Intrapartum care, Immediate newborn care NCLEX Questions

After change of shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a) Visceral b) Referred c) Somatic d) Afterpain

b) Referred

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a) Notify the woman's physician b) Tell the woman to slow the pace of her breathing c) Administer oxygen via mask or nasal canula d) Help her breathe into a paper bag

d) Help her breathe into a paper bag

With regard to spinal and epidural (block) anesthesia, nurses should know that: a) This type of anesthesia is commonly used for cesarean births but it not suitable for vaginal births b) A high incidence of postbirth headache is seen with spinal blocks c) Epidural blocks allow the woman to move freely d) Spinal and epidural blocks are never used together

b) A high incidence of postbirth headache is seen with spinal blocks

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A) counterpressure against the sacrum. B) pant-blow (breaths and puffs) breathing techniques. C) effleurage. D) biofeedback.

*A) counterpressure against the sacrum.* Rationale: Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: A) fentanyl (Sublimaze). B) promethazine (Phenergan). C) butorphanol tartrate (Stadol). D) nalbuphine (Nubain).

*A) fentanyl (Sublimaze).* Rationale: Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. *Stadol and Nubain are opioid agonist-antagonist analgesics. Their use may precipitate withdrawals in a patient with a history of opiate use.*

Nurses should be aware of the difference experience can make in labor pain, such as: A) sensory pain for nulliparous women often is greater than for multiparous women during early labor. B) affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C) women with a history of substance abuse experience more pain during labor. D) multiparous women have more fatigue from labor and therefore experience more pain.

*A) sensory pain for nulliparous women often is greater than for multiparous women during early labor.* Rationale: Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.) A) Keeping the head of bed elevated at all times B) Administration of oral analgesics C) Avoid caffeine D) Assisting with a blood patch procedure E) Frequent monitoring of vital signs

*B) Administration of oral analgesics* *D) Assisting with a blood patch procedure* *E) Frequent monitoring of vital signs* Rationale: The nurse should suspect the patient is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief (Hawkins and Bucklin, 2012). Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential.

With regard to systemic analgesics administered during labor, nurses should be aware that: A) systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B) effects on the fetus and newborn can include decreased alertness and delayed sucking. C) IM administration is preferred over IV administration. D) IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

*B) effects on the fetus and newborn can include decreased alertness and delayed sucking.* Rationale: Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

A nurse is counseling a mother about the immunologic properties of breast milk. The nurse integrates knowledge of immunoglobulins, emphasizing that breast milk is a major source of which immunoglobulin?

A) IgA B) IgG C) IgM D) IgE Ans: A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A) encourage the woman to breathe more slowly. B) help the woman breathe into a paper bag. C) turn the woman on her side. D) administer a sedative.

*B) help the woman breathe into a paper bag.* Rationale: Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension.

After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A) visceral. B) referred. C) somatic. D) afterpain.

*B) referred.* Rationale: *Visceral pain* is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. As labor progresses the woman often experiences *referred pain*. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. *Somatic pain* is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A) Encourage her to empty her bladder. B) Decrease her intravenous (IV) rate to a keep vein-open rate. C) Turn the woman to the left lateral position or place a pillow under her hip. D) No action is necessary since a decrease in the woman's blood pressure is expected.

*C) Turn the woman to the left lateral position or place a pillow under her hip.* Rationale: Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: A) either hot or cold applications may provide relief, but they should never be used together in the same treatment. B) acupuncture can be performed by a skilled nurse with just a little training. C) hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. D) therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.

*C) hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited.* Rationale: Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. The woman and her partner should experiment with massage before labor to see what might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A) Maternal blood pressure of 108/79 B) Maternal heart rate of 98 C) Respiratory rate of 14 breaths/min D) Fetal heart rate of 100 beats/min E) Minimal variability on a fetal heart monitor

*D) Fetal heart rate of 100 beats/min* *E) Minimal variability on a fetal heart monitor* Rationale: After induction of the anesthetic, maternal blood pressure, pulse, and respirations and fetal heart rate and pattern must be checked and documented every 5 to 10 minutes. If signs of serious maternal hypotension (e.g., the systolic blood pressure drops to 100 mm Hg or less or the blood pressure falls 20% or more below the baseline) or fetal distress (e.g., bradycardia, minimal or absent variability, late decelerations) develop, emergency care must be given.

The nurse is teaching a patient, who is pregnant for the first time, about the signals that indicate the beginning of labor. Which sign will the nurse mention as a signal for the beginning of labor? 1 Involuntary contractions 2 Pain in the pelvic joints 3 100% effacement of the cervix 4 Full dilation of the cervix

1

What will the nurse mention about the effect of secondary powers during labor to the patient? 1 Contractions are expulsive in nature. 2 The intraabdominal pressure is decreased. 3 Contractions move downward in waves. 4 Contractions begin at pacemaker points.

1 As soon as the presenting part of the fetus touches the pelvic floor, the patient uses secondary powers or bearing-down efforts. This results in contractions that are expulsive in nature. The voluntary bearing-down efforts of the patient also result in increased intraabdominal pressure. Primary powers signal the beginning of labor with involuntary contractions that move downward over the uterus in waves. These contractions begin at pacemaker points in the thickened muscle layers of the upper uterine segment.

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: 1 counterpressure against the sacrum. 2 pant-blow (breaths and puffs) breathing techniques. 3 effleurage. 4 biofeedback

1 Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

The nurse is caring for a patient in the first stage of labor. What maternal physiologic changes does the nurse expect? 1 Decrease in absorption of solid food 2 Increase in systolic and diastolic pressures 3 Increase in nausea and vomiting sensation 4 Increase in cardiac output by 30% to 50%

1 During the first stage of labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed down. Only systolic blood pressure increases during uterine contractions in the first stage of labor. Systolic and diastolic pressures increase during contractions in the second stage of labor and return to baseline levels between contractions. Nausea and vomiting sensations may occur during the transition from first stage to second stage of labor. In the first stage of labor, the cardiac output increases by 10% to 15%. Cardiac output increases by 30% to 50% only at the end of the first stage of labor and not in the first stage.

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's most appropriate analgesic for pain control is: 1 fentanyl (Sublimaze). 2 promethazine (Phenergan). 3 butorphanol tartrate (Stadol). 4 nalbuphine (Nubain)

1 Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.

What kind of anesthesia does the nurse expect the primary health care provider to prescribe to a patient who is to have an emergency cesarean birth due to fetal distress? 1 General anesthesia 2 Pudendal nerve block 3 Nitrous oxide with oxygen 4 Local infiltration anesthesia

1 General anesthesia may be necessary if indications necessitate rapid birth (vaginal or emergent cesarean), when there is a pressing need for time and/or primary health care providers to perform a block. Pudendal nerve block is administered late in the second stage of labor. It may be required if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Nitrous oxide mixed with oxygen can be inhaled in 50% or less concentration to provide analgesia during the first and second stages of labor. Local infiltration anesthesia may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.

The nurse is caring for a patient who is in the third trimester of pregnancy. The patient reports pain in the pelvic joints. What does the nurse recognize as the cause of the pain? 1 There is relaxation of the pelvic joints. 2 There is decreased mobility of the ligaments. 3 The joint of the symphysis pubis is narrowing. 4 The pelvis may not support vaginal birth.

1 In the third trimester of pregnancy, the pelvic joints relax, leading to pain. There is increased mobility of the pelvic joints and ligaments as a result of hormonal influences. Widening of the joint of the symphysis pubis and the resulting instability may cause pain in any or all of the pelvic joints. Pain in the pelvic joints does not indicate that the pelvis may not support vaginal birth. A heart shaped android pelvis may not support spontaneous vaginal birth.

The nurse is caring for a patient who is administered local perineal infiltration anesthesia. In what situation does the nurse expect the use of local perineal infiltration anesthesia? When a(n): 1 Episiotomy is required. 2 Forceps birth is expected. 3 Cesarean birth is expected. 4 Vacuum extractor is to be used.

