Exam 6

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation

A woman presents in advanced labor, and birth appears imminent. What is the most important and appropriate aspect of admission for this woman?

taking her blood pressure and determining whether clonus or edema is present

A nursing instructor is teaching students about pre-existing illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement?

"A pregnant woman does not have to worry about contracting new illnesses during pregnancy."

Which of the following would the nurse include when teaching the parents of a newborn who have a 2-year-old boy at home?

"Ask your 2-year-old to pick out a special toy for his sister."

A young patient with a cardiac problem wants to get pregnant and tells the nurse that she is sad that she will never be able to have a baby. What is the best response by the nurse?

"Because of improved management, more women with cardiac problems can complete pregnancies successfully."

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?

"Come to the health facility with any vaginal material passed."

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain."

The nurse is helping an indigent HIV-positive pregnant patient set up a postdelivery care plan for her baby. What is an appropriate question/statement during that discussion?

"HIV can be passed to the baby from breast-feeding so it's important that you give the baby formula. Formula's pretty expensive so I'll give you some information for places you can contact if you ever need some help getting it."

Your pregnant patient has had asthma since she was a teenager. What statement by the patient would alert you to the fact her asthma may not be in control?

"I keep waking up at night."

A client is having a routine prenatal visit and asks the nurse what the birth education teacher meant when she used the term zero station. What is the best response by the nurse?

"The presenting part is at the true pelvis and is engaged."

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal."

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely."

A woman asks the nurse if she can eat something during labor. Which response by the nurse would be best?

"You could have some hard candy to suck on."

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort."

A woman at 39 weeks gestation has been in labor for 8 hours and is asking how far she is dilated. She attended childbirth classes and is aware of the stages and phases of labor. She had a vaginal exam 30 minutes prior to her asking again. How should the nurse respond to her question?

"Your labor signs have not changed; we are looking for changes in your labor pattern before we check you again."

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?

0

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation

What is the normally accepted fetal heart rate range?

110-160 bpm

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle?

8 to 12 weeks

A pregnant woman with diabetes is having a glycosylated hemoglobin level drawn. Which result would require the nurse to revise the client's plan of care?

8.5%

A client is 33 weeks pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled?

85 mg/dl

Bonding between a mother and her infant can be defined how?

A process of developing an attachment and becoming acquainted with each other

A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result?

An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.

A client in week 38 of her pregnancy arrives at the emergency room reporting a sharp pain between her umbilicus and the iliac crest in her lower right abdomen that is increasing. She reports having experienced intense nausea and vomiting for the past 3 hours. Given these symptoms, the nurse suspects which of the following conditions?

Appendicitis

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

Applying ice

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness.

You are doing patient teaching with a 30-year-old gravida 1 who has sickle cell anemia. She is not currently in crisis. Providing education on which topic is the highest nursing priority?

Avoidance of infection

A woman has just delivered a baby. Her prelabor vital signs were T - 98.8 B/P-P-R 120/70, 80, 20. Which combination of findings during the early postpartum period should be reported immediately to the RN?

B/P-P-R 90/50, 120, 24

On assessment of a 2-day postpartum patient the nurses finds the fundus is boggy, at U and slightly to the right. What is the most likely cause of this assessment finding?

Bladder distention

A pregnant woman in her 39th week of pregnancy presents to the clinic with a vaginal infection. She tests positive for chlamydia. What would this make her infant at risk for?

Blindness

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by:

Bringing the newborn into the room

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which of the following?

Complex carbohydrates

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

Continue to massage the client's fundus.

A client in her third trimester of pregnancy arrives at a health care facility with a report of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates that the client has edema of the lower extremities, along with an increase in vaginal discharge. What should the nurse do next?

Continue to monitor the client.

A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100 degrees F. Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained

The nurse should encourage a pregnant client who is taking short-acting insulin for her diabetes to avoid eating after self-administering the insulin.

False

A pregnant woman with sickle cell anemia comes to the emergency department in crisis. Which of the following would the nurse expect to find? Select all that apply.

Fever; Joint pain

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: Temp 101.2F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs?

Infection

A client in her eighth month of pregnancy who has cardiac disease is experiencing profound shortness of breath and a cough that produces blood-speckled sputum, in addition to systemic hypotension. The nurse recognizes that this patient most likely is experiencing which of the following conditions?

Left-sided heart failure

Which of the following changes in insulin is most likely to occur in a woman during pregnancy?

Less effective than normal

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver

A woman develops gestational diabetes. Which of the following assessments should she make daily?

Measure serum for glucose level by a finger prick.

A client in her fifth month of pregnancy is having a routine clinic visit. The nurse should assess the client for which common second trimester condition?

Physiological anemia

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions?

Postpartum psychosis

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition?

Postpartum psychosis

A young woman with scoliosis has just learned that she is pregnant. Several years ago, she had stainless-steel rods surgically implanted on both sides of her vertebrae to strengthen and straighten her spine. However, her pelvis is unaffected by the condition. Which of the following does the nurse anticipate in this woman's pregnancy?

