maternity exam 2 questions
8) What are the primary complications of placenta accrete? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal hemorrhage 2. Insomnia 3. Failure of the placenta to separate following birth of the infant 4. Autonomic dysreflexia 5. Shoulder dystocia
Answer: 1, 3
11) The nurse knows that the maternal risks associated with postterm pregnancy include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Polyhydramnios 2. Maternal hemorrhage 3. Maternal anxiety 4. Forceps-assisted delivery 5. Perineal damage
Answer: 2, 3, 4, 5
17) What is the most significant maternal risk factor for preterm birth? 1. Previous preterm birth 2. Smoking 3. Stress 4. Substance abuse
Answer: 1
2) The nurse is admitting a client for a cerclage procedure. The client asks for information about the procedure. What is the nurse's most accurate response? 1. "A stitch is placed in the cervix to prevent a spontaneous abortion or premature birth." 2. "The procedure is done during the third trimester." 3. "Cerclage is always placed after the cervix has dilated and effaced." 4. "An uncomplicated elective cerclage may is done on inpatient basis."
Answer: 1
4) A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for? 1. Oxytocin induction of labor 2. Amnioinfusion 3. Increased intravenous infusion 4. Cesarean section
Answer: 1
24) A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be? 1. Perform a vaginal exam. 2. Notify the physician. 3. Place the client in a left lateral position. 4. Administer oxygen at 2 L per nasal cannula.
Answer: 1 Explanation: 1. A drop in fetal heart rate accompanied by variable decelerations is consistent with a prolapsed cord. The nurse would assess for prolapsed cord via vaginal examination
6) The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old woman at 39 weeks' gestation with a large-for-gestational-age (LGA) fetus 2. 22-year-old woman at 23 weeks' gestation with ruptured membranes 3. 30-year-old woman at 41 weeks' gestation and estimated fetal weight 7 pounds 8 ounces 4. 43-year-old woman at 37 weeks' gestation with hypertension
Answer: 1 Explanation: 1. A risk factor for hypotonic uterine contraction patterns includes a large-for-gestational-age (LGA) fetus.
1) How would the nurse best analyze the results from a client's sonogram that shows the fetal shoulder as the presenting part? 1. Breech, transverse 2. Breech, longitudinal 3. Breech, frank 4. Vertex, transverse
Answer: 1 Explanation: 1. A shoulder presentation is one type of breech presentation, and is also called a transverse lie.
9) The nurse has received end-of-shift reports in the high-risk maternity unit. Which client should the nurse see first? 1. The client at 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 2. The client at 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. The client at 35 weeks' gestation with grade I abruptio placentae in labor who has a strong urge to push 4. The client at 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously
Answer: 1 Explanation: 1. Assessment of the woman with placenta previa must be ongoing to prevent or treat complications that are potentially lethal to the mother and fetus. Painless, bright red vaginal bleeding is the best diagnostic sign of placenta previa. This client is the highest priority.
34) The nurse knows that a baby born to a mother who had oligohydramnios could show signs of which of the following? 1. Respiratory difficulty 2. Hypertension 3. Heart murmur 4. Decreased temperature.
Answer: 1 Explanation: 1. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop
20) A nurse needs to evaluate the progress of a woman's labor. The nurse obtains the following data: cervical dilatation 6 cm; contractions mild in intensity, occurring every 5 minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? 1. Cervical dilatation 6 cm 2. Mild contraction intensity 3. Contraction frequency every 5 minutes 4. Contraction duration 30-40 seconds
Answer: 1 Explanation: 1. Cervical dilatation of 6 cm indicates the active phase of labor. During this phase the cervix dilates from about 4 to 7 cm and contractions and pain intensify.
10) The charge nurse is looking at the charts of laboring clients. Which client is in greatest need of further intervention? 1. Woman at 7 cm, fetal heart tones auscultated every 90 minutes 2. Woman at 10 cm and pushing, external fetal monitor applied 3. Woman with meconium-stained fluid, internal fetal scalp electrode in use 4. Woman in preterm labor, external monitor in place
Answer: 1 Explanation: 1. During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough.