1 Local perineal infiltration anesthesia may be used when an episiotomy is to be performed. It may also be used when lacerations must be sutured after birth in a patient who does not have regional anesthesia. Pudendal nerve block is administered late in the second stage of labor if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Low spinal anesthesia (block) may be used for cesarean birth.

A patient who is pregnant for the first time is anxious about the pain related to labor. Which physiologic factor does the nurse relate that may increase the intensity of pain during childbirth? 1 History of dysmenorrhea 2 Low level of prostaglandin 3 Cramps during menstruation 4 High level of β-endorphin

1 Patients with a history of dysmenorrhea may experience increased pain during childbirth. These patients are known to have high levels of prostaglandin. Low levels of prostaglandin do not increase the intensity of pain during labor. The level of beta (β) endorphins increases during pregnancy and birth. β endorphins are endogenous opioids that reduce pain. Back pain associated with menstruation also increases the likelihood of contraction-related low back pain.

Nurses can advise their patients that which of these signs precede labor? Select all that apply. 1 A return of urinary frequency as a result of increased bladder pressure 2 Persistent low backache from relaxed pelvic joints 3 Stronger and more frequent uterine (Braxton Hicks) contractions 4 A decline in energy, as the body stores up for labor 5 Uterus sinks downward and forward in first-time pregnancies

1, 2, 3 After lightening, a return of the frequent need to urinate occurs as the fetal position causes increased pressure on the bladder. In the run-up to labor , women often experience persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Before the onset of labor, it is common for Braxton Hicks contractions to increase in both frequency and strength. Bloody show may be passed. A surge of energy is a phenomenon that is common in the days preceding labor. In first-time pregnancies, the uterus sinks downward and forward about 2 weeks before term.

Nurses should be aware of the difference experience can make in labor pain, such as: 1 sensory pain for nulliparous women often is greater than for multiparous women during early labor. 2 affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. 3 women with a history of substance abuse experience more pain during labor. 4 multiparous women have more fatigue from labor and therefore experience more pain.

1 Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? 1 The fetal presenting part is 1 cm above the ischial spines. 2 Effacement is 4 cm from completion. 3 Dilation is 50% completed. 4 The fetus has achieved passage through the ischial spines.

1 Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.

The nurse palpates the fontanels and sutures to determine the fetal presentation. What is the feature of the anterior fontanel? 1 It is diamond shaped in appearance. 2 It measures about 1 cm by 2 cm. 3 It closes after 6 to 8 weeks of birth. 4 It lies near the occipital bone.

1 The anterior fontanel is diamond shaped and measures about 3 cm by 2 cm. It closes by 18 months after birth. It lies at the junction of the sagittal, coronal, and frontal sutures. The posterior fontanel is triangular in shape and measures about 1 cm by 2 cm. It closes 6 to 8 weeks after birth. It lies at the junction of the sutures of the two parietal bones and the occipital bone.

The nurse palpates the fontanels and sutures of a fetus during the vaginal examination of a patient in labor after the rupture of membranes. Where does the nurse locate the lambdoid suture? 1. A 2. B 3. C 4. D

1 The fetal skull is composed of two parietal bones, two temporal bones, the frontal bone, and the occipital bone. The lambdoid suture lies between the parietal bone and the occipital bone. The sagittal suture lies between the two parietal bones. The coronal suture lies between the parietal bone and the frontal bone. The frontal suture separates the two halves of the frontal bone.

The nurse is teaching pain relief techniques to a group of expectant patients. What does the nurse teach the patients about the gate-control theory of pain? 1 Distractions block the nerve pathways. 2 Neuromuscular activity can increase pain. 3 All sensations travel together to the brain. 4 Motor activity during labor intensifies pain

1 The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

The nurse is assessing a patient in labor. The nurse documents the progress in the effacement of the cervix and little increase in descent. Which phase of labor is the patient in? 1 Latent phase 2 Active phase 3 Transition phase 4 Descent phase

1 The patient is in the latent phase of the first stage of labor. In this phase, there is more progress in the effacement of the cervix and little increase in the descent of the fetus. In the active and transition phases, there is more rapid dilation of the cervix and increased rate of descent of the presenting part of the fetus. The descent phase, or active pushing phase, occurs in the second stage of labor. In this phase, the patient has a strong urge to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

What response does the nurse expect when a laboring patient is administered analgesic medication early in labor? 1 Painless intrauterine contractions 2 Increased frequency of contractions 3 Increased intensity of contractions 4 Rapid descent of the fetus

1 Uterine contractions are usually independent of external forces. Laboring patients who are administered analgesic medication have normal but painless uterine contractions. However, uterine contractions may decrease in frequency and intensity temporarily, if narcotic analgesic medication is administered early in labor. The first and second stages of labor are lengthened, and the rate of fetal descent slows down.

The nurse is teaching a class on childbirth. What does the nurse teach about signs of local anesthetic toxicity? Select all that apply. 1 Tinnitus 2 Metallic taste 3 Slurred speech 4 Long stage II labor 5 Increased use of oxytocin

1, 2, 3 The central nervous system can be affected if a local anesthetic agent is injected accidentally into a blood vessel leading to local anesthetic toxicity . Signs include metallic taste, tinnitus, and slurred speech. Longer stage II labor and increased use of oxytocin are side effects of epidural and spinal anesthesia.

What interventions does the nurse perform for a laboring patient with hypotension and fetal bradycardia? Select all that apply. 1 Notify the primary health care provider or anesthesiologist. 2 Monitor the fetal heart rate (FHR) every 5 minutes. 3 Monitor maternal blood pressure every 10 minutes. 4 Administer oxygen using a non rebreather facemask. 5 Position the patient in Sims' or modified Sims' position.

1, 2, 4 The nurse must immediately notify the primary health care provider, anesthesiologist, or nurse anesthetist. The nurse must administer oxygen by nonrebreather facemask at 10 to 12 L/min or as per health care facility's protocol. The FHR must be monitored every 5 minutes. The patient must be turned to lateral position or a pillow or wedge must be placed under a hip to displace the uterus. Sims' or modified Sims' position may be used when spinal anesthesia is administered. Maternal blood pressure must be monitored every 5 minutes.

The nurse is caring for a patient who had a normal vaginal birth. The patient is concerned about the shape of the infant's head. What does the nurse tell the patient? Select all that apply. 1 The bones of the skull continue to grow after birth. 2 The shape of the head undergoes molding during labor. 3 The head assumes its normal shape within a month. 4 The skull bones of an infant are generally firmly united. 5 The sutures and fontanels make the skull flexible

1, 2, 5 The bones of the skull continue to grow for some time after birth to accommodate the infant's brain. During labor, the shape of the head gets molded as the bones undergo a slight overlapping. The sutures and fontanels are membranous structures that unite the skull bones and make the skull flexible. Molding can be extensive, but the heads of most newborns assume their normal shape within 3 days after birth. The skull bones are held together by sutures and fontanels and are not firmly united in an infant.

The nurse teaches the patient nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Select all that apply. 1 Biofeedback 2 Massage and touch 3 Patterned breathing 4 Controlled relaxation 5 Slow-paced breathing

1, 3, 4 Patterned breathing, controlled relaxation, and biofeedback techniques must be practiced to obtain best results. Patterned breathing and controlled relaxations help to manage pain during labor. Biofeedback is effective when the patient is able to focus and control body responses during labor. The nurse assisting the laboring patient can use methods such as massage and touch and slow-paced breathing successfully without the patient having any prior knowledge about it.

What are the common signs that are observed in the days preceding labor? Select all that apply. 1 Persistent low backache 2 Sudden increase in lethargy 3 Blood-tinged cervical mucus 4 Increase in weight up to 1.5 kg 5 Profuse vaginal mucus

1, 3, 5 Common signs that precede labor include persistent low backache and sacroiliac distress as a result of relaxation of the pelvic joints. Brownish or blood-tinged cervical mucus may be passed. The vaginal mucus becomes more profuse in response to the extreme congestion of the vaginal mucous membranes. In the days preceding labor, women generally have a sudden surge of energy. They also experience a loss of 0.5 to 1.5 kg in weight. This is caused by water loss resulting from electrolyte shifts that in turn are produced by changes in estrogen and progesterone levels.

