Nur 103 Unit 1 Mixed bag part 3

A woman who is at 36 weeks gestation is having a non-stress test. Which statement indicates her correct understanding of the test? A) "I will need to have a full bladder for the test to be done accurately." B) "I should have my husband drive me home after the test because I may be nauseated." C) "This test will help to determine whether the baby has Down syndrome or a neural tube defect." D) "This test observes for fetal activity and an acceleration of the FHR to determine the well-being of the baby."

D) "This test observes for fetal activity and an acceleration of the FHR to determine the well-being of the baby." Rationale: The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.

*Possible exam question* A client with eclampsia begins to experience a seizure. Which of the following would the nurse do first? A) Pad the side rails B) Place a pillow under the left buttock C) Insert a padded tongue blade into the mouth D) Maintain a patent airway

D) Maintain a patent airway Rationale: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.

A client with type 1 Diabetes who is multigravida visits the clinic at 27 weeks gestation. The nruse should instruct the client that for most pregnant women with type 1 DM: A) Weekly fetal movement counts are made by the mother B) Contraction stress testing is performed weekly C) Induction of labor is begun at 34 weeks gestation D) Nonstress testing is performed weekly until 32 weeks gestation

D) Nonstress testing is performed weekly until 32 weeks gestation Rationale: For most clients with type 1 diabetes mellitus, non-stress testing is done weekly until 32 weeks' gestation and then twice a week to assess fetal well-being.

*Possible exam question* A 31yo multipara is admitted to the birthing room after initial exam reveals her cervix to be at 8 cm, completely effaced (100%) and at 0 station. What phase of labor is she in? A) Active B) Latent C) Expulsive D) Transitional

D) Transitional phase Rationale: The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The active phase extends from 4 to 7 cm; it is moderate for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A) "Nausea and vomiting can be decreased if I eat a few crackers before arising." B) "If I start to leak colostrum, I should cleanse my nipples with soap and water." C) "If I have vaginal discharge, I should wear nylon underwear." D) "Leg cramps can be alleviated if I put an ice pack o the area."

A) "Nausea and vomiting can be decreased if I eat a few crackers before arising." Rationale: Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

The nurse is caring for a client in labor. the external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A) Change the client's position B) Prepare for emergency C-section C) Check for placenta previa D) Administer oxygen

A) Change the client's position Rationale: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side-lying may immediately correct the problem.

A PP patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? A) Endometritis B) Endometriosis C) Salpingitis D) Pelvic thrombophlebitis

A) Endometritis Rationale: Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Symptoms include swelling of the abdomen, abnormal vaginal bleeding or discharge, fever, discomfort with bowel movement, and pain in the lower abdomen or pelvic region.

Which of the following factors would the nurse suspect as predisposing a client to placenta previa? A) Multiple gestation B) Uterine anomalies C) Abdominal trauma D) Renal or vascular diseaseA

A) Multiple gestation Rationale: Multiple gestation is one of the predisposing factors that may cause placenta previa. Placenta previa is more common in older and multiparous women. The reason is not clear but it may be associated with the aging of the vasculature of the uterus. This causes placental hypertrophy and enlargement which increases the likelihood of the placenta encroaching on lower segmen

While assessing a primapara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client's fundus to: A) Prevent uterine inversion B) Promote uterine involution C) Hasten the Postpartum period D) Determine the size of the fundus

A) Prevent uterine inversion Rationale: Using both hands to assess the fundus is useful for preventing uterine inversion. The recent uterine inversion with placenta already separated from it may often be replaced by manually pushing up on the fundus with the palm and fingers in the direction of the long axis of the vagina.

Before birth, which of the following structures connects the right and left auricles of the heart? A) Umbilical vein B) Foramen ovale C) Ductus arteriosus D) Ductus venosus

B) Foramen ovale Rationale: The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed-blood traveling through the vascular system.

A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial plaental previa is which of the following? A) Activity limited to bed rest B) Platelet infusion C) Immediate cesarean delivery D) Labor induction with oxytocin

A) Activity limited to bed rest Rationale: Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.

Normal lochial findings in the first 24 hours post-delivery include: A) Bright red blood B) Large clots or tissue fragments C) A foul odor D) The complete absence of lochia

A) Bright red blood Rationale: Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.

The nurse in charge is caring for a PP client who had a vaginal delivery with a midline episiotomy. which nursing diagnosis takes priority for this client? A) Risk for deficient fluid volume related to hemorrhage B) Risk for infection related to the type of delivery C) Pain related to the type of incision D) Urinary retention related to periurethral edema

A) Risk for deficient fluid volume related to hemorrhage Rationale: Hemorrhage jeopardizes the client's oxygen supply — the first priority among human physiological needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over-diagnoses of Risk for Infection, Pain, and Urinary retention.

A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A) "The ultrasound with help to locate the placenta." B) "The ultrasound identifies blood flow through the umbilical cord." C) "The test will determine where to insert the needle." D) "The ultrasound locates a pool of amniotic fluid."

B) "The ultrasound identifies blood flow through the umbilical cord." Rationale: Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

Which of the following would the nurse assess in a client experiencing abruptio placenta? A) Bright red, painless vaginal bleeding B) Concealed or external dark red bleeding C) Palpable fetal outline D) Soft and nontender abdomen

B) Concealed or external dark red bleeding Rationale: A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to board-like, and the fetal presenting part may be engaged.