7) The client has been pushing for 3 hours, and the fetus is making a slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond? 1. "Your baby is taking a little longer than average, but is making progress." 2. "First babies take a long time to be born. The next baby will be easier." 3. "The birth would go faster if you had taken prenatal classes and practiced." 4. "Every baby is different; there really are no norms for labor and birth."
Answer: 1 Explanation: 1. Establishing rapport and a trusting relationship and providing information that is true is best response.
35) The client gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has not yet delivered. Manual removal of the placenta is planned. What should the nurse prepare to do? 1. Start an IV of lactated Ringer's. 2. Apply anti-embolism stockings. 3. Bottle-feed the infant. 4. Send the placenta to pathology.
Answer: 1 Explanation: 1. In women who do not have an epidural in place, intravenous sedation may be required because of the discomfort caused by the procedure. An IV is necessary.
8) A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be? 1. Perform a vaginal exam 2. Notify the physician 3. Place the client in a left lateral position 4. Administer oxygen at 2 L per nasal cannula
Answer: 1 Explanation: 1. Prolapsed umbilical cord can occur when the membranes rupture. The fetus is more likely to experience variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord. A vaginal exam is the best way to confirm.
34) What is one of the most common initial signs of nonreassuring fetal status? 1. Meconium-stained amniotic fluid 2. Cyanosis 3. Dehydration 4. Arrest of descent
Answer: 1 Explanation: 1. The most common initial signs of nonreassuring fetal status are meconium-stained amniotic fluid and changes in the fetal heart rate (FHR).
20) The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? 1. Hyperventilation 2. Seizure auras 3. Imminent birth 4. Anxiety
Answer: 1 Explanation: 1. These symptoms all are consistent with hyperventilation.
12) By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? 1. Recognizing the client as an active participant in her own care. 2. Attempting to correct any misinformation the client might have received. 3. Acting as an advocate for the client. 4. Establishing rapport with the client.
Answer: 1 Explanation: 1. Understanding the couple's expectations and plans helps the nurse provide optimal nursing care and facilitate the best possible birth experience.
14) The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? 1. Check fetal heart tones. 2. Encourage the mother to go for a walk. 3. Change bed linens. 4. Call the physician.
Answer: 1 Explanation: 1. When the membranes rupture, the nurse notes the color and odor of the amniotic fluid and the time of rupture and immediately auscultates the FHR.
18) Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? 1. Massage the fundus until firm 2. Express retained clots 3. Increase the intravenous solution 4. Call the physician
Answer: 1 Explanation: 1. When the uterus becomes boggy, pooling of blood occurs within it, resulting in the formation of clots. Anything left in the uterus prevents it from contracting effectively. Thus if it becomes boggy or appears to rise in the abdomen, the fundus should be massaged until firm.
7) The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client? 1. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." 2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." 3. "What did you expect? You've only had contractions for a few hours. Labor takes time." 4. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."
Answer: 1 Explanation: 1. With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls.
21) The nurse caring for a client in labor anticipates fetal macrosomia and shoulder dystocia. Appropriate management of shoulder dystocia is essential in order to prevent which fetal complications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Brachial plexus injury 2. Fractured clavicle 3. Asphyxia 4. Neurological damage 5. Puerperal infection
Answer: 1, 2, 3, 4
23) What fetal factors require a cesarean birth? 1. Severe intrauterine growth restriction (IUGR) 2. Fetal anomalies 3. Unfavorable fetal position or presentation 4. Preterm birth 5. Lack of maternal attachment
Answer: 1, 2, 3, 4
26) During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Intravenous access 2. Cesarean delivery 3. Immediate vaginal delivery 4. McRoberts maneuver 5. A crash cart
Answer: 1, 2, 5 Explanation: 1. When an amniotic fluid embolism is suspected, intravenous access is obtained as quickly as possible. 2. Shortness of breath, cyanosis, and hypoxia are symptoms of an amniotic fluid embolus, which necessitates immediate cesarean delivery. 5. The chances of a code are high, so the crash cart needs to be available.
