Exam 2 (Practice Questions I've Gotten Wrong)

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal exams. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal exams. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 4. The fetal heart pattern should be assessed every 1 hour during the latent phase of a low-risk labor. It is not standard protocol to assess every 10 minutes. 5. The nurse should assess the fetal heart before the woman ambulates. TEST-TAKING TIP: Except for invasive procedures, assessment of the fetal heart pattern is the only way to evaluate the well-being of a fetus during labor. The fetal heart pattern should, therefore, be assessed whenever there is a potential for injury to the baby or to the umbilical cord. At each of the times noted in the scenario—vaginal exam, analgesic administration, contraction, and ambulation— either the cord could be compressed or the baby could be compromised.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to push. 1. A bulging perineum indicates progression to the second stage of labor. 2. The bloody show increases as a woman enters the second stage of labor. 3. The amniotic sac can rupture at any time. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The gravida's ability to work with her labor is more dependent on her level of pain and her preparation for labor than on the phases and/or stages of labor. TEST-TAKING TIP: It is important that the test taker clearly understands the difference between the three phases of the first stage of labor and the three stages of labor. The three phases of the first stage of labor—latent, active, and transition— are related to changes in cervical dilation and maternal behaviors. The three stages of labor are defined by specific labor progressions—cervical change to full dilation (stage 1), full dilation to birth of the baby (stage 2), birth of the baby to birth of the placenta (stage 3).

An acute phase nursing intervention aimed at reducing hyperactivity is redirecting the client to: A. write in a diary. B. exercise in the gym. C. direct unit activities. D. orient a new client to the unit.

Answer: A Manic clients often respond well to the invitation to write. They will fill reams of paper. While writing they are less physically active. REF: Page 235-236 Varcarolis

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.

Which side effects of lithium can be expected at therapeutic levels? A. Fine hand tremor and polyuria B. Nausea and thirst C. Coarse hand tremor and gastrointestinal upset D. Ataxia and hypotension

Answer: A The fact that fine hand tremor and polyuria are present at therapeutic levels is quite annoying to some clients. These and other side effects are factors in noncompliance. REF: Page 240 (Table 13-3) Varcarolis

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

On examination, it is noted that a full-term primipara in active labor is right occipito-anterior (ROA), 7 cm dilated, and 3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

Answer: 1 1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines. 2. The fetal head is well past engagement. Engagement is defined as 0 station. 3. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away. 4. External rotation does not occur until after delivery of the fetal head. TEST-TAKING TIP: This question includes a number of concepts. Descent and station are discussed in answer options 1 and 2. The dilation of the cervix, which is related to the fact that the woman is a primigravida, is discussed in choice 3. And, one of the cardinal moves of labor—external rotation—is included in choice 4. The test taker must be prepared to answer questions that are complex and that include diverse information. In a 7-cm dilated primipara, with a baby at 3 station, vaginal delivery is not imminent, but the fetal head is well past engagement and descent is progressing well. External rotation has not yet occurred since the baby's head has not yet been birthed.

The nurse is caring for a client who is at the beginning of her third trimester of pregnancy. The client has been admitted in preterm labor, and magnesium sulfate is being used. Contractions are occurring about every 4 to 5 minutes and lasting 1 to 1½ minutes; blood pressure is 130/88 mm Hg; respirations are 22 breaths/min; pulse is 98 beats/min. What nursing observation would cause the nurse the most concern? 1. Urinary output of a total of 240 mL for the past 8 hours 2. Presence of active 2+ deep tendon reflexes 3. Complaints of hot flashes, nausea, and a headache 4. Blood pressure increases to 145/92 mm Hg

Answer: 1 Rationale: Before the administration of magnesium sulfate, the total urine output should be above 30 mL/hour, respiratory rate should be greater than 12 breaths/min, and deep tendon reflexes should be 2+. The medication should be held until the urinary output can be validated because this amount of urine is borderline for the minimal amount to begin the medication. Deep tendon reflexes are present and the respiratory rate is normal. Hot flashes may occur after the medication is started, but it is not as much a primary concern at this time as the blood pressure is. The urine output is the priority. Magnesium sulfate will reduce the blood pressure after administration is started. (Lowdermilk, et al., 10 ed., p. 787.)

Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1000 cc of Ringer's lactate. 3. Place woman in Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have woman empty her bladder.