Potential for greater than usual back pain

A woman is pregnant and has asthma. Her physician has told her to continue taking prednisone during pregnancy, but she is concerned the drug may be teratogenic. What advice would be best to give her regarding this?

Prednisone is considered safe in the doses prescribed by her physician.

Which of the following is recommended to prevent transmission of HIV to a newborn if the mother has AIDS?

Prepare for cesarean delivery.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal; Labor is slow.

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?

Risk for impaired urinary elimination

Charting on the nursing care plan patient care, which nursing diagnosis has the highest priority for a postpartum patient?

Risk for injury: postpartum hemorrhage related to uterine atony

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse?

Uterine protrusion into the vagina

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

Uterus 1 cm below umbilicus

When caring for a client with postpartum blues, which intervention would be most appropriate?

Validate the client's emotions, allowing her to express them freely

A woman states that she still feels exhausted on her second postpartal day. Your best advice for her would be to do which of the following?

Walk with you the length of her room.

A pregnant single mom living alone tells the nurse she is considering getting a cat for her two year old daughter. Which is the best response by the nurse?

You should wait until after you deliver to obtain the cat for your daughter

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition?

a client who had a myomectomy to remove fibroids

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding.

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor

A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What would be the most likely cause of these symptoms?

premature separation of the placenta

A client is admitted to labor and birth for management of severe preeclampsia. An IV infusion of magnesium sulfate is started. What is the primary goal for magnesium sulfate therapy?

prevent maternal seizures

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

A nurse knows that a doula can be part of a laboring client's health care team. Which intervention would the nurse explain to the client is part of the doula's responsibility?

providing support and explanations during labor and birth

A nursing student learns that a certain condition in 1 in every 2,000 pregnancies is a major cause of death. What is this condition?

pulmonary embolism

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor

A woman the nurse is caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. The nurse's best response would be that:

she needs to rest because her contractions are hypertonic.

A nurse is instructing students on how to check an episiotomy and perineum of a woman after Which of the following are normal in the early postpartum period? (Select all that apply.)

slight bruising; edema

A pregnant client requires administration of an epidural block for management of pain during labor. For which conditions should the nurse check the client before administering the epidural block? Select all that apply.

spinal abnormality; hypovolemia; coagulation defects

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

tachycardia and a falling blood pressure

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization

A postpartum mother has the following lab data recorded: a negative rubella titer. What is the appropriate nursing intervention?

Administer rubella vaccine before discharge.

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void

Which of the following changes in pregnancy would the nurse identify as a contributing factor for arterial thrombosis, especially for the woman with atrial fibrillation?

Hypercoagulable state

A client in her sixth week postpartum complains of general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which of the following?

Hypovolemia

A client the nurse cares for in labor asks what causes labor to begin. Which statement is a possible explanation?

Prostaglandins may be the causative factor of labor.

Which factor would contribute to a high-risk pregnancy?

Type 1 diabetes

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

fetal distress related to hypoxia

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done?

infection

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply.

intensity of contractions; frequency of contractions; uterine resting tone

The skull is the most important factor in relation to the labor and birth process. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

molding

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?

monitor client's vital signs and bleeding

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4°F (38°C)

A client is in the active phase of labor. She is a low-risk client. The nurse evaluates the fetal monitor strip at 10:00 a.m. Moderate variability is present. The FHR is in the 130s with occasional accelerations, no decelerations. At what time does the nurse need to reevaluate the FHR?

10:30 a.m.

The nurse is assigned to a patient on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?

1cm below the umbilicus

The first stage of labor is often a time of introspection. In light of this, which information would guide the nurse's planning of nursing care?

A woman may spend time thinking about what is happening to her.

Which of the following is an appropriate nursing intervention for prevention of a urinary tract infection (UTI) in the postpartum woman?

Encouraging the woman to empty her bladder completely every 2 to 4 hours.

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?

Endometritis

The nurse is assessing a breastfeeding mom 72 hours after delivery. When assessing her breast, the patient complains of bilateral breast pain around the entire breast. What is the most likely cause of the pain?

Engorgement

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.)

Estimate the size of the hematoma and report it; Administer a mild analgesic as prescribed; Apply an ice pack to the site

Over 75% of women who give birth experience postpartum depression.

False

The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy.

False

A nurse is caring for a breastfeeding client who complains of engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which of the following should the nurse suggest to help her prevent engorgement?

Feed the baby at least every two or three hours

A nurse is teaching a group of nursing students about the mechanism of labor when the fetus is in a cephalic presentation. Given in random order are a series of events that take place in a cascade to end with the birth of the baby. Arrange the series of events in the most likely sequence they occur. All options must be used.

Flexion; internal rotation; extension; restitution; external rotation

When doing a health assessment, at which of the following locations would you expect to palpate the fundus in a woman on the second postpartal day and how should it feel?