What are the factors that speed up the dilation of the cervix? Select all that apply. 1 Strong uterine contractions 2 Scarring of the cervix 3 Pressure by amniotic fluid 4 Prior infection of the cervix 5 Force by fetal presenting part

1, 3, 5 Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, which are, in turn, caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix may occur following a surgery. Prior infection or surgery may slow cervical dilation.

A patient inquires about the use of hypnosis for pain management during a prenatal assessment. What does the nurse teach the patient about this modality? Select all that apply. 1 It gives a better sense of control. 2 It must be performed by a support person. 3 It is a form of deep relaxation or meditation. 4 It is more effective than the use of a placebo. 5 It can cause dizziness, nausea, and headache

1, 3, 5 Hypnosis is a form of deep relaxation, similar to daydreaming or meditation. It enhances relaxation and diminishes fear, anxiety, and perception of pain. It allows the patient to have a greater sense of control over painful contractions. Failure to dehypnotize properly may result in mild dizziness, nausea, and headache. Self-hypnosis must be learnt during childbirth preparation classes. It is not performed by a support person. Although hypnosis is beneficial, studies have not found it to be more effective than the use of a placebo or other interventions for pain management during labor.

What interventions does the nurse perform to provide emotional support to a patient in labor? Select all that apply. 1 Compliment patient efforts during labor. 2 Avoid offering food during labor. 3 Use a calm, confident approach. 4 Discourage activities that distract. 5 Involve the patient in care decisions.

1, 3, 5 The nurse must offer emotional support by complimenting the patient and offering positive reinforcement for efforts during labor. The patient must be involved in decision making regarding own care. The nurse must use a calm and confident approach when assisting the patient during labor. The nurse may offer food and nourishment, if allowed by the primary health care provider. The nurse must encourage participation in distracting activities and nonpharmacologic measures for comfort.

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. 1 Imagine breathing in light and energy. 2 Maintain clenched fists to drive out pain. 3 Engage in dance or rhythmic movements. 4 Imagine walking through a restful garden. 5 Envisage breathing out worries and tension.

1, 4, 5 Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.

The nurse teaches acupressure methods for pain relief during labor to a couple in the prenatal clinic. What does the nurse teach about acupressure? Select all that apply. 1 Blood circulation is enhanced. 2 Flow of qi (energy) is restored. 3 Lubricants are used over the area. 4 Pressure is applied with the fingers. 5 Pressure is applied with contractions.

1, 4, 5 Pressure is usually applied with the heel of the hand, fist, or pads of the thumbs and fingers. Pressure is applied with contractions initially and then continuously as labor progresses to the transition phase at the end of the first stage of labor. Acupressure is said to promote the circulation of the blood, the harmony of yin and yang, and the secretion of neurotransmitters. Thus acupressure maintains normal body functions and enhances well-being. Acupressure is applied over the skin without using lubricants. In acupuncture, the flow of qi (energy) is restored.

The nurse acts as an advocate for the patient during an informed consent. What care must the nurse take while obtaining an informed consent? Select all that apply. 1 Check for the patient's signature. 2 Ensure that the consent is in English. 3 Obtain a family member's signature. 4 Check for the date on the consent form. 5 Check the anesthetic care provider's signature.

1, 4, 5 The nurse must ensure that the consent form has the correct date. The nurse must ensure that the patient has not been compelled to consent for the procedure. The form must carry the signature of the anesthetic care provider, certifying that the patient has received and expresses understanding of the explanation. The consent form must be written or explained in the patient's primary language. The nurse need not obtain a family member's signature on the document. The patient's signature is important.

The nurse is assessing a pregnant client and determines that the client has a round pelvis with moderate depth, straight sidewalls, curved sacrum, and wide subpubic arch. The nurse also finds that the client's ischial spines are blunt. How should the nurse classify the client's pelvis based on these findings? 1 Android 2 Gynecoid 3 Anthropoid 4 Platypelloid

2 Based on the shape, depth, and other characteristics of the pelvis, health care providers classify it into four different types. The presence of a round pelvis with moderate depth, straight sidewalls, curved sacrum, and a wide subpubic arch indicates that the client has a gynecoid pelvis. If the client's pelvis is heart-shaped and has convergent sidewalls with a narrow subpubic arch, then it would be classified as an android pelvis. If the client's pelvis is oval with a narrow subpubic arch, then it would be classified as an anthropoid pelvis. If the client's pelvis is flat with a slightly curved sacrum, then it indicates that the client has a platypelloid pelvis.

What care must the nurse take when implementing aromatherapy for a patient in labor? 1 Apply oil to the skin and massage. 2 Ask the patient to choose the scents. 3 Apply a few drops of oil to the hair. 4 Allow inhalation of warm oil vapors

2 Certain scents can evoke pleasant memories and feelings of love and security. So, it is helpful if the patient is allowed to choose the scents. The oils must never be applied in full strength directly on to the skin. Most oils should be diluted in a vegetable oil base before use. Inhaling vapors from the oil can lead to unpleasant side effects like nausea or headache. Drops of essential oils can be put on a pillow or on a woman's brow or palms or used as an ingredient in creating massage oil. It is not applied to the hair. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which of the following when responding to the new mother?

A) Insufficient calorie intake B) Shift of water from extracellular space to intracellular space C) Increase in stool passage D) Overproduction of bilirubin Ans: A Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. Stool passage and bilirubin have no effect on weight loss.

The nurse is assisting a patient in labor. What breathing pattern must the nurse remind the patient to use when the contractions increase in frequency and intensity in the first phase of labor? 1 Slow-paced breathing 2 Modified-paced breathing 3 3:1 pattern-paced breathing 4 4:1 pattern-paced breathing

2 During the first phase of labor, as contractions increase in frequency and intensity, the patient must change breathing patterns to a modified-paced breathing technique. This breathing pattern is shallower and faster than the patient's normal rate of breathing, but should not exceed twice the resting respiratory rate. Slow-paced breathing is performed at approximately half the normal breathing rate and is initiated when the patient can no longer walk or talk through contractions. Patterned-paced breathing is suggested in the second phase of labor. It consists of panting breaths combined with soft blowing breaths at regular intervals. The patterns may vary, the 3:1 pattern is pant, pant, pant, blow and the 4:1 pattern is pant, pant, pant, pant, and blow.

What are the factors that enable the baby to initiate respiration immediately after birth? 1 Fetal respiratory movements increase during labor. 2 Fetal lung fluid is cleared from the air passage. 3 Arterial carbon dioxide pressure is decreased. 4 Arterial pH and bicarbonate level is increased.

2 Fetal lung fluid is cleared from the air passage as the infant passes through the birth canal during labor and vaginal birth. There is a decrease in fetal respiratory movements during labor. Arterial carbon dioxide pressure (Pco2) increases. There is a decrease in arterial pH and bicarbonate levels. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

What does the nurse teach the patient about the benefits of breathing techniques in the second stage of labor? 1 Does not interfere with fetal descent 2 Causes increase in abdominal pressure 3 Reduces discomfort during contractions 4 Increases the size of the abdominal cavity

2 In the second stage of labor breathing technique is used to increase abdominal pressure and expel the fetus. In the first stage of labor, breathing helps to promote the relaxation of the abdominal muscles, thereby increasing the size of the abdominal cavity. This lessens the discomfort during contraction caused by the friction between the abdominal wall and the uterus. It also relaxes the muscles of the genital area and does not interfere with fetal descent. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.

