N132 Exam 1 practice question

The nurse has been asked to present information to a group of civic leaders concerning women's health issues. In preparing the information, the nurse includes what goal from Healthy People 2030 related to women in labor? a.Reduce the rate of cesarean births among low-risk women. b.Encourage women with previous cesareans to always have a cesarean. c.Ensure care during labor includes immunizations. d.Ensure all couples receive preconception genetic counseling.

Healthy People 2030 includes one goal related to cesarean births in the United States, "Reduce cesarean births among low-risk women with no prior births." Immunizations and genetic counseling are not associated with women in labor.

Which client immunization titer is most important to assess and document in the prenatal record of the pregnant woman? a.polio b.rubella c.rotavirus d.diphtheria

Rubella (German measles) is an infection caused by the rubella virus. The virus causes a rash and mild symptoms in children but can be teratogenic to a fetus. A rubella titer determines if the mother is immune to the virus. If the mother is not immune, she will receive a rubella immunization immediately after delivery. Diphtheria and polio are infant vaccines but not as teratogenic to the fetus. Rotavirus is a gastrointestinal virus typically mild in adults.

At 34 weeks' gestation a client is diagnosed with preeclampsia and sent home on bed rest. The nurse teaches the client to contact the provider immediately if she experiences which change? a.Decreased fetal movement b.Increased appetite c.Decreased weight d.Increased urine output

a Decreased fetal movement may indicate decreased fetal oxygenation as a result of hypertension. This is a risk to fetal well-being and the provider needs to be contacted. Decreased weight and increased urine output are signs that the body is mobilizing excessive fluid, and are normal findings. Change in appetite is unrelated to preeclampsia. Reference:

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? a.duration b.intensity c.frequency d.peak

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

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating: a. the buttocks are presenting first with both legs extended up toward the face. b. the fetus is sitting cross-legged above the cervix. c. one leg is presenting. d. one arm is presenting.

a In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating: a.the buttocks are presenting first with both legs extended up toward the face. b.the fetus is sitting cross-legged above the cervix. c.one leg is presenting. d.one arm is presenting.

a In a frank breech position, the buttocks present first with both legs extended up toward the face. The full or complete breech occurs when the fetus sits crossed-legged above the cervix. In a footling or incomplete breech one or both legs are presenting.

A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which information? a.Further testing will be required to confirm any diagnosis. b.The blood tests are definitive. c.Treatment can be started once the test results are back. d.A second set of screening tests can be obtained to confirm results.

a Nursing management related to marker screening tests consists primarily of providing education about the tests. Remind the couple that a definitive diagnosis is not made without further tests such as an amniocentesis. The blood tests are not definitive but only strongly suggest the possibility of a defect. For some conditions there are no treatments. The couple may request a second set, but the health care provider will probably suggest proceeding with the more definitive methods to confirm the diagnosis.

A client at 32 weeks' gestation is admitted to labor and delivery with vaginal bleeding and contractions. The physician orders a course of two steroid injections. The client asks why she needs steroids. What is the best explanation by the nurse? a.The steroids speed up the development of the lungs. b.The steroids will help to slow the development of infection. c.The steroids will increase the baby's muscle mass. d.The steroids will create a layer of fat to help with temperature regulation.

a Steroids given to the mother before birth help to speed up the development of the fetal lungs. The use of prenatal steroids has decreased the mortality rate in preterm infants. Prenatal steroids do not increase muscle mass or amount of fat tissue to aid in temperature regulation. Prenatal steroids do not have an impact on the development of sepsis in either the mother or neonate.

Before beginning the initial prenatal examination, a nurse should instruct a client to complete what procedure before undressing? a.clean-catch urine b.initial blood tests c.measurement of fundal height d.ultrasound for fetal measurements

a The first procedure a nurse should ask the client to do is obtain a clean-catch, midstream urine before undressing. Lab tests can be done after the examination is complete. At the first visit, the fetus is too small to be measured or have an ultrasound performed.