10) The nurse is presenting a class on preterm labor, its causes, and treatments to a group of newly pregnant couples. Which statements regarding preterm labor are true? Note: Credit will be given only of all correct choices and no incorrect choices are selected. Select all that apply. 1. Antepartum hemorrhage can cause preterm labor. 2. Trauma can cause preterm labor. 3. Infection can cause preterm labor. 4. Magnesium sulfate is a drug used to stop contractions. 5. Sedatives and narcotics may be given to stop labor.
Answer: 1, 2, 3, 4 Explanation: 1. Hemorrhage from placenta previa or abruption can cause preterm labor. 2. Trauma to the abdomen or uterus can cause preterm labor. 3. Infections such as urinary tract infections can cause preterm labor. 4. Magnesium sulfate acts as a CNS depressant by decreasing the quantity of acetylcholine released by motor nerve impulses and thereby blocking neuromuscular transmission.
21) The nurse is caring for a client who is having fetal tachycardia. The nurse knows that possible causes include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal dehydration 2. Maternal hyperthyroidism 3. Fetal hypoxia 4. Prematurity 5. Anesthesia or regional analgesia
Answer: 1, 2, 3, 4 Explanation: 1. Maternal dehydration can cause fetal tachycardia. 2. Maternal hyperthyroidism can cause fetal tachycardia. 3. Fetal tachycardia can indicate fetal hypoxia. 4. Prematurity can cause fetal tachycardia.
22) The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal hypotension 2. Prolonged umbilical cord compression 3. Fetal dysrhythmia 4. Central nervous system malformation 5. Late fetal asphyxia
Answer: 1, 2, 3, 5 Explanation: 1. Maternal hypotension results in decreased blood flow to the fetus. 2. Cord compression can cause fetal bradycardia. 3. This will cause fetal bradycardia if there is a fetal heart block. 5. This is a depression of myocardial activity.
3) Risk factors for tachysystole include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cocaine use 2. Placental abruption 3. Low-dose oxytocin titration regimens 4. Uterine rupture 5. Smoking
Answer: 1, 2, 4
21) The nurse is caring for a client in labor. Which signs and symptoms would indicate the client is progressing into the second stage of labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Bulging perineum 2. Increased bloody show 3. Spontaneous rupture of the membranes 4. Uncontrollable urge to push 5. Inability to breathe through contractions
Answer: 1, 2, 4 Explanation: 1. As the fetal head continues its descent, the perineum begins to bulge, flatten, and move anteriorly. 2. Bloody show increases as a woman enters the second stage of labor. 4. As the fetal head descends, the woman has the urge to push because of pressure of the fetal head on the sacral and obturator nerves.
22) A full-term infant has just been born. Which interventions should the nurse perform first? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Placing the infant in a radiant-heated unit 2. Suctioning the infant with a bulb syringe 3. Wrapping the infant in a blanket 4. Evaluating the newborn using the Apgar system 5. Offering a feeding of 5% glucose water
Answer: 1, 2, 4 Explanation: 1. If the newborn is placed in a radiant-heated unit, he or she is dried, laid on a dry blanket, and left uncovered under the radiant heat. 2. Newborns are suctioned with a bulb syringe to clear mucus from the newborn's mouth. 4. The purpose of the Apgar score is to evaluate the physical condition of the newborn at birth.
33) When caring for a laboring client with oligohydramnios, what should the nurse be aware of? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased risk of cord compression 2. Decreased variability 3. Labor progress is often more rapid than average 4. Presence of periodic decelerations 5. During gestation, fetal skin and skeletal abnormalities can occur
Answer: 1, 2, 4, 5 Explanation: 1. During the labor and birth, the lessened amounts of fluid reduce the cushioning effect for the umbilical cord, and cord compression is more likely to occur. 2. The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasing baseline, decreased variability, or presence of periodic decelerations). 4. The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasing baseline, decreased variability, or presence of periodic decelerations). 5. During the gestational period, fetal skin and skeletal abnormalities may occur because fetal movement is impaired as a result of inadequate amniotic fluid volume.