Nurses can help their patients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? 1 Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours 2 Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours 3 Lull: no contractions; dilation stable; duration of 20 to 60 minutes 4 Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours

2 The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.

The nurse is performing the pelvic examination of a patient during the prenatal visit. Which pelvic type is least favorable for a vaginal birth? 1 Gynecoid 2 Android 3 Anthropoid 4 Platypelloid

2 The android pelvis is heart shaped and angulated. The sidewalls are convergent, the sacrum is slightly curved, and the terminal portion is often beaked. The subpubic arch is narrow, often resulting in cesarean births or difficult vaginal forceps births. It is least favorable for vaginal birth. The gynecoid pelvis is slightly ovoid or transversely rounded. The sidewalls are straight, and the sacrum is deep and curved. The subpubic arch is wide, thus enabling spontaneous vaginal births. The anthropoid pelvis is oval and wider anteroposteriorly. The sidewalls are straight, sacrum slightly curved. The subpubic arch is narrow and may result in a forceps vaginal birth. The platypelloid pelvis is flattened anteroposteriorly and wide transversely. The sidewalls are straight, the sacrum slightly curved, and the subpubic arch is wide, resulting in spontaneous vaginal birth.

When assessing a patient for the possibility of a vaginal birth, what must the nurse keep in mind about the coccyx of the bony pelvis? 1 It is the part above the brim of the bony pelvis. 2 It is movable in the latter part of the pregnancy. 3 It has three planes: the inlet, midpelvis, and outlet. 4 It is ovoid and bound by the pubic arch anteriorly

2 The coccyx is movable in the latter part of the pregnancy, unless it has been broken and fused to the sacrum during healing. The bony pelvis is separated by the brim into the false and the true pelves. The false pelvis is the part above the brim and plays no part in childbearing. The true pelvis is involved in birth and is divided into three planes: inlet, midpelvis, and outlet. The pelvic outlet is the lower border of the true pelvis. Viewed from below it is the ovoid. It is shaped somewhat like a diamond and bound by the pubic arch anteriorly, the ischial tuberosities laterally, and the tip of the coccyx posteriorly.

Which pelvic shape is most conducive to vaginal labor and birth? 1 Android 2 Gynecoid 3 Platypelloid 4 Anthropoid

2 The gynecoid pelvis is round and cylinder shaped, with a wide pubic arch. Prognosis for vaginal birth is good. Only 23% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The platypelloid pelvis is flat, wide, short, and oval. The anthropoid pelvis is a long, narrow oval with a narrow pubic arch. It is more favorable than the android or platypelloid pelvic shape.

The nurse is assisting a patient who is prepared to use the paced breathing method. What does the nurse remind the patient to do at the beginning of the breathing pattern? 1 Exhale a deep breath. 2 Take a deep relaxing breath. 3 Take 32 breaths per minute. 4 Take three breaths per minute.

2 The patient must remember that all breathing patterns begin with a deep, relaxing "cleansing breath" to "greet the contraction." The patient must then exhale a deep breath to "blow the contraction away." These deep breaths ensure adequate oxygen for the mother and the baby and signal that a contraction is beginning or has ended. The patient must take three to four breaths per minute when performing slow-paced breathing. As contractions increase in frequency and intensity, the patient takes shallow, fast breaths, about 32 to 40 per minute.

The nurse is assessing a pregnant patient who is paralyzed due to a spinal injury at the level of the twelfth thoracic vertebra. Presently, she is in full-term gestation and under nursing care. What should the nurse inform the patient? 1 "You may have a prolonged labor." 2 "You may have painless uterine contractions." 3 "Your uterus may not contract due to paralysis." 4 "Your baby may develop neurologic problems."

2 The pregnant patient is paralyzed due to a spinal lesion above the twelfth thoracic vertebra. In this case, the patient would not perceive the uterine contractions and thus would have painless uterine contractions. The spinal injury has no effect on the duration of labor. The uterine contractions are not dependent on any external forces, and thus this patient would have normal uterine contractions. Neurologic problems in the fetus are not a complication associated with spinal cord injury.

The nurse is briefing a patient who is pregnant for the first time about lightening. Which statement should the nurse mention to describe lightening to the patient? 1 It occurs when true labor is in progress. 2 It allows the patient to breathe more easily. 3 It decreases the pressure on the bladder. 4 It leads to decreased urinary frequency.

2 When the fetal head descends into the true pelvis during lightening, the patient will feel less congested and can breathe more easily. In a first-time pregnancy, lightening occurs about 2 weeks before term. In a multiparous pregnancy, lightening may not take place until after the uterine contractions are established and the true labor is in progress. This shift increases the pressure on the bladder and causes a return of urinary frequency. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part? 1 2 cm above the ischial spine. 2 1 cm above the ischial spine. 3 at the level of the ischial spine. 4 1 cm below the ischial spine.

2 When the lowermost portion of the presenting part is 1 cm above the ischial spine, it is noted as being minus (-)1. When positioned 2 cm above the ischial spine, it is -2 station. At the level of the spines the station is referred to as 0 (zero). When the presenting part is 1 cm below the spines, the station is said to be plus (+)1.

What major side effect does the nurse expect if a patient in labor is administered diazepam (Valium)? 1 Severe nausea and vomiting in the mother 2 Neonatal central nervous system depression 3 Disrupted temperature control in the newborn 4 Magnified pain if administered without analgesic

3 Diazepam (Valium) disrupts thermoregulation in the newborn. Thus the newborn is less able to maintain body temperature. Benzodiazepines, when given with an opioid analgesic, seem to enhance pain relief and reduce nausea and vomiting. Pain is magnified if a barbiturate is given without an analgesic to a patient who is experiencing pain. This is because the normal coping mechanism in the patient may be blunted. Barbiturates should be avoided if birth is anticipated within 12 to 24 hours because it has the potential to cause neonatal central nervous system depression.

The nurse knows that the second stage of labor, the descent phase, has begun when the: 1 amniotic membranes rupture. 2 cervix cannot be felt during a vaginal examination. 3 woman experiences a strong urge to bear down. 4 presenting part is below the ischial spines.

3 During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.

The nurse is caring for a patient who is using fentanyl citrate (Sublimaze) through patient-controlled analgesia (PCA) while in labor. What effects of fentanyl citrate does the nurse expect? 1 Provides long duration of action 2 Requires only a single dose 3 Provides quick relief to pain 4 Causes sedation and nausea

3 Fentanyl citrate (Sublimaze) is a potent short-acting opioid agonist analgesic. Therefore it provides quick pain relief. It rapidly crosses the placenta, so it is present in the fetal blood within 1 minute after intravenous maternal administration. It is a short-acting drug, so the patient will require more frequent dosing. It is often administered as a patient controlled analgesic. It has fewer neonatal effects as compared to meperidine, and causes less maternal sedation and nausea.

The nurse is caring for a nulliparous patient in labor. How is the experience for a nulliparous patient different from that of a multiparous patient? The patient experiences: 1 Less sensory pain during early labor. 2 Greater sensory pain in the second stage of labor. 3 Greater fatigue due to longer duration of labor. 4 Greater affective pain in the second stage of labor.

3 Parity influences the perception of labor pain. The nulliparous patient often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous patient is greater in the first stage as compared to a multiparous patient. It decreases for both patients during the second stage of labor. During the second stage of labor, the multiparous patient may experience greater sensory pain than the nulliparous patient. This is because tissues of the multiparous patient are more supple and increase the speed of fetal descent, thereby intensifying the pain. Test-Taking Tip: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question.

What intervention does the nurse perform to provide a relaxed environment for labor? 1 Stand at the bedside. 2 Encourage rapid birth. 3 Control sensory stimuli. 4 Demonstrate excitement

3 The nurse must assist the patient by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the patient's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the patient for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the patient. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? 1 Pallor 2 Nausea 3 Dizziness 4 Diaphoresis

3 The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, light-headedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain.

During the prenatal assessment of a patient, the nurse teaches the patient about nonpharmacologic pain management. What does the nurse tell the patient about this method? 1 It is technical and expensive. 2 It requires intensive training. 3 It provides the patient with a sense of control. 4 It is used only in stage I of labor.