Which of the following would the nurse identify as a classic sign of pregnancy induced hypertension (PIH)? A) Edema of the feet and ankles B) Edema of the hands and face C) Weight gain of 1lb/week D) Early morning headache

B) Edema of the hands and face Rationale: Edema of the hands and face is a classic sign of PIH. Aggressive volume resuscitation may lead to pulmonary edema, which is a common cause of maternal morbidity and mortality. Pulmonary edema occurs most frequently 48-72 hours postpartum, probably due to mobilization of extravascular fluid. Because volume expansion has no demonstrated benefit, patients should be fluid restricted when possible, at least until the period of postpartum diuresis.

Following a delivery, examination of the client's vagina reveals a 4th degree laceration. Which of the following would be contraindicated when caring for this client? A) Applying cold to limit edema during the first 12-24 hours B) Instructing the client to use two or more peri pads to cushion the area C) Instructing the client on the use of sitz baths if ordered D) Instructing the client about the importance of kegel exercises

B) Instructing the client to use two or more peri pads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. A fourth-degree perineal laceration is the injury to the perineum involving the anal sphincter complex and anorectal mucosa.

What is an appropriate indicator for performing a contraction stress test? A) Increased fetal movement and small for gestational age B) Maternal diabetes and postmaturity C) Adolescent pregnancy and poor prenatal care D) History of preterm labor and IUGR

B) Maternal diabetes and postmaturity Rationale: The contraction stress test helps predict how the baby will do during labor. The test triggers contractions and registers how the baby's heart reacts. A normal heartbeat is a good sign that the baby will be healthy during labor.

When PROM occurs, which of the following provides evidence of the nurse's understanding of the client's immediate needs? A) The chorion and amnion rupture 4 hours before the onset of labor B) PROM removes the fetus's most effective defense against infection C) Nursing care is based on fetal viability and gestational age D) PROM is associated with malpresentation and possibly incompetent cervix

B) PROM removes the fetus's most effective defense against infection Rationale: PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client's most immediate need at this time.

Which of the following is the nurse's initial action when umbilical cord prolapse occurs? A) Begin monitoring maternal vital signs and FHR B) Place the client in knee-chest position in bed C) Notify the physician and prepare the client for delivery D) Apply a sterile warm saline dressing to the exposed cord

B) Place the client in a knee-chest position in bed Rationale The immediate priority is to minimize pressure on the cord. Thus the nurse's initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR is important, but it does not have an effect on minimizing the pressure on the cord.Before notifying the physician, the nurse must do her independent nursing intervention to minimize the pressure on the cord. Applying sterile, warm saline dressing on the exposed cord prevents its drying out and the growth of infectious organisms, however, it does not minimize cord pressure.

Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A) Excessive vaginal bleeding B) Rigid, board-like abdomen C) Tetanic uterine contractions D) Premature rupture of membranes

B) Rigid, board-like abdomen Rationale: The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. It's possible for the blood to become trapped inside the uterus, so even with a severe placental abruption, there might be no visible bleeding.

Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? A) Weak contraction prolonged to more than 70 seconds B) Tetanic contractions prolonged to more than 90 seconds C) Increased pain with bright red vaginal bleeding D) Increased restlessness and anxiety

B) Tetanic contractions prolonged to more than 90 seconds Rationale: Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture.

After completing a second vaginal exam of a client in labor, the nurse determines that the fetus is in the right occiput anterior position and at (-1) station. Based on these findings, the nurse knows that the fetal presenting part is: A) 1 cm below the ischial spines B) Directly in line with the ischial spines C) 1 cm above the ischial spines D) In no relationship to the ischial spines

C) 1 cm above the ischial spines Rationale; Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as -1, -2, or -3. A presenting part below the ischial spines, as +1, +2, or +3.

Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A) Increased plasma HCG levels B) Decreased intestinal motility C) Decreased gastric acidity D) Elevated estrogen levels

C) Decreased gastric acidity Rationale: During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation can cause heartburn and flatulence.

A new mom is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A) Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking B) Hold the infant's head firmly against the breast until he latches onto the nipple C) Encourage the mother to stop feeding for a few minutes and comfort the infant D) Provide a formula for the infant until he becomes calm, and then offer the breast again

C) Encourage the mother to stop feeding for a few minutes and comfort the infant Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful.

*Possible Exam Question* The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administrating antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A) Herpes B) Trichomonas C) Gonorrhea D) Syphilis

C) Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.

*Possible exam question* A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A) Sometimes uses vibroacoustic stimulation B) Is an invasive test; however, contractions are stimulated C) Is considered to have a negative result if no late decelerations are observed with the contractions D) Is more effective than non-stress test (NST) if the membranes have already been ruptured

C) Is considered to have a negative result if no late decelerations are observed with the contractions Rationale: No late decelerations indicate a positive CST result.

A patient with pregnancy induced hypertension probably exhibits which of the following symptoms? A) Proteinuria, headaches, vaginal breathing B) Headaches, double vision, vaginal bleeding C) Proteinuria, headaches, double vision D) Proteinuria, double vision, uterine contractions

C) Proteinuria, headaches, double vision Rationale: A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria.

*Possible Exam Question* A client, 30 weeks pregnant is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? A) The fetus should be delivered within 24 hours B) The client should repeat the test in 24 hours C) The fetus isn't in distress at this time D) The client should repeat the test in 1 week

C) The fetus isn't in distress at this time Rationale: The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn't in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn't within normal limits.

Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? A) Occurring at irregular intervals B) Starting mainly in the abdomen C) Gradually increasing intervals D) Increasing intensity with walking

D) Increasing intensity with walking Rationale: With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens.

The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A) Active phase B) Complete phase C) Latent phase D) Transitional phase

D) Transitional phase Rationale: The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds.