The BPP does not assess for fetal position. It is important to look for factors that affect the well-being status of the fetus. Option 2: One or more extremity extension with return to fetal flexion or opening and closing of the hand is expected within 30 minutes. Option 3:A pocket of amniotic fluid that measures at least 2 cm in two planes perpendicular to each other is expected. Option 4: One or more episodes of rhythmic breathing movements of 30 seconds or movement within 30 minutes is expected. Option 5: Three or more discrete body or limb movements in 30 minutes are expected.

The nurse calls to notify the provider that the patient has a Category II tracing. Which would the nurse include in her charting that was interpreted from the tracing? 1.Absent variability, FHR 120, recurrent variable decelerations 2.Minimal variability, FHR 165, recurrent variable decelerations 3.Early decelerations, FHR 145, moderate variability 4.No accelerations, FHR 110, moderate variability

2.Minimal variability, FHR 165, recurrent variable decelerations Option 1: This is Category III tracing. Option 2: This is Category II tracing. Option 3: This is Category I tracing. Option 4: This is Category I tracing.

The nurse is assessing a patient who has been admitted for preeclampsia. Which findings would indicate severe features of preeclampsia? Select all that apply. 1.Blood pressure 158/98 mmHg 2.Platelet count of 90,000/mm3 3.Severe headache 4.Visual changes 5.Non-pitting edema of lower extremities

2.Platelet count of 90,000/mm3 3.Severe headache 4.Visual changes rationale: Platelet count less than 100,000/mm3 is a severe feature of preeclampsia. A severe headache indicates central nervous system irritability and is a severe feature of preeclampsia. Visual changes indicate central nervous system irritability and is a severe feature of preeclampsia. 1. A blood pressure greater than 160/110 mmHg is considered a severe feature of preeclampsia. 5.This is a common feature in preeclampsia and with normal pregnancy.

A woman experiencing preterm labor has an order to receive betamethasone. Which statement is correct regarding antenatal corticosteroids? Select all that apply. 1.They reduce the risk of GBS sepsis in the newborn. 2.They are most beneficial from 24 to 34 weeks' gestation. 3.They accelerate fetal lung maturity. 4.They reduce the risk of necrotizing enterocolitis in the neonate. 5.They decrease the contractility of the uterus.

2.They are most beneficial from 24 to 34 weeks' gestation. 3.They accelerate fetal lung maturity. 4.They reduce the risk of necrotizing enterocolitis in the neonate.

A nursing student is examining a client's chart on the Antepartum unit and asks why an umbilical artery Doppler flow test is ordered. which would be an appropriate response for the nurse? Select all that apply. 1. "It is used for some mothers to identify the gestational age of the fetus." 2. "It is used to detect any abnormal structures of the fetus." 3. "It is non-invasive screening technique that uses advanced ultrasound technology to assess resistance to blood flow in the placenta." 4."Images are obtained of blood flow in the umbilical artery." 5. "This test assesses placental perfusion."

3. "It is non-invasive screening technique that uses advanced ultrasound technology to assess resistance to blood flow in the placenta." 4."Images are obtained of blood flow in the umbilical artery." 5. "This test assesses placental perfusion." Rationale" This test is used to assess placental blood flow and is also used with other diagnostic tests to assess fetal status in IUGR fetuses. It is used to assess the blood flow in the umbilical artery and to identify any interruption in flow. It is used to assess the blood flow in the umbilical artery and to identify any interruption in flow.

A pregnant mother in her third trimester is scheduled for an amniotic fluid index (AFI) test. The nurse understands the reason for the test when she verbalizes which statement? 1."The test is a screening tool that assesses fetal accelerations." 2."The test evaluates the uterine and cervical structures of the pregnancy." 3. "The test is a screening tool that measures the volume of amniotic fluid with ultrasound." 4."The test uses a needle to puncture the abdomen to obtain amniotic fluid."

3. "The test is a screening tool that measures the volume of amniotic fluid with ultrasound." Rationale: This test helps to assess the fetal well-being and placental function by measuring the pockets of amniotic volume in four quadrants of the uterine cavity via ultrasound.

The biophysical profile reports the following test results: Three episodes of limb movement; one episode of active extension with return to flexion of the fetal limb or trunk and opening and closing of the hand; absent pockets of amniotic fluid; one breathing episode that lasts a minimum of 30 secs; the NST was reactive. Which is the total score? 1.5 2.10 3.8 4.6

3. 8 Correct. Three episodes of limb movement = score 2; at least one episode of active extension with flexion of the fetal limb or trunk and opening and closing of the hand = score 2; absent pockets of amniotic fluid = score 0; breathing episode lasting a minimum of 30 secs = score 2; and a reactive NST = score 2

The nurse admits a client who is 34 weeks pregnant on the Labor & Delivery unit. The client complains of no fetal movements since the morning. The health care provider (HCP) orders a non-stress test (NST) which is performed, but the result does not show any fetal heart rate accelerations within a 20-minute period. Which test would the nurse anticipate the HCP ordering? Select all that apply. 1.Maternal serum alfa-fetoprotein profile (MSAFP) 2.Biophysical profile 3.Amniocentesis 4.Ultrasound 5.Vibroacoustic Stimulation (VAS)