3 The patient makes choices about the nonpharmacologic pain management methods that are best suited. This provides the patient with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the patient may obtain best results from the practice. It can be used throughout labor.

In which stage of labor does the nurse expect the placenta to be expelled? 1 First 2 Second 3 Third 4 Fourth

3 The placenta is expelled in the third stage of labor. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The fourth stage of labor lasts for the first 2 hours after birth.

A patient asks the nurse about the use of transcutaneous electrical nerve stimulation (TENS). What does the nurse teach about TENS? 1 It involves the use of one pair of electrodes. 2 It is kept at low intensity during contractions. 3 It releases continuous low-intensity impulses. 4 It is useful for pain in the second stage of labor.

3 When TENS is applied for pain relief, the electrodes provide continuous low-intensity electrical impulses or stimuli from a battery-operated device. TENS is most useful for lower back pain during the early first stage of labor. TENS involves the placing of two pairs of flat electrodes on either side of the woman's thoracic and sacral spine. During a contraction, the patient increases the stimulation from low to high intensity by turning the control knobs on the device.

During a prenatal assessment a patient asks the nurse about the disadvantages of spinal anesthesia. What does the nurse teach the patient about the potential effect of spinal anesthesia? 1 It reduces maternal consciousness. 2 It increases maternal muscular tension. 3 It increases probability of operative birth. 4 It increases the possibility of fetal hypoxia.

3 When a spinal anesthetic is given, the need for episiotomy, forceps-assisted birth, or vacuum-assisted birth tends to increase because voluntary expulsive efforts are reduced or eliminated. Maternal consciousness is maintained. Fetal hypoxia is absent as maternal blood pressure is maintained within a normal range. There is no muscular tension; excellent muscular relaxation is achieved.

A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?

A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he's okay." Ans: C Soaking 6 to 12 diapers a day indicates adequate hydration. Contentedness after feeding is not an indicator for adequate hydration. Typically a newborn wakes up 8 to 12 times per day for feeding. As the infant gets older, the time on the breast increases. Moist mucous membranes help to suggest adequate hydration but this is not the best indicator.

What care must the nurse take when assisting a laboring patient with hydrotherapy? 1 Initiate hydrotherapy in the first stage of labor at 3 cm. 2 Ensure water is warm at 32.5° to 34° C (90.5° to 93.2°F). 3 Check the fetal heart rate (FHR) with internal electrodes. 4 Obtain the approval of the primary health care provider.

4 Agency policy must be consulted to determine if the approval of the laboring woman's primary health care provider is required. The nurse must ensure that all criteria are met in terms of the status of the maternal and fetal unit. Hydrotherapy is usually initiated when the patient is in active labor, at approximately 5 cm. This reduces the risk of a prolonged labor. FHR monitoring is done by Doppler, fetoscope, or wireless external monitor when hydrotherapy is in use. Use of internal electrodes for monitoring FHR is contraindicated in jet hydrotherapy. The temperature of the water should be maintained at 36° to 37° C (96.8° to 98.6° F). Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

The nurse is caring for a patient in the last trimester of pregnancy. What assessments will the patient display related to the effects of fear and anxiety during labor? An increase in: 1 Blood flow. 2 The progression of labor. 3 Contractions. 4 Muscle tension

4 Fear and excessive anxiety leads to increased muscle tension. It causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus fear and anxiety magnifies the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions leading to increased discomfort. This slows the progress of labor. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

The nurse is caring for a multiparous patient. In which stage can the nurse expect the fetal head to be engaged in the pelvic inlet? 1 About 2 weeks before term 2 Before the start of active labor 3 When labor stage I begins 4 After labor is established

4 In a multiparous patient, the abdominal musculature is relaxed. The fetal head often remains freely movable above the pelvic brim and becomes engaged in the pelvic inlet only after labor is established. In a nulliparous patient, the uterus sinks downward and forward about 2 weeks before term, when the presenting part of the fetus descends into the true pelvis. The fetal head is engaged in the pelvic inlet before the onset of active labor. The abdominal muscles are firm in a nulliparous pregnancy and direct the presenting part into the pelvis. The first stage of labor lasts from the onset of regular uterine contractions to full dilation of the cervix.

A primigravida asks the nurse about signs she can look for that indicate that the onset of labor is getting closer. The nurse should describe: 1 weight gain of 1 to 3 lbs. 2 quickening. 3 fatigue and lethargy. 4 bloody show.

4 Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens. Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct.

The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part? 1. -1 2. +1 3. +3 4. +5

4 Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. The placement of the presenting part is measured in centimeters above or below the ischial spines. Birth is imminent when the presenting part is at +4 to +5 cm. When the lowermost portion of the presenting part is 1 cm above the spine, it is noted as minus (-)1. When the presenting part is 1 cm below the spine, the station is said to be plus (+)1. At +3, the presenting part is still descending the birth canal. Birth is imminent when the presenting part is at +4 to +5 cm.

When caring for a patient in the first phase of labor, the nurse observes that the patient is experiencing visceral pain. In which area does visceral pain occur? 1 Abdominal wall and thighs 2 Gluteal area and iliac crests 3 Lumbosacral area of the back 4 Lower portion of the abdomen

4 Visceral pain in the first stage of labor occurs in the lower portion of the abdomen. Visceral pain is a result of distention of the lower uterine segment and stretching of cervical tissue as it effaces and dilates. Pressure and traction on uterine tubes, ovaries, ligaments, nerves, and uterine ischemia also cause visceral pain. Pain that originates in the uterus radiates to the gluteal area, iliac crests, abdominal wall, thighs, lumbosacral area of the back, and lower back. This pain is called referred pain.

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following?

A) "We can put a tiny bit of lotion on his skin and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair." Ans: B Powders should not be used because they can be inhaled, causing respiratory distress. If the parents want to use oils and lotions, have them apply a small amount onto their hand first, away from the newborn; this warms the lotion. Then the parents should apply the lotion or oil sparingly. Parents need to be instructed that a bath two or three times weekly is sufficient for the first year because too frequent bathing may dry the skin. The eyes are cleaned first and only with plain water; then the rest of the face is cleaned with plain water.

When assisting a patient in labor, the nurse expects to observe the cardinal movements that lead to the birth of the baby. Arrange the movements in the order of their occurrence. 1. Internal rotation 2. Extension 3. Descent 4. Flexion 5. Restitution 6. Engagement

6, 3, 4, 1, 2, 5 The cardinal movements that occur in a vertex presentation are engagement, descent, flexion, internal rotation, extension, restitution (external rotation), and finally birth by expulsion. The fetal head is said to be engaged in the pelvic inlet when the biparietal diameter of the head passes through the pelvic inlet. During descent, the presenting part progresses through the pelvis. As soon as the descending head meets resistance from the cervix or pelvic wall or pelvic floor, it undergoes flexion. The fetus flexes such that the chin is brought into closer contact with the fetal chest. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. When the fetal head reaches the perineum for birth, it undergoes extension. It is deflected anteriorly by theperineum. Restitution occurs after the head is born.It rotates briefly to the position it occupied when it was engaged in the inlet.

A nurse is caring for a pregnant client at her 34-week checkup. The client has chosen the Lamaze method for her birthing plan but states that her partner does not agree. The client says she will just change her plan. Which response by the nurse would be appropriate to support the female client? A) "Have you and your partner discussed what his / her role will be in the birth?" B) "Just wait until the birth; your partner's mind could change." C) "Preparing for the birth works for some clients, but not for all." D) "Maybe you should choose a different support person."

A) "Have you and your partner discussed what his / her role will be in the birth?" The nurse should explain to the client the different roles the partner can take in the birth process. The nurse should encourage the client to discuss both her feelings and her partner's feelings to better understand the partner's disapproval of Lamaze. This could help improve family communication. The other three answers are not therapeutic because they ignore the client's concern and do not help to prepare the client.

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location?