27) The nurse is caring for a client who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal anemia 2. Chronic fetal bleeding 3. Maternal hypotension 4. Twin-to-twin transfusion 5. Umbilical cord occlusion
Answer: 1, 2, 4, 5 Explanation: 1. Fetal anemia can cause a sinusoidal heart rate. 2. Chronic fetal bleeding can cause a sinusoidal heart rate. 4. Twin-to-twin transfusion will cause a sinusoidal heart rate. 5. Umbilical cord occlusion can cause a sinusoidal fetal heart rate.
) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fetal heart rate of 130 with average variability 2. Blood pressure of 130/80 3. Maternal pulse of 160 4. Protein of +1 in urine 5. Odorless, clear fluid on underwear
Answer: 1, 2, 5
28) Fetal factors that possibly indicate electronic fetal monitoring include which of the following? 1. Meconium passage 2. Multiple gestation 3. Preeclampsia 4. Grand multiparity 5. Decreased fetal movement
Answer: 1, 2, 5 Explanation: 1. Meconium passage is an indicator for electronic fetal monitoring. 2. Multiple gestation is an indicator for electronic fetal monitoring. 5. Decreased fetal movement is an indicator for electronic fetal monitoring.
36) The nurse is planning care for a client with hydramnios. For which interventions might the nurse need to prepare the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Artificial rupture of the membranes 2. Amnioinfusion 3. Amniocentesis 4. Administration of prostaglandin synthesis inhibitor 5. Administration of indomethacin
Answer: 1, 3, 4, 5 Explanation: 1. Artificial rupture may be performed to remove the excessive fluid. 3. Amniocentesis may be performed to remove some excess fluid. 4. A prostaglandin synthesis inhibitor is used to treat hydramnios. 5. Indomethacin can decrease amniotic fluid by decreasing fetal urine output.
1) The nurse has admitted a woman with cervical insufficiency. The nurse is aware that causes of this condition include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Congenital factors 2. Intercourse during pregnancy 3. Infection 4. Increased uterine volume 5. Past cervical surgeries
Answer: 1, 3, 4, 5 Explanation: 1. Congenitally incompetent cervix may be found in women exposed to diethylstilbestrol (DES) or those with a bicornuate uterus. 3. Infection or trauma can cause acquired cervical incompetence. 4. Cervical insufficiency can occur in multiple-gestation pregnancies. 5. Previous elective abortion or cervical manipulation can lead to cervical insufficiency.
9) A first-time 22-year-old single labor client, accompanied by her boyfriend, is admitted to the labor unit with ruptured membranes and mild to moderate contractions. She is determined to be 2 centimeters dilated. Which nursing diagnoses might apply during the current stage of labor? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Fear/Anxiety related to discomfort of labor and unknown labor outcome 2. Knowledge, Deficient, related to lack of information about pushing methods 3. Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent 4. Pain, Acute, related to perineal trauma 5. Coping: Family, Compromised, related to labor process
Answer: 1, 3, 5 Explanation: 1. A Fear/Anxiety diagnosis would apply to the first stage of labor for a first-time labor client. 3. Contractions become more regular in frequency and duration, increasing discomfort and pain. 5. The woman and her boyfriend are about to undergo one of the most meaningful and stressful events in life together. Physical and psychologic resources, coping mechanisms, and support systems will all be challenged.