The nurse is assessing a client with rheumatoid arthritis. The nurse knows that prolonged inflammation can cause compression of nerves. Which symptoms would accompany this level of involvement? a.Paresthesias of both hands b.Limited motion in the wrists c.Restricted movement in tendons d.Crepitus when moving major joints

a The rheumatoid arthritis inflammatory process has been implicated in other disease processes. The nervous system is affected as synovial inflammation can compress adjacent nerves, causing neuropathies and paresthesias. Limited motion in the wrists and restricted movement in the tendons is caused by a breakdown of collagen and pannus formation which destroys cartilage and erodes the bone. This causes a loss of articular surfaces and joint motion and tendon and ligament elasticity and contractility is lost. *Rheumatoid arthritis does not cause crepitus with movement.*

Which psychosocial state is anticipated when the client enters the active phase of labor? a.The client will become more quiet and introverted. b.The client will become angry and begin to scream. c.The client will become more talkative and excited about the birth. d.The client will become tired and want the process over.

a The woman's psychosocial state typically changes as she enters the active phase of labor. As the contractions are increasing in amount and intensity, the woman becomes more quiet and introverted as she is focused on the work of labor. The other options may occur but are not anticipated.

The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording? a.Acceleration of at least 15 bpm for 15 seconds b.Increase in variability by 27 bpm c.Deceleration followed by acceleration of 15 bpm d.Decrease in variability for 15 seconds

a A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock? a.tachypnea and a widening pulse pressure b.tachycardia and a falling blood pressure c.bradycardia and auscultation of fluid in the base of the lungs d.bradypnea and hypertension

b Monitor the woman's vital signs at least every 15 minutes during the third stage of labor. Tachycardia and a falling blood pressure are signs of impending shock; the nurse should immediately report these signs.

The nurse is preparing the client for the routine laboratory tests that will be obtained at the first prenatal visit. Which test will the nurse prioritize at this visit? a.prolactin levels b.hepatitis screen c.magnesium level d. rubeola titer

b The woman will undergo tests for hepatitis B, HIV, syphilis, gonorrhea, and chlamydia. Each of these infections can cause serious fetal problems unless they are treated. Rubella is more concerning than rubeola and a titer may be completed to assess the woman's immunity to rubella. Other blood tests will include a complete blood count to evaluate anemia, blood type and antibody screen, and possibly thyroid screen to evaluate for hypothyroidism.

The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client? a.Reduce walking to half a block daily. b.Continue this as long as she enjoys it. c.Stop and rest every block. d. Engage in aerobics for greater benefits.

b Walking is an excellent exercise during pregnancy because it is low impact and increases venous circulation. Exercise should be maintained as long as it is comfortable, but intensity should not increase over what is normally performed.

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. occiput c. brow d. buttocks

b 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.

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.intensity. c.frequency. d.peak.

c 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.

Which disease process would the nurse screen for under potential genetic disorders? a.tuberculosis b.rheumatic fever c.cystic fibrosis d. asthma

c Screening of genetically linked disorders is important when obtaining a family history. Cystic fibrosis is a genetically linked disorder. Tuberculosis is an infectious disorder. Rheumatic fever stems from a streptococcus infection. Asthma is a hypersensitivity typically from an environmental allergy.

A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply. a. a relaxed and distended uterus b. falling downward of uterus in the abdomen c. fresh gushing of blood from the vagina d. umbilical cord descending lower down e. a globular shaped uterus

c,d,e The signs of placental separation include a fresh gush of blood from the vagina, lengthening of the umbilical cord, and a globular shape to the uterus. When the client is in her third stage of labor, these indicate placental separation. A rising upward 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 woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her? a. Impaired urinary elimination related to inability to excrete creatine from her muscles b. Risk for ineffective breathing pattern related to pressure of the growing uterus c. Pain related to severe complications of pregnancy d. Health-seeking behaviors related to ways to relieve discomforts of pregnancy

d Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? a.Test a sample of amniotic fluid for protein. b.Ask her to bear down with the next contraction. c.Elevate her hips to prevent cord prolapse. d. Assess fetal heart rate for fetal safety.

d Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects this.

Which feature would alert the nurse that the client is in the transition phase of labor? a.reduction of rectal pressure b.decrease in the bloody show c.enthusiasm in the client d.beginning urge to bear down

d The beginning of the urge to bear down is a feature associated with the transition phase of labor. The transition phase is the last phase of the first stage of labor. In this phase, the process of cervical dilation (dilatation) is completed. During this phase the client experiences an increase in rectal pressure, an increase in the bloody show, and an urge to bear down. The contractions are stronger and hence the client feels irritable, restless, and nauseous. The client feels enthusiastic during the latent phase and not the transition phase.

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? a.Palpate the mother's radial pulse at the same time. b.Ask the woman to hold her breath while assessing the FHR. c.Have the woman lie completely flat on her back while auscultating. d.Instruct the woman to bend her knees and flex her hips.

d To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. Having the woman hold her breath would be inappropriate and possibly dangerous. Lying flat or bending the knees and flexing the hips would have no effect on determining if the heart rate being assessed is of the fetus or the mother.