Fundus two fingerbreadths below umbilicus and firm

A woman yesterday delivered a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at delivery. The nurse's priority is to assist the mother to

Grieve for the loss of the perfect baby

Human papillomavirus (HPV) can cause condylomata acuminata that can develop in clusters on the vulva, within the vagina, on the cervix, or around the anus. What is their risk?

Heavy bleeding during vaginal delivery

During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent, and the baseline FHR is within normal limits. What should the nurse do first?

Help the woman change positions.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication?

Her blood pressure is below 140/90.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution?

Her uterus is at the level of the umbilicus.

For which of the following problems would the nurse be alert in a pregnant woman with gestational diabetes?

Hydramnios related to glucose/insulin imbalance

A pregnant client with sickle cell anemia is at an increased risk for having a sickle cell crisis during pregnancy. Aggressive management for a client experiencing a sickle cell crisis with severe pain includes which measure?

I.V. fluids

You are the clinic nurse caring for a pregnant woman in her third trimester. The woman is HIV positive and voices concerns about passing the infection on to her baby. What is your best response?

If you are taking antiretroviral medications and you don't breastfeed your baby, you greatly reduce the risk of perinatal transmission of the disease.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which of the following would the nurse identify as the most likely factor for this development?

Inability of infant to empty breasts

Given that the first 24 hours after delivery is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply.

Moderate saturation of peripad every 3 hours; Fundus one fingerbreadth above umbilicus

A pregnant woman diagnosed with diabetes should be instructed to do which of the following?

Notify the physician if unable to eat because of nausea and vomiting.

A nurse is assessing a client in her seventh month of pregnancy who has an artificial valve prosthesis. The client is taking an oral anticoagulant to prevent the formation of clots at the valve site. Which of the following nursing interventions is most appropriate in this situation?

Observe the client for signs of petechiae and premature separation of the placenta

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

Obtain a clean-catch urine specimen

Which of the following measures would you stress with her during the remainder of the pregnancy?

Obtaining enough rest

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

One fingerbreadth below the umbilicus

The nurse explains to a pregnant patient that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with which of the following?

Orange juice

A nurse is caring for a client who is nursing her baby boy. The client complains of afterpains. Secretion of which of the following should the nurse identify as the cause of afterpains?

Oxytocin

The nurse is teaching a pregnant woman with iron deficiency anemia about foods high in iron. Which food(s) if selected by the woman indicates a successful teaching program? Select all that apply.

Peanut butter; Raisins; Broccoli

Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness

A postpartum client complains of stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?

Perform Kegel's exercises

A woman with no previous history of heart disease begins to have symptoms of myocardial failure a few weeks before the delivery of her first child. Findings include shortness of breath, chest pain, and edema, with her heart also showing enlargement. Which disease should the nurse suspect?

Peripartal cardiomyopathy

The nurse is assessing a woman with class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this patient is in heart failure?

Persistent rales in the bases of the lungs

During a postpartum exam on the day of delivery, the woman complains that she is still so sore that she can't sit comfortably. You examine her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point?

Place an ice pack

Which of the following factors in a postpartum woman's history would lead the nurse to watch the woman closely for an infection?

Placenta removed via manual extraction

A 40-year-old woman comes to the clinic complaining of having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for?

Placental abnormalities

When palpating for fundal height on a postpartal woman, which technique is preferable?

Placing one hand at the base of the uterus, one on the fundus

A pregnant woman calls her provider's office to report she thinks she is in labor. The client reports contractions have been fairly strong and at these times: 12:05, 12:10, 12:15, and 12:20. What information is gathered based on this data?

The frequency of the contractions is every 5 minutes.

A patient who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be ruled out before a vaginal examination can be performed?

placenta previa

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption

When educating a group of nursing students about the different types of pelvis, the nurse describes one type as being flat, having a wider transverse diameter than anterior-posterior diameter, with ischial spines that are wide apart, and a short sacrum. The students are correct when they identify this description with which type?

platypelloid

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?

poorly ossified cranial vault

When teaching a group of nursing students about uterine contractions, which of the following would the instructor include as a typical feature?

Retracting of the lower segment

Which finding would the nurse describe as "light" or "small" lochia?

4-inch stain or a 1 to 25 ml loss

Which signs signify that the second stage of labor has begun?

The urge to push occurs.

When developing a plan of care for a pregnant woman who is HIV-positive, which of the following is essential?

Using Standard Precautions

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s

Place the following stages of labor in order from what occurs first to last. All options must be used.

latent stage; active stage; transition stage; second stage; third stage

A nurse is talking to a newly pregnant woman who had a mitral valve replacement in the past. Which of the following statements by the patient reveals an understanding about the pre-existing condition?

"I understand that my fetus and I both are at risk for complications."