30) The nurse is admitting a client who was diagnosed with hydramnios. The client asks why she has developed this condition. The nurse should explain that hydramnios is sometimes associated with which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Rh sensitization 2. Postmaturity syndrome 3. Renal malformation or dysfunction 4. Maternal diabetes 5. Large-for-gestational-age infants
Answer: 1, 4
2) A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Android 2. Anthropoid 3. Gynecoid 4. Platypelloid 5. Lambdoidal suture
Answer: 1, 4 Explanation: 1. In the android and platypelloid types, the pelvic diameters are diminished. Labor is more likely to be difficult (longer) and a cesarean birth is more likely.
13) A client who is having false labor most likely would have which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Contractions that do not intensify while walking 2. An increase in the intensity and frequency of contractions 3. Progressive cervical effacement and dilatation 4. Pain in the abdomen that does not radiate 5. Contractions that lessen with rest and warm tub baths
Answer: 1, 4, 5 Explanation: 1. True labor contractions intensify while walking. 4. True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. 5. In true labor, contractions do not lessen with rest and warm tub baths.
23) The nurse is caring for a client in the transition phase of labor and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous. 5. Reassure the client and her partner that she is doing fine.
Answer: 1, 5 Explanation: 1. The tracing is normal, so the nurse can continue support of the labor. 5. The nurse can reassure the client at this time, as the tracing is normal.
2) Dystocia encompasses many problems in labor. What is the most common? 1. Meconium-stained amniotic fluid 2. Dysfunctional uterine contractions 3. Cessation of contractions 4. Changes in the fetal heart rate
Answer: 2
28) The nurse is caring for a client with hydramnios. What will the nurse watch for? 1. Possible intrauterine growth restriction 2. Newborn congenital anomalies 3. Newborn postmaturity and renal malformations 4. Fetal adhesions
Answer: 2
29) Slowly removing some amniotic fluid is a treatment for hydramnios. What consequence can occur with the withdrawal of fluid? 1. Preterm labor 2. Prolapsed cord 3. Preeclampsia 4. Placenta previa
Answer: 2 Explanation: 2. A needle or a fetal scalp electrode is used to make a small puncture in the amniotic sac. There is a risk that the force of the fluid could make a larger hole in the amniotic sac, thus increasing the risk of a prolapsed cord.
17) A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? 1. Active 2. Transition 3. Latent 4. Second
Answer: 2 Explanation: 2. During transition, contractions have a frequency of 1 1/2 to 2 minutes, a duration of 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety.
22) What can be determined based on ultrasound visualization or the lack of visualization of an intertwin membrane? 1. Toxicity 2. Amnionicity 3. Variability 4. Prematurity
Answer: 2 Explanation: 2. Evidence supports the use of ultrasound for accurately determining chorionicity and amnionicity in multiple pregnancies. Determination of amnionicity is based on ultrasound visualization or the lack of visualization of an intertwin membrane.
33) The client is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The client's partner asks why the nurse did that. What is the best response by the nurse? 1. "I stimulated the top of the fetus's head to wake him up a little." 2. "I stimulated the top of the fetus's head to try to get his heart rate to accelerate." 3. "I stimulated the top of the fetus's head to calm the fetus down before birth." 4. "I stimulated the top of the fetus's head to find out whether he is in distress."
Answer: 2 Explanation: 2. Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being.
19) The client has undergone an ultrasound, which estimated fetal weight at 4500 g (9 pounds 14 ounces). Which statement indicates that additional teaching is needed? 1. "Because my baby is big, I am at risk for excessive bleeding after delivery." 2. "Because my baby is big, his blood sugars could be high after he is born." 3. "Because my baby is big, my perineum could experience trauma during the birth." 4. "Because my baby is big, his shoulders could get stuck and a collarbone broken."
Answer: 2 Explanation: 2. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus.
32) If oligohydramnios occurs in the first part of pregnancy, the nurse knows that there is a danger of which of the following? 1. Major congenital anomalies 2. Fetal adhesions 3. Maternal diabetes 4. Rh sensitization
Answer: 2 Explanation: 2. If oligohydramnios occurs in the first part of pregnancy, there is a danger of fetal adhesions (one part of the fetus may adhere to another part).