Answer: 1, 2, 5 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should infuse Ringer's lactate before the woman is given regional anesthesia. 3. It is not necessary to place the woman in the Trendelenburg position. 4. The blood pressure will need to be monitored every 5 minutes for 15 minutes after administration of the anesthesia, but not before. 5. The nurse should ask the woman to empty her bladder. TEST-TAKING TIP: Before any medication, whether analgesia or anesthesia, is administered during labor, the fetal heart should be assessed to make sure that the baby is not already compromised. Before regional anesthesia administration, a liter of fluid should be infused to increase the woman's vascular fluid volume. This will help to maintain her blood pressure after the epidural insertion. And the woman's bladder should be emptied because she will not have the sensation of a full bladder once the epidural is in place.

The postpartum primipara client asks the nurse, "What can I do if I experience the breast engorgement that several of my friends had when trying to breast-feed their newborns?" Which of the following nurse responses are appropriate? Select all that apply. 1. "Feeding the baby every 2 hours often helps." 2. "Pump the breast or breasts that the infant does not empty after feedings." 3. "Apply chilled romaine lettuce leaves to the breasts inside a nursing bra." 4. "Apply heat to the engorged breast area." 5. "Take a warm shower after breastfeeding." 6. "Take ibuprofen as needed for pain control."

Answer: 1, 2, 6 Rationale: Frequent feeding of the infant and completely emptying the breast of milk helps to prevent and/or relieve engorgement. If engorgement occurs, the client can take ibuprofen as needed. Chilled cabbage leaves around the breasts help relieve engorgement, not lettuce leaves, and ice rather than heat (which causes increased blood flow to the area) is helpful. A warm shower before breastfeeding stimulates the let-down response and facilitates emptying of the breast as the infant feeds, not a shower after breastfeeding. (Lowdermilk, et al., 10 ed., p. 627.)

A client has been diagnosed with placenta previa. What nursing measures should be taken to care for this client in managing hemorrhage? Select all that apply. 1. Start an intravenous (IV) line and provide volume replacement. 2. Perform a vaginal examination. 3. Encourage bed rest in a position of comfort. 4. Anticipate a cesarean birth. 5. Monitor intake and output.

Answer: 1, 3, 4, 5 Rationale: Starting an IV to provide volume replacement will help prevent hypovolemic shock. The nurse should try to keep the client in a comfortable position in bed. A cesarean birth is anticipated because it will help prevent further blood loss. Intake and output should be monitored closely because the nurse needs to know how much fluid the client is losing versus taking in. Performing a vaginal examination could cause the client to lose more blood and the nurse should minimize chances for further bleeding. (Lowdermilk, et al., 10 ed., pp. 681-683.)

The nurse is caring for a woman who has just had a midline episiotomy. What items would be selected in preparation to teach perineal care? Select all that apply. 1. Squeeze bottle 2. Witch hazel pads 3. Ice pack 4. Analgesic spray or ointment 5. Peripad 6. Toilet tissue

Answer: 1, 5 Rationale: The client should be instructed in the use of a squeeze bottle to clean the perineal area after elimination by directing the flow from the squeeze bottle from front to back (urethra to anus). Ice packs are used for pain management and to reduce swelling. Analgesic spray assists in the reduction of irritation and pain. Peripads are used to absorb the normal postpartum discharge and should be changed from front to back each time she voids or defecates. Witch hazel pads are for hemorrhoids and to reduce perineal edema. Toilet tissue should be avoided. (Lowdermilk, et al., 10 ed., p. 493.)

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

Answer: 2 1. The woman should not push until the next contraction. She should be allowed to sleep at this time. 2. The woman's privacy should be maintained while she is resting. 3. The woman is in no apparent distress. Vital sign assessment is not indicated. 4. The woman is in no apparent distress. Oxygen is not indicated. TEST-TAKING TIP: Since the woman is in second stage, she is pushing with contractions. If she is very tired, she is likely to fall asleep immediately following a contraction. It is important for the nurse to maintain the woman's privacy by covering her perineum with a sheet between contractions. It would also be appropriate to awaken the woman at the beginning of the next contraction.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

Answer: 2 1. This client has probably moved into the second stage of labor. Providing a bedpan is not the first action. 2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor. 3. It is too early to notify the physician. 4. It is too early to advise the mother to push. TEST-TAKING TIP: The average length of transition in multiparas is 10 minutes. This client is likely, therefore, to have moved into the second stage of labor. The nurse's first action, therefore, is to assess the progress of labor. If she is in second stage, the physician will be notified and the client will be encouraged to push. If she is not yet in second stage, she may need the bedpan.