A) Just superior to the nipple, at the midsternum B) Lateral to the midclavicular line at the fourth intercostal space C) At the fifth intercostal space to the left of the sternum D) Directly adjacent to the sternum at the second intercostals space Ans: B The point of maximal impulse (PMI) in a newborn is a lateral to midclavicular line located at the fourth intercostal space.

A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?

A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the doctor if we notice a funny odor." Ans: B The cord stump should change color from yellow to brown or black. Therefore the parents need additional teaching if they state the color changes from brown to yellow. Tub baths are avoided until the cord has fallen off and the area is healed. Exposing the stump to the air helps it to dry. The parents should notify their primary care provider if there is any bleeding, redness, drainage, or foul odor from the cord stump.

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate?

A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this." Ans: B The mother is describing meconium. Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be:

A) 30 cm B) 32 cm C) 34 cm D) 36 cm Ans: B The newborn's chest should be round, symmetric, and 2 to 3 cm smaller than the head circumference. Therefore, this newborn's chest circumference would be 31 to 32 cm to be normal.

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?

A) 38 breaths per minute B) 46 breaths per minute C) 54 breaths per minute D) 68 breaths per minute Ans: D After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following?

A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled Ans: A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. Which of the following would the nurse do first?

A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe. Ans: D Feedback: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

Just after delivery, a newborn's axillary temperature is 94° C. What action would be most appropriate?

A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower. Ans: B A newborn's temperature is typically maintained at 36.5 to 37.5° C (97.7 to 99.7° F). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the physician of the newborn's current temperature since it is outside normal parameters.

The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex?

A) Babinski B) Tonic neck C) Stepping D) Plantar grasp Ans: A The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.

After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply.)

A) Cephalhematoma B) Molding C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm Ans: A, B, D Normal variations in newborn head size and appearance include cephalhematoma, molding, and caput succedaneum. Microcephaly, closed fontanels, or a posterior fontanel diameter greater than 1 cm are considered abnormal.

After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborn's primary method of heat production?

A) Convection B) Nonshivering thermogenesis C) Cold stress D) Bilirubin conjugation Ans: B The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

A nursing instructor is preparing a class on newborn adaptations. When describing the change from fetal to newborn circulation, which of the following would the instructor most likely include? (Select all that apply.)

A) Decrease in right atrial pressure leads to closure of the foramen ovale. B) Increase in oxygen levels leads to a decrease in systemic vascular resistance. C) Onset of respirations leads to a decrease in pulmonary vascular resistance. D) Increase in pressure in the left atrium results from increases in pulmonary blood flow. E) Closure of the ductus venosus eventually forces closure of the ductus arteriosus. Ans: A, C, D, E When the umbilical cord is clamped, the first breath is taken and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Boxwell, 2010). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. Ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed.

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next?

A) Document this as pseudomenstruation B) Notify the practitioner immediately C) Obtain a culture of the discharge D) Inspect for engorgement Ans: A The nurse should assess pseudomenstruation, a vaginal discharge composed of mucus mixed with blood, which may be present during the first few weeks of life. This discharge requires no treatment. The discharge is a normal finding and thus does not need to be reported immediately. It is not an indication of infection. The female genitalia normally will be engorged, so assessing for engorgement is not indicated.

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation?

A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket. Ans: A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism?

A) Evaporation B) Conduction C) Convection D) Radiation Ans: B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

A group of nursing students are reviewing the changes in the newborn's lungs that must occur to maintain respiratory function. The students demonstrate understanding of this information when they identify which of the following as the first event?

A) Expansion of the lungs B) Increased pulmonary blood flow C) Initiation of respiratory movement D) Redistribution of cardiac output Ans: C Before the newborn's lungs can maintain respiratory function, the following events must occur: respiratory movement must be initiated; lungs must expand, functional residual capacity must be established, pulmonary blood flow must increase, and cardiac output must be redistributed.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary Ans: C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find?

A) Greenish black, tarry stool B) Yellowish-brown, seedy stool C) Yellow-gold, stringy stool D) Yellowish-green, pasty stool Ans: B After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating:

A) Habituation B) Motor maturity C) Orientation D) Social behaviors Ans: B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which of the following?

A) Habituation B) Motor maturity C) Social behavior D) Orientation Ans: D Orientation refers to the response of newborns to stimuli. It reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held.

While observing the interaction between a newborn and his mother, the nurse notes the newborn nestling into the arms of his mother. The nurse identifies this behavior as which of the following?

A) Habituation B) Self-quieting ability C) Social behaviors D) Orientation Ans: C Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Habituation self-quieting ability refers to newborns' ability to quiet and comfort themselves, such as by hand-to-mouth movements and sucking, alerting to external stimuli and motor activity. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Orientation refers to the response of newborns to stimuli, becoming more alert when sensing a new stimulus in their environment.

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following?

A) Harlequin sign B) Nevus flammeus C) Erythema toxicum D) Port wine stain Ans: C Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. The rash is common on the face, chest, and back. One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn's eosinophils reacting to the environment as the immune system matures. Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. Nevus flammeus or port wine stain is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red. This skin lesion is made up of mature capillaries that are congested and dilated.

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production Ans: D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

A nurse is developing a teaching plan for the parents of a newborn. When describing the neurologic development of a newborn to his parents, the nurse would explain that the development occurs in which fashion?

A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-to-caudal Ans: A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature?

A) Hearing B) Touch C) Taste D) Vision Ans: D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?

A) Hemoglobin 19 g/dL B) Platelets 75,000/uL C) White blood cells 20,000/mm3 D) Hematocrit 52% Ans: B Normal newborn platelets range from 150,00 to 350,000/uL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product?

A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia Ans: B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?

A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birth weight? D) Is acrocyanosis present? Ans: A The typical heart rate of a newborn ranges from 120 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birth weight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?

A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment Ans: A The newborn's heart rate is slightly below the accepted range of 120 to 160 beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.5° F. Therefore, the priority nursing diagnosis is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is a risk for deficient fluid volume or a risk for infection.

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level Ans: D Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.

The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem?

A) Limited rugae B) Large scrotum C) Palpable testes in scrotal sac D) Absence of engorgement Ans: A The scrotum usually appears relatively large and should be pink in white neonates and dark brown in neonates of color. Rugae should be well formed and should cover the scrotal sac. There should not be bulging, edema, or discoloration. Testes should be palpable in the scrotal sac and feel firm and smooth and be of equal size on both sides of the scrotal sac.

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse documents this finding as which of the following?

A) Milia B) Mongolian spots C) Stork bites D) Birth trauma Ans: B Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma Ans: C Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following?

A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation Ans: A From 30 to 120 minutes of age, the newborn enters the second stage of transition, the period of decreased responsiveness or that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate?

A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine. Ans: B Feedback: Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?

A) Palmar grasp reflex B) Tonic neck reflex C) Moro reflex D) Rooting reflex Ans: D The rooting reflex is elicited by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements. The palmar grasp reflex is elicited by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. The tonic neck reflex is elicited by having the newborn lie on the back and turning the head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position. The Moro reflex is elicited by placing the newborn on his or her back, supporting the upper body weight of the supine newborn by the arms using a lifting motion without lifting the newborn off the surface. The arms are released suddenly and the newborn will throw the arms outward and flex the knees and then the arms return to the chest. The fingers also spread to form a C.

A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection?

A) Placing a cap on a newborn's head B) Working inside an isolette as much as possible. C) Placing the newborn skin-to-skin with the mother D) Using a radiant warmer to transport a newborn Ans: B To prevent heat loss by convection, the nurse would keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on the newborn's head would help minimize heat loss through evaporation. Placing the newborn skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant warmer to transport a newborn helps minimize heat loss through radiation.

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds, integrating understanding that this most likely is due to which of the following?

A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter Ans: D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.)

A) Respiratory distress B) Decreased oxygen needs C) Hypoglycemia D) Metabolic alkalosis E) Jaundice Ans: A, C, E Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess?

A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation Ans: A Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis Ans: C Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.)