Fourteen-year-old Ann and her parents have presented at the obstetrician's office in the second trimester, the teen had been hiding the pregnancy. The nurse is helping them develop a plan of care. What is the best thing she can say to the clearly angry parents?

"I know you must be very upset and angry about Ann's pregnancy but because she's still an adolescent herself, she'll need your guidance in making nutritional and health choices that will be good for the baby and for herself."

After teaching a postpartum woman about postpartum blues, which statement indicates effective teaching?

"I might feel like laughing one minute and crying the next."

A pregnant client at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse?

"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid."

A mother just delivered 3 hours ago. The nurse enters the room to continue hourly assessments and finds the patient on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?

"It sounded like you had quite a time getting here. Would you like to continue your story?"

You are the home health nurse making an initial call on a new mother who delivered her third baby five days ago. The woman says to you "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the delivery. They will most likely go away in a day or two."

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness."

A pregnant woman who has had cardiovascular disease for the last 3 years asks the nurse why this disorder makes her pregnancy an "at-risk" pregnancy. What is the nurse's best response?

"Pregnancy taxes the circulatory system of every woman."

Two days after giving birth, a client is to receive RhoGAM. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

A woman is documented on the labor and birth board to be 7 cm dilated. Her family wants to know how long she will be in labor. The nurse should provide which information to the family?

"She is in active labor; she is progressing at this point and we will keep you posted."

A nursing instructor teaching students how to check the patient's uterus postpartum realizes that further instruction is needed when one of the students says:

"Six to twelve hours after birth the fundus is typically at the level of the umbilicus."

A woman who is breast-feeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." Which response by the nurse would be least helpful?

"Some women just can't breast-feed. Maybe you're one of these women."

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."

A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which of the following statements would be the nurse's best answer?

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS."

A pregnant woman is determined to be at high risk for gestational diabetes. At which time would the nurse expect the client to undergo rescreening?

24 to 28 weeks

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA). What does the nurse tell the patient is a normal level for this test?

6%

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less.

A pregnant woman, multipara, has been in labor for several hours. She cries out that her contractions are getting harder and that she cannot do this. The client is really irritable, nauseated, annoyed, and fearful of being left alone. Considering the client's behavior, the nurse would expect the cervix to be dilated how many centimeters?

8 to 10

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection?

A nonelective cesarean birth.

A woman with a long history of controlled asthma has just had her first antenatal visit for her fourth child. She is late for a meeting and says she knows what to do. What is the best action the nurse can take?

Acknowledge her need to leave but ask her to demonstrate the use of her inhaler and her peak flow meter before she goes; make any necessary corrections to her technique. Remind her to take her regular medications.

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion.

An alert, diabetic, pregnant woman in the hospital experiences some shakiness and diaphoresis with a fasting blood sugar of 60 mg/dl when she awakens in the morning. Which action should the nurse take first?

Administer the patient's glucose tablets.

The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis?

Ambulate the client as soon as her vital signs are stable

Which of the following findings would lead you to suspect that a woman is developing a postpartum complication?

An absence of lochia

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused due to perineal edema?

Apply ice

A client with juvenile rheumatoid arthritis (JRA) is in week 38 of her pregnancy. Which of the following interventions should the nurse make with this client?

Ask the client to decrease her intake of salicylates

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad.

The nurse should initially implement which intervention when a nulliparous woman telephones the hospital to report that she is in labor?

Ask the woman to describe why she believes that she is in labor.

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Assess amount of cervical dilation.

Seven hours ago, a G5 P4014 woman delivered a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to

Assess and massage the fundus

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next?

Assess fetal heart rate for fetal safety.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds.

A postpartal woman has a history of thrombophlebitis. Which of the following would help you to determine if she is developing this postpartally?

Assess for calf redness and edema.

When caring for a postpartum woman who is Muslim, which of the following would be a priority?

Assigning a female nurse to care for her

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?

Assist the woman in placing ice packs on her breasts

A G1 P1001 mother is just home after delivering her first child 5 days ago. Her delivery was complicated by an emergency cesarean delivery resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this patient care issue is

At risk for postpartum depression due to inadequate rest

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple.

You encourage a woman with gestational diabetes to maintain an active exercise period during pregnancy. Prior to this exercise period, you would advise her to do which of the following?

Eat a sustaining-carbohydrate snack

Nursing care for women diagnosed with gestational diabetes includes which of the following?

Encourage blood glucose control

A woman in week 40 of her pregnancy has developed a urinary tract infection (UTI). The nurse recognizes that which of the following treatments would be safe and appropriate to use with this client? (Select all that apply.)

Cephalosporins; Amoxicillin; Ampicillin

The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly bright red blood gushes from the vagina. The nurse recognizes that which of the following is the most likely cause of this postpartum hemorrhage?

Cervical laceration

A woman with a positive history of genital herpes is in active labor. She has small pin-point vesicles in the perineum area. Her membranes are ruptured, she is dilated 5cm, effaced 70%. The nurse should anticipate what type of delivery?