12) A client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and that over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lower legs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? 1. Engagement 2. Lightening 3. Molding 4. Braxton Hicks contractions
Answer: 2 Explanation: 2. Lightening describes the effect occurring when the fetus begins to settle into the pelvic inlet.
15) The nurse should anticipate the labor pattern for a fetal occiput posterior position to be which of the following? 1. Shorter than average during the latent phase 2. Prolonged as regards the overall length of labor 3. Rapid during transition 4. Precipitous
Answer: 2 Explanation: 2. Occiput posterior (OP) position of the fetus is the most common fetal malposition and occurs when the head remains in the direct OP position throughout labor. This can prolong the overall length of labor.
35) The client at 38 weeks' gestation has been diagnosed with oligohydramnios. Which statement indicates that teaching about the condition has been effective? 1. "My gestational diabetes might have caused this problem to develop." 2. "When I go into labor, I should come to the hospital right away." 3. "This problem was diagnosed with blood and urine tests." 4. "Women with this condition usually do not have a cesarean birth."
Answer: 2 Explanation: 2. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid. The client with oligohydramnios should come to the hospital in early labor.
27) Which client requires immediate intervention by the labor and delivery nurse? 1. Client at 8 cm, systolic blood pressure has increased 35 mm Hg 2. Client who delivered 1 hour ago with WBC of 50,000 3. Client at 5 cm with a respiratory rate of 22 between contractions 4. Client in active labor with polyuria
Answer: 2 Explanation: 2. The white blood cell (WBC) count increases to 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high, and requires further assessment and provider notification.
26) Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply? 1. "I'm checking the blood vessels in the cord to see whether it has one artery and one vein." 2. "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein." 3. "I'm checking the blood vessels in the cord to see whether it has two veins and one artery." 4. "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins."
Answer: 2 Explanation: 2. Two arteries and one vein are present in a normal umbilical cord.
13) The nurse is planning an in-service educational program to talk about disseminated intravascular coagulation (DIC). The nurse should identify which conditions as risk factors for developing DIC? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Diabetes mellitus 2. Abruptio placentae 3. Fetal demise 4. Multiparity 5. Preterm labor
Answer: 2, 3 Explanation: 2. As a result of the damage to the uterine wall and the retroplacental clotting with covert abruption, large amounts of thromboplastin are released into the maternal blood supply, which in turn triggers the development of disseminated intravascular coagulation (DIC) and the resultant hypofibrinogenemia. 3. Perinatal mortality associated with abruptio placentae is approximately 25%. If fetal hypoxia progresses unchecked, irreversible brain damage or fetal demise may result.
5) A client has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the client and her fetus? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode. 2. Auscultate the fetal heart rate between and during contractions. 3. Palpate contractions and resting uterine tone. 4. Assess the blood pressure, temperature, respiratory rate, and pulse rate. 5. Perform a vaginal exam for cervical dilation, and perform Leopold maneuvers.
Answer: 2, 3 Explanation: 2. Fetal heart rate auscultation gives information about the physical status of the fetus. 3. Contraction palpation provides information about the frequency, duration, and intensity of the contractions.
5) Nonreassuring fetal status often occurs with a tachysystole contraction pattern. Intrauterine resuscitation measures may become warranted and can include which of the following measures? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Position the woman on her right side. 2. Apply oxygen via face mask. 3. Call for anesthesia provider for support. 4. Increase intravenous fluids by at least 700 mL bolus. 5. Call the physician/CNM to the bedside.