A) Sleeping B) Interest in environmental stimuli C) Passage of meconium D) Difficulty arousing the newborn E) Spontaneous Moro reflexes Ans: B, C The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect?

A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone Ans: B A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.

The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.)

A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movement E) Absent red reflex Ans: B, C, D Assessment of the eyes should reveal a rapid blink reflex, ability to track objects to the midline, transient strabismus (deviation or wandering of the eyes independently), searching nystagmus (involuntary repetitive eye movement), and a red reflex.

The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?

A) Stop Rh sensitization B) Increase erythropoiesis C) Enhance bilirubin breakdown D) Promote blood clotting Ans: D Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn?

A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions Ans: D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following?

A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib. Ans: B The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.

The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed?

A) The newborn's skin and that of an adult are similar in thickness. B) The lipid composition of the skin of a newborn and adult is about the same. C) Skin development in the newborn is complete at birth. D) The newborn has more fibrils connecting the dermis and epidermis. Ans: C The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?

A) To aid in maturing the newborn's sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn's respiratory passages Ans: C Breast-feeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.

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? A) allowing the woman time to be alone B) promoting the woman's feelings of control C) providing clear information about procedures D) encouraging the woman to use relaxation techniques

A) allowing the woman time to be alone Positive support, not being alone, promotes a positive birth experience. Being alone can increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-confidence and self-esteem, which in turn help the woman to cope with the challenges of labor. Information about procedures reduces anxiety about the unknown and fosters cooperation and self-confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the woman's ability to cope with labor.

A nurse is caring for a client in her third stage of labor. Which findings would the nurse assess as indicating placental separation? Select all that apply. A) fresh gushing of blood from the vagina B) a relaxed and distended uterus C) umbilical cord descending lower down D) renewed bearing down efforts by client E) falling downward of uterus in the abdomen

A) fresh gushing of blood from the vagina C) umbilical cord descending lower down D) renewed bearing down efforts by client The signs of placental separation include a fresh gush of blood from the vagina, lengthening of the umbilical cord, and renewed bearing-down efforts by the client. When the client is in her third stage of labor, these indicate placental separation. A rising upwards of the uterus and a well-contracted globular uterus are the other signs of placental separation. Falling downward of the uterus in the abdomen and a relaxed uterus are the signs of uterine atony.

A pregnant client has come to the labor and birth suite in labor. The nurse reviews the client's medical record and determines that a vaginal birth is favorable based on which finding related to the client's pelvic shape? A) gynecoid B) platypelloid C) anthropoid D) android

A) gynecoid Vaginal birth is most favorable with a gynecoid pelvis because the inlet is round and the outlet is roomy. This shape offers the optimal diameters in all three planes of the pelvis. This type of pelvis allows early and complete fetal internal rotation during labor. Although vaginal birth is favorable with an anthropoid pelvis, it is less favorable than a gynecoid pelvis. However, vaginal birth is more favorable with an anthropoid pelvic shape compared with the android or platypelloid shape.

A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor? A) increase in frequency of the contractions B) irregularity in the duration of the contractions C) lessening of the contractions with position change D) decrease in the intensity of the contractions

A) increase in frequency of the contractions The nurse should identify that there is an increase in the duration of the contractions associated with true labor. In true labor, the duration, frequency, and intensity of uterine contractions increase. Position change does not reduce the uterine contractions. In false labor, the uterine contractions often disappear with ambulation and sleep. Also, there is no increase in frequency, duration, or intensity of the contractions, and the cervix fails to dilate any further.

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? A) increased risk of infection B) increased risk of breech presentation C) potential placenta previa D) potential rapid birth of fetus

A) increased risk of infection After the amniotic sac has ruptured, the barrier to infection is gone, and an ascending infection is possible. In addition, there is a danger of cord prolapse. The spontaneous rupture does not hasten labor, although it might signal the beginning of labor. The client may have placenta previa with the membranes intact.

The nurse is performing a vaginal examination of a pregnant patient who is in the first stage of labor. During the examination, the patient reports that she has an urge to bear down. Why does the patient feel this urge? Select all that apply. A The descending part of the fetus reaches the pelvic floor. B The presenting part of the fetus descends into the true pelvis. C Levels of estrogen increase and levels of progestogen decrease. D Levels of progestogen increase and levels of estrogen decrease. E Levels of oxytocin increase due to activation of stretch receptors in the vagina.

A, E When the presenting part of the fetus reaches the pelvic floor, it activates stretch receptors in the posterior vagina and releases endogenous oxytocin in a pregnant woman, which causes the urge bear down and push the baby out. This phenomenon is called the Ferguson reflex. The presenting part of the fetus descends into the true pelvis about 2 weeks before term; this "dropping" does not cause the urge to bear down. Levels of estrogen and progestogen do not change due to vaginal stimulation. Receptors in the vagina are activated rather than inhibited, which releases oxytocin and causes the urge to push.

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? a. Massaging the woman's back b. Changing the woman's position c. Giving the prescribed medication d. Encouraging the woman to rest between contractions

ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord and thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman's position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.

The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic analgesia in the newborn is: a. Respiratory depression. b. Bradycardia. c. Acrocyanosis. d. Tachypnea.

ANS: A An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase.

With regard to nerve block analgesia and anesthesia, nurses should be aware that: a. Most local agents are related chemically to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. A pudendal nerve block is designed to relieve the pain from uterine contractions. d. A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex.

A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) b. Promethazine (Phenergan) c. Butorphanol tartrate (Stadol) d. Nalbuphine (Nubain)

ANS: A Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are opioid agonist-antagonist analgesics.

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: a. Counterpressure against the sacrum. b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Conscious relaxation or guided imagery.

ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.

With regard to breathing techniques during labor, maternity nurses should understand that: a. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. b. By the time labor has begun, it is too late for instruction in breathing and relaxation. c. Controlled breathing techniques are most difficult near the end of the second stage of labor. d. The patterned-paced breathing technique can help prevent hyperventilation.

ANS: A First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.

Nurses should be aware of the differences experience can make in labor pain such as: a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

In assessing a woman for pain and discomfort management during labor, a nurse most likely would: a. Have the woman use a visual analog scale (VAS) to determine her level of pain. b. Note drowsiness as a sign that the medications were working. c. Interpret a woman's fist clenching as an indication that she is angry at her male partner and the physician. d. Evaluate the woman's skin turgor to see whether she needs a gentle oil massage.

ANS: A The VAS is a means of adding the woman's assessment of her pain to the nurse's observations. Drowsiness is a side effect of medications, not usually (sedatives aside) a sign of effectiveness. The fist clenching likely is a sign of apprehension that may need attention. Skin turgor, along with the moistness of the membranes and the concentration of the urine, is a sign that helps the nurse evaluate hydration.

To help clients manage discomfort and pain during labor, nurses should be aware that: a. The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort between contractions. c. The somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the second stage.

ANS: A This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.

While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include (Select all that apply): a. Culture. b. Anxiety and fear. c. Previous experiences with pain. d. Intervention of caregivers. e. Support systems.

ANS: A, B, C, E Culture: a woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: an anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, intravenous lines).

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would include (Select all that apply): a. Yawning, runny nose. b. Increase in appetite. c. Chills and hot flashes. d. Constipation. e. Irritability, restlessness.

ANS: A, C, E The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It is important for the nurse to assess both mother and baby and to plan care accordingly.

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called: a. An epidural. b. A pudendal. c. A local. d. A spinal block.

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

With regard to a pregnant woman's anxiety and pain experience, nurses should be aware that: a. Even mild anxiety must be treated. b. Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B Anxiety and pain reinforce each other in a negative cycle. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.

After change-of-shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. Visceral. b. Referred. c. Somatic. d. Afterpain.

ANS: B As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

It is important for the nurse to develop a realistic birth plan with the pregnant woman in her care. The nurse can explain that a major advantage of nonpharmacologic pain management is: a. Greater and more complete pain relief is possible. b. No side effects or risks to the fetus are involved. c. The woman remains fully alert at all times. d. A more rapid labor is likely.

ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The woman's alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace.

With regard to systemic analgesics administered during labor, nurses should be aware that: a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular administration (IM) is preferred over intravenous (IV) administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

ANS: B Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.

With regard to spinal and epidural (block) anesthesia, nurses should know that: a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. b. A high incidence of after-birth headache is seen with spinal blocks. c. Epidural blocks allow the woman to move freely. d. Spinal and epidural blocks are never used together.

ANS: B Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

The role of the nurse with regard to informed consent is to: a. Inform the client about the procedure and have her sign the consent form. b. Act as a client advocate and help clarify the procedure and the options. c. Call the physician to see the client. d. Witness the signing of the consent form.

ANS: B Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman's advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurse's responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the state's guidelines, the woman's husband or another hospital health care employee may sign as witness.

A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because: a. "The two together work the best for you and your baby." b. "Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea." c. "They work better together so you can sleep until you have the baby." d. "This is what the doctor has ordered for you."

ANS: B Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications will not occur. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. "This is what the doctor has ordered for you" may be true, but it is not an acceptable comment for the nurse to make.

The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. The mother gives birth without any analgesic or anesthetic. b. The mother and family's priorities and preferences are incorporated into the plan. c. The primary health care provider decides the best pain relief for the mother and family. d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting.

ANS: B The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.

To assist the woman after delivery of the infant, the nurse knows that the blood patch is used after spinal anesthesia to relieve: a. Hypotension. b. Headache. c. Neonatal respiratory depression. d. Loss of movement.

ANS: B The subarachnoid block may cause a postspinal headache resulting from loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.

If an opioid antagonist is administered to a laboring woman, she should be told that: a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push.

ANS: B The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure (Select all that apply)? a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen. e. Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.

A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial because of its effects on the neonate.

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help clients. Nurses should know that _____ women may be stoic until late in labor, when they may become vocal and request pain relief. a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

ANS: C Hispanic women may be stoic early and more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start. They may prefer pain medications. African-American women may express pain openly; use of medications for pain is more likely to vary with the individual.

The laboring woman who imagines her body opening to let the baby out is using a mental technique called: a. Dissociation. b. Effleurage. c. Imagery. d. Distraction.

ANS: C Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman engage in another activity.

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dL, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

ANS: C The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia/anesthesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is: a. Not used much anymore. b. Likely to be used in the second stage of labor but not in the first stage. c. An application of nitrous oxide. d. A prelude to cesarean birth.

ANS: C This is an application of nitrous oxide, which could be used in either the first or second stage of labor (or both) as part of the preparation for a vaginal birth. Nitrous oxide is self-administered and found to be very helpful.

The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is: a. Respiratory depression. b. Uterine relaxation. c. Inadequate muscle relaxation. d. Aspiration of stomach contents.

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, "My contractions are so strong that I don't know what to do with myself." The nurse should: a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized for each individual.

ANS: D Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.

In the current practice of childbirth preparation, emphasis is placed on: a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Having expectant parents attend childbirth preparation in any or no specific method.

ANS: D Encouraging expectant parents to attend childbirth preparation class is most important because preparation increases a woman's confidence and thus her ability to cope with labor and birth. Although still popular, the "method" format of classes is being replaced with other offerings such as Hypnobirthing and Birthing from Within.

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions are experiencing more pain. d. Levels of pain-mitigating b-endorphins are higher during a spontaneous, natural childbirth.

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.

Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation? a. Epidural anesthesia b. Narcotics c. Spinal block d. Breathing and relaxation techniques

ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. It is unlikely that enough time remains to administer epidural or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a. Notify the woman's physician. b. Tell the woman to slow the pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag

ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion.

Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks may be more effective than a long soak. Counterpressure can help the woman cope with lower back pain.

The nurse informs the patient that she will likely have difficulty delivering vaginally, and a cesarean delivery may be necessary. Which findings led the nurse to this conclusion? Select all that apply. A The patient has a gynecoid pelvis. B The patient has an android pelvis. C The patient has an anthropoid pelvis. D The fetus is in a cephalic presentation. E The fetal head is in a brow presentation.

B, E The android pelvis is heart-shaped, and it resembles the male pelvis. The pelvic outlet in this type is very narrow, which may make vaginal delivery difficult. Thus, the patient with this type of pelvis is most likely to require a cesarean delivery. If the fetal head is in a brow position, the diameter of the head is often too large to pass through the pelvis; therefore, a resolution is required before vaginal delivery, or a cesarean delivery is necessary. A gynecoid pelvis is round in shape, and it is the classic female pelvis. An anthropoid pelvis is oval in shape, and it resembles the pelvis of anthropoid apes. The gynecoid and anthropoid pelvises have a comparatively broader pelvic outlet, and vaginal delivery is the usual mode of birth with these types. The fetus is in a cephalic presentation for 96% of births. Cephalic presentation does not create difficulties for vaginal delivery or necessitate a cesarean delivery.

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) A woman should be left entirely alone during this period. B) A woman will rarely speak or laugh during this period. C) A woman may spend time thinking about what is happening to her. D) No nursing care is needed to be done during this time.

C) A woman may spend time thinking about what is happening to her. Women need a support person with them during all stages of labor.

The nurse is determining how often contractions occur measuring from the beginning of the one contraction to the beginning of the next contraction. The nurse documents this finding as: A) duration. B) peak. C) frequency. D) intensity.

C) frequency. Frequency refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction. Duration refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The peak or acme of a contraction is the highest intensity of a contraction.

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? A) 3 to 5 B) 0 to 2 C) 5 to 6 D) 8 to 10

D) 8 to 10 The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation would be 8-10 cm. Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A) shoulders B) buttocks C) brow D) occiput

D) occiput With a vertex presentation, a type of cephalic presentation, the fetal presenting part is the occiput. The shoulders are the presenting part when the fetus is in a shoulder presentation. The brow or sinciput is the presenting part when a fetus is in a brow presentation. The buttocks are the presenting part when a fetus is in a breech presentation.

With regard to breathing during labor, maternity nurses should be aware that: a) Breathing techniques in the first stage of labor is designed to increase the size of the abdominal cavity to reduce friction b) By the time labor has begun, it is too late for instruction in breathing and relaxation c) Controlled breathing techniques are most difficult near the end of the second stage of labor d) The patterned-paced breathing technique can help prevent hyperventilation

a) Breathing techniques in the first stage of labor is designed to increase the size of the abdominal cavity to reduce friction

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: a) Counterpressure against the sacrum b) Pant-blow (breaths and puffs) breathing techniques c) Effleurage d) Biofeedback

a) Counterpressure against the sacrum

A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease? a) Meperidine (Demerol) b) Promethazine (phenergan) c) Butorphanol tartrate (Stadol) d) Nalbuphine (Nubain)

a) Meperidine (Demerol)

Nurses should be aware of the difference experience can make in labor pain, such as: a) Sensory pain for nulliparous women often is greater than for multiparous women during early labor b) Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor c) Women with a history of substance abuse experience more pain during labor d) Multiparous women have more fatigue from labor and therefore experience more pain

a) Sensory pain for nulliparous women often is greater than for multiparous women during early labor

With regard to systemic analgesics administered during labor, nurses should be aware that: a) Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier b) Effects on the fetus and newborn can include decreased alertness and delayed sucking c) IM administration is preferred over IV administration d) IV patient-controlled analgesia (PCA) results in increased use of an analgesic

b) Effects on the fetus and newborn can include decreased alertness and delayed sucking

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: a) Either hot or cold applications may provide relief, but they should never be used together in the same treatment b) Acupuncture can be performed by a skilled nurse with just a little training c) Hand and foot massage may be especially relaxing in advanced labor when a womans tolerance for touch is limited d) Therapeutic touch uses handheld electronic stimulators that produce sympathetic vibrations

c) Hand and foot massage may be especially relaxing in advanced labor when a womans tolerance for touch is limited