Maternity Test 3 - Saunders

The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid?

- Allows for fetal movement - Surrounds, cushions, and protects the fetus - Maintains the body temperature of the fetus - Can be used to measure fetal kidney function - In addition the amniotic fluid contains urine from the fetus and can be used to asses fetal kidney function. - The PLACENTA prevents large particles such as bacteria from passing to the fetus and provides an exchange in nutrients and waste products between the mother and the fetus.

272. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

"I need to lie flat on my back to perform the procedure."

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

"I need to lie flat on my back to perform the procedure." - The client should sit or lie quietly on her side to perform kick counts. - Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. - The client is instructed to place her hands ont he largest part of the abdomen and concentrate on the fetal movements. - The client records the number of movements felt during a specified time period. The client needs to notify her health care provider if she feels fewer than 10 kicks over two, 2 hour intervals or as instructed by her HCP.

298. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instructions?

"I will begin abdominal exercises immediately." - A cesarean delivery requires an incision made throught the abdominal wall and into the uterus. - Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision.

A nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy." - Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin.

302. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity." - True labor is present when contractions increase in duration and intensity. - Lightening or dropping is also known as engagement --> occurs when the fetus descends into the pelvis about 2 weeks before delivery - Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor

The nurse should include which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth." - A GYNECOID pelvis is a normal female pelvis and is the most favorable for successful labor and birth. - An ANDROID pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. - An ANTHROPOID pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. - A PLATYPELLOID pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

The nurse should include which statement to a prengant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth." - A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. - Android pelvis (resembling a male pelvis) --> would be unfavorable for labor because of the narrow pelvic planes - Anthropoid pelvis --> has an outlet that is adequate, with a normal or moderately narrow pubic arch - Platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate

318. The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note?

- Bright reg vaginal bleeding - Soft, relaxed, nontender uterus - Fundal height may be greater than expected for gestational age - Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. - Painless, bright red vaginal bleeding in the 2nd or 3rd trimester of pregnancy is a sign of placenta previa - Client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. - In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and baordlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

300. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

- Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being - Accelerations are transient increases in the FHR that often accompany contractions or are caused by fetal movement. - Episodic accelerations --> thought to be a sign of fetal well-being and adequate oxygen reserve.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at -1 station. This documented finding indicates that the fetal presenting part is located at which area?

1 cm above the ischial spine - Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part of the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. - At the negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

A normal test result

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask - Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. - Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. - Supine position is avoided → it decreases uterine blood flow to the fetus. - The client should be turned onto her side to displace pressure of the gravis uterus on the inferior vena cava - IV oxytocin infusion is discontinued when a late decelerate is noted. - Oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication.

316. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen, 8 to 10 L/minute, via face mask - Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. - IV infusion should be increased to increase maternal blood volume. - Client placed in lateral position with legs raised to increase maternal blood volume and improve fetal perfusion - Oxytocin stimulation of uterus is discontinued if FHR patterns change for any reason.

301. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline FHR - Assessing the baseline FHR is important so that abnormal variations of the baseline rate can be identified if they occur. - The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor - FHR is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the FHR.

308. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that aburptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

Delivery of the fetus - Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. - The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. - Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy.

305. The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin (Pitocin) - The priority nursing action is to stop the infusion and oxytocin. Oxytocin can cause foreceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability - After stopping the oxytocin, the nurse should reposition the laboring mother. - Applying oxygen, increasing the rate of the IV fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation - Contacting the client's primary support person(s) is not a priority action.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?

Fetal heart rate of 180 beats/minute - A normal fetal heart rate is 110 to 160 beats/minute. - FHR of 180 beats/minute could indicate fetal distress and would warrant immediate notification to the HCP - By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. - The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. - WBC counts in a normal pregnancy begin to increase in the second trimester and peak in the 3rd trimester with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). - During the immediate postpartum period, the WBC count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.

The nurse is preforming an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up?

Fetal heart rate of 180 beats/minute - The normal range of the fetal heart rate depends on the gestational age. The heart rate is usually 160 to 170 beats/minute in the 1st trimester and slows with fetal growth. - Near and at term, the fetal heart rate changes from 110 to 160 beats/minute.

303. Which assessment finding following an amniotomy should be conducted first?

Fetal heart rate pattern - Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. - Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examiniations would be done because of the risk of infection

317. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage - In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding

310. The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?

Hypotonic - Hypotonic labor contractions are short, irregular and weak and usually occur duruing tha ctive phase of labor. - Hypertonic dystocia usually occurs during the latent phase of labor, and contractions are painful, frequent, and usually uncordinated. - Precipitous labor --> labor that lasts in its entirety for 3 hours or less - Preterm labor --> onset of labor after 20 weeks of gestation and before 37th week of gestation

295. A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy?

Increased efficiency of contractions - Amniotomy (artificial rupture of the membreanes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow - Rupturing of the membreanes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. - Increased monitoring of maternal blood pressure is unnecessary following this procedure. - The FHR needs to be monitored frequently, however

315. The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate - Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. - Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

Notify the HCP - The fetal heart rate (FHR) depends on gestational age and ranges from 160 to 170 beats/minute in the 1st trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCp.

299. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP) - A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. - Fetal bradycardia between contractions may indicate the need for immediate medical management, and the hCP or nurse-midwife needs to be notified.

307. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination - Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. - Manual pelvic examiniations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. - Digital examination of the cervix can lead to hemorrhage A diagnosis of placenta previs is made by ultrasounds - The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. - Electronic fetal monitoring (external) is crucial in evaluation the status of the fetus, who is at risk for severe hypoxia

314. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 wees. Which prescription should the nurse question?

Perform a vaginal examination every shift. - Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. - The nurse would expect to monitor FHR, monitor maternal vital signs, and administer an antibiotic

312. The nurse in a labor room is monitoring a client with a dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate - Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium - Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise - Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor

313. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures - Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated - Management of hypertonic labor depends on the cause - Relief of pain is the primary intervention to promote normal labor pattern. - An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction - A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

304. The nurse has been wroking with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions - The birth process expands a great deal of energy, particularly during the transition stage. - Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. - Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. - Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids are likely to be withheld at this time.

297. A client in labor is transported to the delivery room and prepared for a cesarean delivery. Ater the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine with a wedge under the right hip - Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. - This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. - The best position to prevent this woul dbe side-lying, with the uterus displaced off the abdominal vessels. - Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. - Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. - Semi-Fowler's position or prone position --> not practical for this type of abdominal surgery

311. After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant - Precipitous labor --> labor that lasts 3 hours or less - Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. - To assist the client process what has happened, the best option is to support the client in her reaction to the newborn infant.

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?

The cervix is dilated completely - The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate.

309. The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease - Preterm labor occurs after the 20th week but before the 37th week of gestation - Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. - Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

A HCP has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client?

The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

306. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspect diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness - Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. - In abruptio placentae, acute abdominal pain is present. - Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood being the placenta. - The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. - A soft abdomen and painless, bright red vaginal bleeding in the 2nd or 3rd trimester of prenancy is a sign of placenta previa

296. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations - Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. - Variability refers to fluctuations in the baseline fetal heart rate. - Accelerations are a reassuring sign and usually occur with fetal movement. - Early decelerations result from pressure on the fetal head during a contraction