Cesarean.

The laboring client is on continuous fetal monitoring when the nurse notes a decrease in the fetal heart rate with variable deceleration to 75 bpm. What is the initial nursing intervention?

Change the position of the client.

A nurse is caring for a client postpartum who complains of sore nipples. The nurse observes that the client's newborn is unable to suck properly although latched well. What intervention should the nurse perform to assist the baby to suck properly?

Check the baby's frenulum

The nurse is assessing a woman in active labor. She notes a small mass above the symphysis pubis, rounded, distended, and nontender. What intervention should the nurse take next?

Check the chart for the last void.

A pregnant client with a history of heart disease has been admitted to a healthcare center with complaints of breathlessness. The client also complains of shortness of breath and easy fatigue when doing ordinary activity. The client's condition is markedly compromised. The nurse would document the client's condition using the New York Heart Association (NYHA) classification system as which class?

Class III

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm?

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

The patient under your care is complaining she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement?

Encourage the patient to eat more fiber rich foods

A client who gave birth by cesarean delivery 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

Encouraging the client to wear a supportive bra.

A woman with cardiac disease is 32 weeks gestation and alerts the nurse she has been having spells of light-headedness and dizziness every few days. The nurse provides which of the following interventions as an option to the patient?

Decrease activity and rest more often.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which of the following is responsible for this change?

Decreased intra-abdominal pressure

Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after delivery make a woman more susceptible to infection? Select all that apply.

Denuded endometrial arteries; Episiotomy

A nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment?

Detection of herpes virus infection

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply.

Determining the presentation of the fetus; determining the position of the fetus; determining the lie of the fetus

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

Diet

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which of the following observations would indicate the presence of tissue?

Difficult to separate clots

A client in the postpartum period complains of constipation. The nurse should inform the client of which of the following that contributes to postpartum constipation?

Discomfort due to hemorrhoids

A nursing student is learning about intermittent fetal heart rate monitoring during labor. The student correctly chooses which of the following as used routinely for this procedure? (Select all that apply.)

Doppler; fetoscope; fetal monitor

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this?

Dorsiflex her right foot and ask if she has pain in her calf.

Elevation of a patient's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

During the first 24 hours after delivery owing to dehydration from exertion

Which clinical manifestation in a woman with DVT should you report immediately?

Dyspnea

Inspection of a woman's perineal pad reveals a 5-inch stain. The nurse documents this amount as which of the following?

Moderate

A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient?

Increased intake will rehydrate the patient and decrease her skin temperature.

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that patients empty their bladders. A full bladder can lead to which of the following complications?

Increased lochia drainage

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips.

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process?

Initiate the technique only when the client is in active labor.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate?

Instruct the client to empty her bladder before the examination

A nurse is assessing a postpartum client. Which of the following measures is appropriate?

Instruct the client to empty her bladder before the examination.

When educating a pregestational patient on how to control her blood sugar, the nurse knows there are three main facets to glycemic control: diet, exercise and _______. Which of the following is the third facet?

Insulin

The process by which the reproductive organs return to the nonpregnant size and function is termed what?

Involution

A pregnant client is admitted to a maternity clinic for birth. The client wishes to adopt the kneeling position during labor. The nurse knows that which to be an advantage of adopting a kneeling position during labor?

It helps to rotate fetus in a posterior position.

A 16-year-old girl comes to the public health office and tells you she is pregnant. She is afraid to tell her parents. As a nurse, what is important for you to know that can help this 16 year old?

Know about community resources for the pregnant teen

A woman with Class II heart disease is in the third trimester of her pregnancy. She's been taking good care of herself and has had little difficulty, but to be on the safe side the obstetrician has ordered bed rest for her for the final month. For her own and the baby's safety, in what position should the nurse advise the patient to sleep?

Lie in a semirecumbent position.

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?

Lie on her side so she is comfortable.

After teaching a pregnant client who is in her last weeks of pregnancy about the signs and symptoms of approaching labor, which signs or symptoms if identified by the client would indicate effective teaching? Select all that apply.

Lightening; bloody show; backache

You assess a postpartum woman's perineum and notice that her lochial discharge is moderate in amount and red. You would record this as what type of lochia?

Lochia rubra

A pregnant client is admitted to a maternity clinic for birth. Which assessment finding indicates that the client's fetus is in the transverse lie position?

Long axis of fetus is perpendicular to that of client.

When providing education to a teenage prenatal class, the nurse states that infants born to teenage mothers are more likely to have which of the following?

Low-birth weight

A pregnant woman at 4 weeks' gestation who has preexisting diabetes mellitus visits her primary care provider for a check-up. Which fetal complications might occur because of this maternal condition? Select all that apply.

Macrosomia (oversized fetus); Respiratory disorder; Congenital malformations

Two days ago, a woman delivered her third infant; she is now preparing for discharge home. After the delivery of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following EXCEPT:

Maintain previous household routines to prevent infection

Which action could the nurse initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position?