3. Amniocentesis 4. Ultrasound 5. Vibroacoustic Stimulation (VAS) Rationale: Option 1:This diagnostic test is performed to identify fetal defects, lung maturity, hemolytic disease or any genetic disorders. Option 2: This is used to assess the well-being of the fetus and is appropriate for further evaluation for a non-reactive NST. Option 3: This diagnostic procedure is performed to identify fetal defects, hemolytic disease, or any genetic disorders. Option 4: This is a diagnostic and screening test used to assess cardiac activity, fetal well-being with EFM when NST is nonreactive. It is appropriate for follow up testing for a non-reactive NST. Option 5: This is a screening tool used to assess fetal well-being with EFM when NST is nonreactive.

Misoprostol has been ordered for a pregnant patient at 41 weeks' gestation. Which statement made by the patient indicates to the nurse that teaching about the use of misoprostol has been effective? 1."Misoprostol enhances uteroplacental perfusion in an aging placenta." 2.Misoprostol increases amniotic fluid volume." 3."Misoprostol ripens the cervix in preparation for labor induction." 4."Misoprostol stimulates the amniotic membranes to rupture."

3."Misoprostol ripens the cervix in preparation for labor induction."

Which patient with a fetus displaying minimal variability would the nurse assess first? 1.A patient who received nalbuphine 10 mg slow IV push 10 minutes ago 2.A patient who is 25 weeks gestation with intermittent contractions 3.A patient who is 39 weeks gestation with 8 contractions in 10 minutes 4.A patient who is 37 weeks gestation contracting every 6 to 7 minutes with no accelerations

3.A patient who is 39 weeks gestation with 8 contractions in 10 minutes This patient is exhibiting tachysystole and requires intervention to improve fetal oxygenation.

The nurse reviews the client's amniotic fluid index (AFI) report and the AFI shows 24 cm. The nurse's best action would be to: 1. Inform the charge nurse. 2.Assess the maternal vital signs. 3.Call the physician. 4.Administer IV fluids

3.Call the physician. Rationale: An AFI above 24 cm is polyhydramnios, meaning there is too much amniotic fluid present. The physician must be notified. The result may indicate fetal malformation, such as NTDs, or obstruction of the fetal gastrointestinal tract.

A nurse is caring for a pregnant client who is to have a contraction stress test (CST). Which findings are indications for this procedure? Select all that apply. 1.History of bleeding 2.A reactive nonstress test (NST) 3.Decreased fetal movement 4. Preterm labor 5.A non-reactive NST

3.Decreased fetal movement 4. Preterm labor 5.A non-reactive NST

The nurse is assessing all assigned patients and notes that one patient is at risk for preterm labor. Which of the following criteria does the nurse recognize as putting the patient at risk? 1.G2P0 at 35 0/7 weeks reporting four contractions in one hour 2.G6P5 at 37 5/7 weeks with cervical dilation of 3 cm 3.G1P0 at 32 3/7 weeks with regular contractions and a change in cervical dilation 4.G3P2 at 28 0/7 weeks complaining of increased vaginal discharge and low back ache

3.G1P0 at 32 3/7 weeks with regular contractions and a change in cervical dilation Preterm labor is less than 37 0/7 weeks.

The nurse is reading the contraction stress test (CST) result and interprets it as a negative result. Which is the criteria for interpretation of a negative result? 1. There are two late decelerations of fetal heart rate (FHR) with 50% of uterine contractions noted on the EFM. 2. There are significant variable decelerations. 3. There is no fetal activity. 4. There are no decelerations (variable or late) in a 10-minute EFM strip with three uterine contractions greater than 40 seconds.

4. There are no decelerations (variable or late) in a 10-minute EFM strip with three uterine contractions greater than 40 seconds. Rationale: A negative result shows no FHR decelerations. Decelerations are associated with IUGR, increased rate of fetal death, and neonatal depression. Negative CSTs are associated with good fetal outcomes. options 1, 2, & 3 are positive results

Which plan would be most appropriate for monitoring a patient who presents to the labor and delivery unit in the active phase of labor with ruptured membranes? 1.At least hourly by auscultation 2.Every 30 minutes by electronic fetal heart monitoring 3.Every 15-30 minutes by auscultation 4.Every 15 minutes by electronic fetal heart monitoring

4.Every 15 minutes by electronic fetal heart monitoring This is appropriate for latent and active phases, and second stages of labor with oxytocin or risk factors.

. During the transition phase, the client states that she feels a strong urge to push. The nurse explains that which reflex triggers this urge? 1.Deep tendon reflex 2. moro reflex 3.Naegele's reflex 4.Ferguson's reflex

4.Ferguson's reflex

The nurse is caring for a gravid woman with preeclampsia. Which finding would indicate worsening condition and should be reported to the physician? 1.Proteinuria 2.Platelet count 120,000/mm3 3.Blood pressure 158/98 mmHg 4.Increased respiratory rate and report of shortness of breath

4.Increased respiratory rate and report of shortness of breath These are signs of pulmonary edema, indicating a worsening condition and should be reported to the physician.