The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Variable baseline of 140 with V-shaped decelerations to 120 unrelated to contractions. 2. Variable baseline of 140 with decelerations to 100 that mirror each of the contractions. 3. Flat baseline of 140 with decelerations to 120 that return to baseline after the end of the contractions. 4. Flat baseline of 140 with no obvious decelerations or accelerations.

Answer: 2 1. V-shaped decelerations are variable decelerations. These are related to cord compression and are not normal. 2. Decelerations that mirror contractions are early decelerations. These are related to head compression and are expected during transition and second stage labor. 3. A flat baseline indicates absent variability. Also, there are late decelerations. Late decelerations are related to uteroplacental insufficiency. This situation is an obstetric emergency. 4. A flat baseline, even when no decelerations are noted, would not be normal in this situation. TEST-TAKING TIP: The test taker must be prepared to differentiate between normal situations and obstetric emergencies. Even though there are decelerations in choice 2, the decelerations are expected because the woman is currently in the transition phase of the first stage of labor.

The nurse is monitoring a client during labor and observes an erratic fetal heart pattern on the monitor at the height of the contraction. What is the first action of the nurse? 1. Position the mother on her side. 2. Check the monitor leads for placement. 3. Begin oxygen administration at 4 L/min and check the fetal heart rate. 4. Determine if contractions are increasing in duration, intensity, and frequency.

Answer: 2 Rationale: The erratic pattern on the fetal monitor most often is caused by faulty lead placement. Although positioning the client on the side is an excellent nursing measure, it does not address the rationale behind the erratic pattern. Beginning oxygen administration and noting characteristics of contractions would possibly be done after the leads were checked. (Lowdermilk, et al., 10 ed., p. 427.)

The mother of a 6-day-old infant asks the nurse "How can I tell if I am providing enough breast milk for the baby?" Which of the following nurse responses are appropriate? Select all that apply. 1. "Your baby should have at least four wet diapers per day." 2. "Your baby should not need constant feeding." 3. "The baby should be gaining at least 0.5 oz (14 g) per day." 4. "Your baby should be having at least one stool per day." 5. "The baby's stool should no longer be black and tarry (meconium) by the tenth day of age." 6. "You should feel breast fullness before each feeding."

Answer: 2, 3, 6 Rationale: Signs of effective breastfeeding include the baby feeling satiated after a feeding and not requiring constant feeding, gaining at least 0.5 oz (14 g) per day, and feeling breast fullness before each feeding by day four. The baby should have at least six, not four, wet diapers per day, should be having at least three stools per day, and stools should no longer be black and tarry by the fourth day of life. (Lowdermilk, et al., 10 ed., p. 620.)

During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

Answer: 3 1. Flexion is one of the first of the cardinal moves of labor. 2. Internal rotation occurs while the baby is still in utero. 3. During extension, the baby's head is birthed. 4. The baby rotates externally after the birth of the head. TEST-TAKING TIP: The baby must move through the cardinal moves because the fetal head is widest anterior-posterior but the fetal shoulders are widest laterally. On the other hand, the maternal pelvis is widest laterally in the inlet but anterior-posterior at the outlet.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

Answer: 3 1. Since the baby's back is facing the mother's right side, the fetal monitor should not be placed in the LUQ. 2. Since the baby's back is facing the mother's right side, the fetal monitor should not be placed LLQ. 3. Since the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. 4. The monitor electrode should have been placed in the RLQ if the nurse had assessed a vertex presentation. TEST-TAKING TIP: Although the question does not tell the test taker whether the sacrum is facing anteriorly or posteriorly, it does provide the information that the sacrum is felt toward the mother's right. Since this baby is in the sacral presentation and the back is toward the right, the best location for the fetal monitor is in the RUQ, at the level of the fetal back.