Massage her lower back.

A nurse assessing a postpartum patient notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm.

During a routine prenatal check-up, the nurse interviews a pregnant client to identify possible risk factors for developing gestational diabetes. Which of the following would alert the nurse to an increased risk? Select all that apply.

Maternal obesity with body mass index more than 35; Previous birth of small for gestational age baby; Client of African-American lineage

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver

Which medication would the nurse prepare to administer if prescribed as treatment for an unruptured ectopic pregnancy?

Methotrexate

Which medication is prescribed most commonly for a pregnant woman with chronic hypertension?

Methyldopa

Your patient is pregnant and she has tested positive for cytomegalovirus. What can this cause in the newborn?

Microcephaly

The nurse is providing education to women who had diabetes prior to pregnancy. The nurse is discussing pregnancy-related complications from diabetes. Which of the following is a potential complication?

Polyhydramnios

A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which of the following conditions?

Postpartum depression

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which of the following should the nurse identify as a potential cause for urinary frequency?

Postpartum diuresis

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening.

A nurse is assigned the task of educating a pregnant client about birth. Which nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive birth experience? Select all that apply.

Provide the client clear information on procedures involved; Encourage the client to have a sense of mastery and self-control; Encourage the client to have a positive reaction to pregnancy.

A patient delivered 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the patient was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the physician and the nurse-midwife to her concern that the patient may be experiencing

Pulmonary embolism

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord.

A woman arrives in the labor and birth department and is panting and screaming "the baby is coming". What is the priority intervention by the nurse?

Quickly move the woman to a labor bed, and check the perineum.

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA

Not all mothers express joy at seeing their newborn upon delivery and during their hospitalization. A behavior that indicates impaired attachment of the mother to the newborn is

Referring to a facial feature as "ugly"

A woman with cardiac disease delivered a seven-pound baby by C-Section. Which of the following interventions should be implemented during the immediate postpartum period?

Rest, stool softeners, and monitoring tolerance of activity.

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis?

Restless and agitated, concerned with self

A client is diagnosed with peripartum cardiomyopathy (PPCM). Which of the following would the nurse expect to administer to the client?

Restricted sodium intake

Patient teaching is conducted throughout a patient's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge?

Resumption of intercourse; Signs and symptoms of infection

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?"

Saturating 1 pad in 1 hour

What is the primary function of uterine contractions after delivery of the infant and placenta?

Seal off the blood vessels at the site of the placenta

When dealing with a pregnant adolescent, the nurse assists the client to integrate the tasks of pregnancy while at the same time fostering development of which of the following?

Self-identity

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression.

You are doing patient teaching with a 28 weeks' gestation woman who has tested positive for gestational diabetes mellitus (GDM). What would be important to include in your patient teaching?

She is at increased risk for type II diabetes mellitus after her baby is born.

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate?

She should continue to breast-feed; mastitis won't infect the neonate

A woman who has sickle cell anemia asks you if her infant will develop sickle cell disease. The nurse would base the answer on which of the following?

Sickle cell anemia is recessively inherited.

Which of the following would you emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area.

Which of the following would the nurse expect to find in a newborn of a mother who abuses heroin?

Sneezing

Working with pregnant teenagers as a special population requires the nurse to have knowledge of adolescent development. Which of the following is crucial for a positive pregnancy and outcome for the mother and fetus?

Support network

A patient who has just delivered a baby girl demonstrates behavior not indicative of bonding when she does which of the following?

Talks to company and ignores the baby lying next to her

A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. The nurse's institution has a policy of taking photographs of such fetuses once they are born. The nurse informs the woman that pictures have been taken and asks her if she wants them; she angrily tells the nurse no, then bursts into tears. How should the nurse respond?

Tell her that the hospital will keep the photos for her in case she changes her mind.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

Temperature

While educating a class of postpartum patients before discharge home after delivery, one woman asks when "will I stop bleeding?" How should the nurse respond?

The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?

The cervix takes around 12 to 16 hours to dilate during first pregnancy.

Which situation should concern the nurse treating a postpartum client within a few days of delivery?

The client feels empty since she delivered the neonate

Labor can be indicated by which occurrence?

The client reports back pain, and the cervix is effacing and dilating.

You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits?

The color of the flow is red.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

The level of the umbilicus

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.

The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?

The uterus contracts and squeezes the cord against the fetus.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this as which of the following?

Third-degree laceration

A postbirth complete blood count (CBC) has noted an elevated white blood cell (WBC) count of 22,000/mm3. Which rationale is accurate regarding the elevated WBC count?

This is a normal variation due to the stress of labor.

While the nurse is weighing a pregnant woman at a regularly scheduled OB visit, the patient complains of vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. She says this is her first pregnancy and she didn't know this was what happened. What can the nurse tell her?