Answer: 2, 3, 4
17) Which of the following potential problems would the nurse consider when planning care for a client with a persistent occiput posterior position of the fetus? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased fetal mortality 2. Severe perineal lacerations 3. Ceasing of labor progress 4. Fetus born in posterior position 5. Intense back pain during labor
Answer: 2, 3, 4, 5
9) Risk factors for labor dystocia include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Tall maternal height 2. Labor induction 3. Small-for-gestational-age (SGA) fetus 4. Malpresentation 5. Prolonged latent phase
Answer: 2, 4, 5
16) What is the most significant cause of neonatal morbidity and mortality? 1. Amenorrhea 2. Posttraumatic stress disorder 3. Prematurity 4. Endometriosis
Answer: 3
3) A client is admitted to the labor and delivery unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. What is this client at risk for? 1. Gestational diabetes 2. Placenta previa 3. Abruptio placentae 4. Placenta accreta
Answer: 3 Explanation: 3. Abruptio placentae is more frequent in pregnancies complicated by smoking, premature rupture of membranes, multiple gestation, advanced maternal age, cocaine use, chorioamnionitis, and hypertension.
14) The nurse is preparing a client education handout on the differences between false labor and true labor. What information is most important for the nurse to include? 1. True labor contractions begin in the back and sweep toward the front. 2. False labor often feels like abdominal tightening, or "balling up." 3. True labor can be diagnosed only if cervical change occurs. 4. False labor contractions do not increase in intensity or duration.
Answer: 3 Explanation: 3. Cervical change is the only factor that actually distinguishes false from true labor. The contractions of true labor produce progressive dilatation and effacement of the cervix. The contractions of false labor do not produce progressive cervical effacement and dilatation.
19) Persistent early decelerations are noted. What would the nurse's first action be? 1. Turn the mother on her left side and give oxygen. 2. Check for prolapsed cord. 3. Do nothing. This is a benign pattern. 4. Prepare for immediate forceps or cesarean delivery.
Answer: 3 Explanation: 3. Early decelerations are considered benign, and do not require any intervention.
11) A client in her second trimester is complaining of spotting. Causes for otting in the second trimester are diagnosed primarily through the use of which of the following? 1. A nonstress test 2. A vibroacoustic stimulation test 3. An ultrasound 4. A contraction stress test
Answer: 3 Explanation: 3. Indirect diagnosis is made by localizing the placenta via tests that require no vaginal examination. The most commonly employed diagnostic test is the transabdominal ultrasound scan.
4) The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature? 1. Every hour 2. Every 2 hours 3. Every 4 hours 4. Every shift
Answer: 3 Explanation: 3. Maternal temperature is taken every 4 hours unless it is above 37.5°C. If elevated, it is taken every hour.
18) If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist? 1. Call a second physician to assist. 2. Prepare for an immediate cesarean delivery. 3. Assist the woman into McRoberts maneuver. 4. Utilize fundal pressure to push the fetus out.
Answer: 3 Explanation: 3. The McRoberts maneuver is thought to change the maternal pelvic angle and therefore reduce the force needed to extract the shoulders, thereby decreasing the incidence of brachial plexus stretching and clavicular fracture
14) The student nurse is to perform Leopold maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? 1. The client is assisted into supine position, and the position of the fetus is assessed. 2. The upper portion of the uterus is palpated, then the middle section. 3. After determining where the back is located, the cervix is assessed. 4. Following voiding, the client's abdomen is palpated from top to bottom.
Answer: 3 Explanation: 3. The cervical exam is not part of Leopold maneuvers. Abdominal palpation is the only technique used for Leopold maneuvers.
12) The nurse has just palpated contractions and compares the consistency to that of the forehead to estimate the firmness of the fundus. What would the intensity of these contractions be identified as? 1. Mild 2. Moderate 3. Strong 4. Weak
Answer: 3 Explanation: 3. The consistency of strong contractions is similar to that of the forehead.
31) The nurse is aware that labor and birth will most likely proceed normally when the fetus is in what position? 1. Right-acromion-dorsal-anterior 2. Right-sacrum-transverse 3. Occiput anterior 4. Posterior position
Answer: 3 Explanation: 3. The most common fetal position is occiput anterior. When this position occurs, labor and birth are likely to proceed normally.
2) A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? 1. Latent phase 2. Active phase 3. Transition phase 4. Fourth stage
Answer: 3 Explanation: 3. The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense.