When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Where should the nurse place a fetoscope best to hear the fetal heart beat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

Answer: 3 1. The left upper quadrant (LUQ) would be the appropriate place to place a fetoscope to hear the fetal heart beat if the baby were in the LSA position, not the LOA position. 2. The right upper quadrant would be appropriate if the baby were in the RSA position. 3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question. 4. The right lower quadrant would be appropriate if the baby were in the ROA position. TEST-TAKING TIP: The fetal heart is best heard through the fetal back. Since, as determined by doing Leopold's maneuvers the baby is LOA, the fetal back (and, hence, the fetal heart) is in the left lower quadrant.

The nurse is administering carboprost to a client. Which condition is the client most likely experiencing? 1. Premature separation of the placenta 2. Placenta previa 3. Postpartum hemorrhage 4. Hypertension

Answer: 3 Rationale: Carboprost (Hemabate) is a synthetic prostaglandin used to treat postpartum hemorrhage by inducing uterine contractions. The medication causes contraction of smooth muscle, which works by causing intense uterine contractions. Carboprost can also be used to induce abortion in the second trimester of pregnancy. Side effects of carboprost include hypertension, fever, bronchoconstriction, nausea, vomiting, and diarrhea. Premature separation of the placenta and placenta previa are conditions that may lead to prenatal hemorrhage. (Lehne, 8 ed., p. 820.)

During the third stage, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts firmly. 4. The uterine surface area dramatically decreases.

Answer: 3, 4, 1, 2 3. The contraction of the uterus after delivery of the baby is the first step in the third stage of labor. 4. As the uterus contracts, its surface area decreases more and more. 1. A hematoma forms behind the placenta as the placenta separates from the uterine wall after the uterus has contracted and its surface area has decreased. 2. The membranes separate from the uterine wall after the placenta separates and begins to be born. TEST-TAKING TIP: The test taker should become familiar with the process of placental separation. Once the baby is born, the uterus contracts. When it does so, the surface area of the internal uterine wall decreases, forcing the placenta to begin to separate. As the placenta separates, a hematoma forms behind it, further promoting placental separation. Once the placenta separates and begins to be born, the membranes peel off the uterine wall and are delivered last.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

Answer: 3, 4, 5 1. Hypnotic suggestion is usually not included in childbirth education based on the Lamaze method. 2. Rhythmic chanting is usually not included in childbirth education based on the Lamaze method. 3. Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5. Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education. TEST-TAKING TIP: The test taker may have expected to find breathing techniques included in the question related to Lamaze childbirth education. Although breathing techniques are taught, there are a number of other techniques and principles that couples learn in Lamaze classes. The test taker should be familiar with all aspects of childbirth education.

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

Answer: 4 1. A fetus in a sacral presentation is in a vertical lie. 2. A fetus in an occipital presentation is in a vertical lie. 3. A fetus in a mentum presentation is in a vertical lie. 4. A fetus in a scapular presentation is in a horizontal lie. **TEST-TAKING TIP: Lie is concerned with the relationship between the fetal spine and the maternal spine. When the spines are parallel, the lie is vertical (or longitudinal). When the spines are perpendicular, the lie is horizontal (or transverse). It is physiologically impossible for a baby in the horizontal lie to be delivered vaginally

A woman, G2 P0101, 5 cm dilated and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Assist the woman in changing position. 4. Urge the woman to perform the next level breathing.

Answer: 4 1. It is inappropriate to encourage her to have an epidural at this time. 2. It is inappropriate to encourage her to have an IV analgesic at this time. 3. A change of position might help but will probably not be completely effective. 4. This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time. TEST-TAKING TIP: If a woman has learned Lamaze breathing, it is important to support her actions. Encouraging her to take pain-relieving medications may undermine her resolve and make her feel like she has failed. The initial response by the nurse should be to support her by encouraging her to use her breathing techniques.

The nurse is interpreting the results of a fetal blood sampling test. Which of the following reports would the nurse expect to see? 1. Oxygen saturation of 99%. 2. Hgb of 11 gm/dL. 3. Serum glucose of 140 mg/dL. 4. pH of 7.30.