This is not normal for pregnancy; the doctor might test her for trichomoniasis. If it is trichomoniasis, she can be treated with an oral dose of metronidazole. Remind the patient that she should call immediately if she has any symptoms that don't seem normal to her.

What is the most important thing a nurse can do during labor and birth to prevent maternal and fetal infection?

Thoroughly wash the hands before and after client contact.

A nurse is preparing a patient for rhythm strip testing. She places the woman into a semi-Fowler's position. What is the appropriate rationale for this measure?

To prevent supine hypotension syndrome

A pregnant woman in her second trimester comes to the prenatal clinic for a routine visit. She reports that she has a new kitten. The nurse would have the woman evaluated for which infection?

Toxoplasmosis

You are doing a nursing assessment on a new patient in the obstetric clinic. The woman estimates that she is approximately 16 weeks pregnant. While assessing her you ask about what appear to be scratch marks on her hands, and she tells you that she has three cats at home. What screening would be ordered for this woman?

Toxoplasmosis

As a rule, women can receive chemotherapy in the second and third trimesters without adverse fetal effects.

True

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth.

True

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

Turn her or ask her to turn to her side.

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?

Turn off the pitocin.

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side; Administer oxygen by mask; Assess client for underlying causes.

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?

dilation of cervix diameter to 10 cm

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which of the following?

Urinary tract infection

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back.

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage?

Uterine atony

Which factor puts a client on her first postpartum day at risk for hemorrhage?

Uterine atony

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

Uterine atony

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

Venous duplex ultrasound of the right leg

A postpartal woman asks you about perineal care. Which of the following recommendations would you give?

Wash her perineum with her daily shower.

The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care?

Wear a tight, supportive bra

A nurse is caring for a non-breastfeeding client in the postpartum period. The client complains of engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra

A woman with severe preeclampsia is receiving magnesium sulfate. The woman serum magnesium level is 9.0mEq/L. Which finding would the nurse most likely note?

diminished reflexes

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which of the following?

atony

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which of the following?

attachment

A nursing instructor is teaching students about anemia during pregnancy. Which type of anemia does the instructor teach students is most prevalent during pregnancy?

iron-deficiency anemia

The expected fetal heart rate response in an active fetus is:

acceleration of at least 15 bpm for 15 seconds.

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

acme

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

allowing the woman time to be alone

A client is in the first stage of labor, latent phase. Her membranes are intact, and her contractions are mild. Considering the client's condition and phase of labor, the nurse knows that which aid will facilitate labor?

ambulation ad lib

Rho(D) immune globulin will be prescribed for an Rh negative mother undergoing which test?

amniocentesis

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy

A woman whose fetus in in the occiput-posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain?

applying counter pressure to the back

A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that:

as long as she receives RhoGAM, there is no limit.

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion.

A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?

assessing fetal heart tones by use of an external monitor

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status

Which intervention has been demonstrated to reduce the release of catecholamines and anxiety, and has resulted in better birth outcomes for women?

continuous labor support

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR.

A client is now in the second stage of labor. While doing the assessment, the nurse would gather what data at this time?

contraction pattern every 15 minutes

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfunction?

contractions most forceful in the middle of uterus rather than the fundus

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression

A nurse is instructing a patient who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is best described as which of the following?

creamy yellow

A client in labor is agitated and nervous about the birth of her child. The nurse explains to the client that fear and anxiety cause the release of certain compounds which can prolong labor. Which compounds is the nurse referring to in the explanation?

catecholamines

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

cervix

A nursing student is studying postpartal complications. Thromboembolic conditions have which of the following risk factors? (Select all that apply.)

cigarette smoking; anemia; diabetes; obesity; multiparity

A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor?

first, active

Many patients experience a slight fever after delivery especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes

When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive assessment that uterine contractions are effective would be:

dilatation of cervix.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache; malodorous vaginal discharge; dysuria

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation (congestive heart failure), which include:

dyspnea, crackles, irregular weak pulse.

A 28-year-old woman presents in the emergency department with severe abdominal pain. She has not had a normal period for 2 months, but she reports that that is not abnormal for her. She has a history of endometriosis. What might the nurse suggest to the primary care provider as a possible cause of the client's abdominal pain?

ectopic pregnancy

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?

endorphins

The initial descent of the fetus into the pelvis to zero station is which one of the cardinal movements of labor?

engagement

A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect?

ensures passage of all the products of conception

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?

every 15 minutes

When planning the care of a woman in the active phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?

every 15 to 30 minutes

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?

external electronic fetal monitoring

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version

During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions?

felt first in lower back and sweep around to the abdomen in a wave; begin irregularly but become regular and predictable; increase in duration, frequency, and intensity

A pregnant client in her 32nd week of gestation has been admitted to a health care center reporting decreased fetal movement. What should the nurse determine first before placing the fetoscope on the woman's abdomen, so as to auscultate the fetal heart sounds?

fetal back

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones.