2) The nurse is admitting a client to the labor and delivery unit. Which aspect of the client's history requires notifying the physician? 1. Blood pressure 120/88 2. Father a carrier of sickle-cell trait 3. Dark red vaginal bleeding 4. History of domestic abuse
Answer: 3 Explanation: 3. Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus.
32) An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Skin color: Body blue with pinkish extremities 2. Umbilical cord: two veins and one artery 3. Respiration rate of 30-60 irregular 4. Temperature of above 36.5°C (97.8°F) 5. Sole creases that involve the heel
Answer: 3, 4, 5
3) The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. Woman at 7 cm, fetus in general flexion 2. Woman at 3 cm, fetus in longitudinal lie 3. Woman at 4 cm, fetus with transverse lie 4. Woman at 6 cm, fetus at -2 station, mild contractions 5. Woman at 5 cm, fetal presenting part is right shoulder
Answer: 3, 4, 5 Explanation: 3. A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a right angle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. 4. Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. 5. When the fetal shoulder is the presenting part, the fetus is in a transverse lie and the acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part.
28) Five clients are in active labor in the labor unit. Which women should the nurse monitor carefully for the potential of uterine rupture? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Age 15, in active labor 2. Age 22, with eclampsia 3. Age 25, last delivery by cesarean section 4. Age 32, first baby died during labor 5. Age 27, last delivery 11 months ago.
Answer: 3, 5 Explanation: 3. A woman who has had a previous cesarean section is at risk for uterine rupture. 5. A woman who does not have at least 18 months between deliveries is at greater risk for uterine rupture
26) Intervention to reduce preterm birth can be divided into primary prevention and secondary prevention. What does secondary prevention include? 1. Diagnosis and treatment of infections 2. Cervical cerclage 3. Progesterone administration 4. Antibiotic treatment and tocolysis
Answer: 4
30) As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? 1. Cultural background 2. Plans for keeping the infant 3. Support persons 4. Developmental level
Answer: 4 Explanation: 4. Because her cognitive development is incomplete, the younger adolescent may have fewer problem-solving capabilities. The very young woman needs someone to rely on at all times during labor. She may be more childlike and dependent than older teens
25) The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best be characterized as? 1. Weak 2. Mild 3. Moderate 4. Strong
Answer: 4 Explanation: 4. Strong intensity exists when the uterine wall cannot be indented
24) During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? 1. Turn the client onto her left side. 2. Place the bed in Trendelenburg position. 3. Massage the fundus. 4. Continue to monitor.
Answer: 4 Explanation: 4. The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia.
29) While caring for a client in labor, the nurse notices during a vaginal exam that the fetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be? 1. Flexion, extension, restitution, external rotation, and expulsion 2. Expulsion, external rotation, and restitution 3. Restitution, flexion, external rotation, and expulsion 4. Extension, restitution, external rotation, and expulsion
Answer: 4 Explanation: 4. The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion.
4) The charge nurse has received the shift change report. Which client requires immediate intervention? 1. Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes 2. Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation 3. Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge 4. Woman at 3 cm screaming in fear because her mother died during childbirth
Answer: 4 Explanation: 4. This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority.
16) After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following? 1. Breech presentation 2. Uteroplacental insufficiency 3. Compression of the fetal head 4. Umbilical cord compression
Answer: 4 Explanation: 4. Variable decelerations occur when there is umbilical cord compression
8) A woman who is 40 weeks pregnant calls the labor suite to ask whether she should be evaluated. Which statements by the client indicate she is likely in labor? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply. 1. "The contractions are 5-20 minutes apart." 2. "I had pink discharge on the toilet paper." 3. "I have had cramping for the past 3-4 hours." 4. "The contractions start in my back and then go to my abdomen and are very intense." 5. "The contractions hurt more when I walk."
Answer: 4, 5 Explanation: 4. This is a sign of true labor. The contractions increase in duration and intensity and begin in the back and radiate around to the abdomen. 5. It is a sign of true labor when the client is unable to walk during the contraction.