Answer: 4 1. Oxygen saturations are noninvasive. Plus, fetal oxygen saturation levels are well below those seen in extrauterine life— approximately 50% and 75%. 2. Normal fetal hemoglobin levels are well above those seen in extrauterine life—14 to 20 gm/dL. 3. This fetal glucose level is indicative of maternal hyperglycemia. 4. This fetal pH value is within normal limits. TEST-TAKING TIP: It is essential that the test taker be aware that many fetal lab values are much different than those seen in extrauterine life. The nurse would expect to see fetal oxygen saturation of 50% to 75%, not 99%, and fetal hemoglobin levels of 14 to 20 gm/dL, not 11 gm/dL. The nurse would expect to see a fetal serum glucose level of 140 mg/dL only if the mother had diabetes. The only expected value listed is a pH of 7.30 since this is consistent with a normal, slightly acidic fetal pH. The differences in fetal and extrauterine values reflect the fact that the fetus is not oxygenating efficiently through the lungs, as happens in the extrauterine environment, but rather is "breathing" indirectly via the placenta.

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and 3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Assess for signs of rectal pressure.

Answer: 4 1. This client is fully dilated and effaced, but the baby is not yet engaged. Until the baby descends and stimulates rectal pressure, it is inappropriate for the client to begin to push. 2. Fundal pressure is inappropriate. 3. Many women push in the squatting position, but it is too early to push at this time. 4. Assessing for rectal pressure is appropriate at this time. TEST-TAKING TIP: Although the test taker may see in practice that women are encouraged to begin to push as soon as they become fully dilated, it is best practice to wait until the woman exhibits signs of rectal pressure. Pushing a baby that is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord.

A pregnant client had an abruptio placentae after a hemorrhagic episode; an emergency delivery was completed. The client is stable and the cesarean delivery was performed 2 days ago. During the postoperative period, the nurse is observing for potential complications. What would be important for the nurse to assess regarding the development of complications? 1. Check the blood sugar level every 2 hours. 2. Assess the vital signs hourly. 3. Place the client in side-lying position. 4. Monitor fibrinogen and coagulation studies.

Answer: 4 Rationale: Clients with abruptio placentae are prone to the development of disseminated intravascular coagulation after delivery, which is characterized by abnormal fibrinogen and coagulation studies. Although checking vital signs is important, the delivery and hemorrhagic episode has occurred. Checking blood sugar would be appropriate for a client with gestational diabetes. Side-lying position would improve placental perfusion. (Lowdermilk, et al., 10 ed., p. 685.)

The nurse is assessing a client 12 hours after a prolonged labor and delivery. What assessment data would cause the nurse the most concern? 1. Oral temperature of 100.6° F (38.1° C) 2. Moderate amount of dark red lochia 3. Episiotomy area bruised with small amount of dark bloody drainage 4. Uterine fundus palpated to the right of the umbilicus

Answer: 4 Rationale: Uterus palpated to the right of the umbilicus may indicate a full bladder. The fundus should be at the level of the midline. The temperature, lochia, and episiotomy assessment findings are within normal limits. (Lowdermilk, et al., 10 ed., p. 482.)

A woman is in labor with contractions 3 minutes apart. Her membranes rupture, and the umbilical cord is visibly protruding from the vagina. Rank the nursing actions in order of importance with the first noted as the most important action. Place the options in the correct order. 1. Wrap the exposed cord loosely in sterile saline soaks. 2. Place an emergency call to the physician or health care provider. 3. Initiate an intravenous (IV) line or increase the rate of flow on the existing IV. 4. Begin administering oxygen to the mother and have her assume a knee-chest position.

Answer: 4, 2, 3, 1 Rationale: The most important action is to immediately attempt to relieve the pressure on the umbilical cord and increase the amount of oxygen being delivered to the infant. Placing the woman in a modified Sims', Trendelenburg, or knee-chest position will help to relieve some of the pressure. The other action is to insert sterile, gloved fingers into the vagina on either side of the cord and apply gentle manual pressure to relieve the pressure of the presenting part on the cord. An emergency call should be placed to the physician or health care provider. An IV should be initiated or the rate increased on an existing IV. The exposed cord should be loosely wrapped in sterile saline soaks to keep it moist. (Lowdermilk, et al., 10 ed., p. 459.)

A desirable short-term goal for the nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors would be: A. making no attempts at self-harm within 12 hours of admission. B. sleeping soundly for 12 of the next 24 hours. C. willingly taking prescribed medication as offered by staff within 24 hours of admission. D. demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.

Answer: A Whenever aggressive verbal or physical behaviors are demonstrated, a desirable goal is cessation of those behaviors. Verbal and physical aggression are most apt to occur when staff are trying to structure the client's behavior for his or her own safety or the safety of others. REF: Page 234-235 Varcarolis