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor. The earlier baseline FHR was 140. The FHR now is 168. The nurse knows that which factors can affect changes in the FHR? Select all that apply.

fetal movement; fetal distress; maternal fever

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client?

general anesthesia

A client is being admitted to labor and birth. When admitting an obstetric client in early labor, the first intervention by the nurse is:

good rapport is established with the client and significant other.

A new OB/GYN care provider has just finished evaluating her one hundredth client. In reviewing the documentation from all clients thus far, which types of pelvis would the nurse assume the care provider has seen the most and the least?

gynecoid and platypelloid, respectively

The nurse who works on a post-partum floor is mentoring a new graduate. She informs the new nurse that a post-partum assessment of the mother includes which of the following? (check all that apply)

head-to-toe assessment; vital signs of mother; pain level

Thirty minutes after receiving pain medication, a postpartum woman states that she sill has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma

A patient who delivered twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 to 96/50. Her pulse drops from 80 to 56. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage

A pregnant patient with mitral stenosis needs to begin taking an anticoagulant. The nurse identifies the drug of choice, which is used in early pregnancy and again during the last month of pregnancy, to be which of the following?

heparin

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical

A woman is admitted with a diagnosis of ectopic pregnancy. For which procedure should the nurse prepare?

immediate surgery

A pregnant woman diagnosed with cardiac disease 4 years ago is told that her pregnancy is a high-risk pregnancy. The nurse then explains that the danger occurs primarily because of the increase in circulatory volume. The nurse informs the patient that the most dangerous time for her is when?

in weeks 28-32

The nurse is teaching a prenatal class the signs and symptoms of true labor. What is the appropriate response by the class that shows an understanding of true labor contractions?

increase even if I relax and take a shower

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

increase in blood pressure; increase in respiratory rate; increase in heart rate

A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor?

increase in frequency of the contractions

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

increase in heart rate; increase in blood pressure; increase in respiratory rate

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increased white blood cell count

A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the patient at risk for developing?

infection

A woman is told she has an anthropoid pelvis. This means her pelvis:

is narrow transversely.

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used.

labor dystocia; abnormal fetal heart rate tracing; fetal malpresentation; multiple gestation; suspected macrosomia

A patient is admitted to the labor and delivery unit. Upon examination, she is found to be dilated 3 cm. The nurse notes that the woman is having contractions that last about 45 seconds and are about 5 minutes apart. Based on this information, in which phase of labor is this patient?

latent phase

The nurse is working with a client in labor. She is happy and cheerful and states she is "ready to see her baby." What stage or phase of labor would she anticipate the client to be in right now?

latent phase

A nurse informs a pregnant woman with cardiac disease that she will need two rest periods each day and a full night's sleep. The nurse further instructs the patient that the best position for this rest is which of the following?

left lateral recumbent

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant.

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours

Hypercoagulability during pregnancy protects the mother against excessive blood loss during childbirth. It also can increase a woman's risk of developing a blood clot. It does this by which of the following ways? (Select all that apply.)

localized vascular damage; altered coagulation; stasis

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of delivery, because studies show that keeping extra weight longer is a predictor of which of the following?

long-term obesity

What would be the physiologic basis for a placenta previa?

low placental implantation

A nurse is required to obtain the fetal heart rate (FHR) for a pregnant client. If the presentation is cephalic, which maternal site should the nurse monitor to hear the FHR clearly?

lower quadrant of the maternal abdomen

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis

The nurse notes that a client's amniotic fluid is green when the membranes rupture. What finding would the nurse document?

meconium in the amniotic sac

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which of the following?

negative attachment

A 37-year-old woman in the final weeks of her first pregnancy visits the health care provider's office for a scheduled check-up. What might a nurse note as a sign of labor in speaking with the woman prior to the examination?

nesting

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position

The nurse working on a postpartum must check lochia in terms of amount, color, change with activity and time, and:

odor

A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?

pain from the dilation or stretching of the cervix

The five "Ps" of labor are:

passageway, passenger, position, powers, psych

A nurse is auscultating the lungs of a postpartum patient and notices crackles and some dyspnea. The patient's respiratory rate is 12 breaths/min; she appears in some distress. What complication should the nurse suspect based on these data?

pulmonary edema

A woman who had a cesarean delivery of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect?

pulmonay emboli

A pregnant woman comes to the emergency department because she thinks she is in labor. The nurse determines that the client is in true labor when assessment of contractions reveals which finding?

radiating to the front of the abdomen from the back

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment?

reciprocity

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

respiratory rate

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

restoration of blood flow to uterus and placenta

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?

third

A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?

transition phase

A nursing student is studying labor and delivery and has learned that the first stage of labor consists of which of the following phases? (Select all that apply.)

transition; active; latent

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie

During the second stage of labor, a woman is generally:

turning inward to concentrate on body sensations.

A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?

twin-to-twin transfusion syndrome (TTTS)

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

uterine rupture

While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:

uteroplacental insufficiency.